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A 77-year-old man was admitted to our hospital with a 2-day history of dyspnoea that had started suddenly. Chest x-ray showed a left hydropneumothorax under tension with mediastinal shift (figure 1); blood analyses revealed a high inflammatory reaction. Chest drainage improved symptoms initially with re-expansion of the collapsed lung and a yellowish purulent effusion discharged from the chest drain with little or no air leakage under continuous suction. Biochemical test results of the fluid included: lactate dehydrogenase (LDH) 1522 IU/l, glucose 2 mg/dl and protein 5.7 g/dl.