A Rare Case of Polymicrobial Empyema Associated With COVID-19 Infection Complicated by a Bronchopleural Fistula.

Empyema is a rare but serious complication in patients with COVID-19, and its association with bronchopleural fistula (BPF) is even more uncommon. We present the case of a 40-year-old woman with a history of intravenous drug use who developed polymicrobial empyema in the setting of COVID-19, further complicated by BPF. She presented with hypoxic respiratory failure, leukocytosis, and lactic acidosis. Imaging revealed a large right-sided hydropneumothorax and bilateral lung opacities. Broad-spectrum antibiotics, antivirals, and corticosteroids were initiated, and 3 liters of purulent fluid were drained via chest tube, confirming empyema. Cultures identified multiple pathogens, including Bacteroides fragilis, Arcanobacterium hemolyticum, methicillin-sensitive Staphylococcus aureus, and Group C/G streptococci. Persistent air leak and incomplete lung re-expansion led to a diagnosis of BPF. The patient was successfully managed with prolonged antibiotic therapy and chest tube drainage without requiring surgical or bronchoscopic intervention. This case highlights the importance of recognizing and conservatively managing small BPFs in COVID-19-associated empyema, emphasizing the potential for non-surgical resolution in select cases.