The chest x-ray shows an area of consolidation with small cavities in the right upper lobe. There are left para hilar infiltrates. There is a large left pleural based opacity protruding into the left lung field causing a ‘D Sign‘. The ‘D Sign‘ should alert one to the possibility of an empyema.

A thoracic ultrasound and aspiration of the contents of the pleural fluid confirmed an empyema. The culprit bug was Streptococcus Pneumonia.

Reference: www.emedicine.medscape.com/empyema imaging.