Right-Sided Empyema Thoracis Mimicking Pulmonary Tuberculosis Secondary to a Complicated Hepatic Cyst: A Diagnostic Pitfall.

Pleural empyema commonly presents with constitutional and respiratory symptoms that may closely mimic pulmonary tuberculosis (TB), particularly in patients from TB-endemic regions. We report a diagnostically challenging case of a 42-year-old man admitted with chronic cough, weight loss, night sweats, and a massive right-sided pleural effusion, initially managed under airborne isolation as suspected pulmonary TB. Comprehensive pleural fluid analysis demonstrated an advanced bacterial empyema, while molecular and microbiological testing excluded TB. Thoracoabdominal computed tomography (CT) unexpectedly identified a large (12.5 x 9 cm), multiloculated cystic lesion in the right hepatic lobe exhibiting mass effect and transdiaphragmatic extension into the pleural space. Subsequent ultrasound-guided liver aspiration confirmed a pyogenic liver abscess (PLA), with fluid cultures definitively growing Klebsiella pneumoniae. This case highlights an uncommon extra-thoracic source of pleural infection (a "silent" Klebsiella liver abscess) that completely masqueraded as pulmonary TB due to the overshadowing respiratory symptoms. It underscores the critical importance of evaluating the subdiaphragmatic space via extended thoracoabdominal imaging in cases of unexplained right-sided empyema. Early recognition of invasive Klebsiella syndromes is essential to prevent diagnostic anchoring, ensure targeted antimicrobial therapy, and achieve simultaneous dual-compartment source control.