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Empyema necessitans, a rare complication of pleural effusion, could result in significant morbidity and mortality in children. It is characterized by the dissection of pus through the soft tissues and the skin of the chest wall. It was first described in 1640 by Guillan De Baillon, and later by Laennec in 1849. In 1940, 115 cases were described, 73% of which were caused by tuberculosis; however, to date it is rare to find cases.The clinical examination and computed tomography (CT) are diagnostic, the microorganisms are diverse. We present two cases, of patients with different immune status, who presented empyema necessitatis for two different germs. One of the cases described was caused by Serratia marcescens, a microorganism that has not been previously reported in the literature. Cases A 19-month old girl previously healthy patient, with 6 days of evolution of indurated and painful mass of approximately 10 x 10 cm in left lateral thoracoabdominal region, associated with fever, with pleural effusion and extrathoracic collection that is finally diagnosed as empyema necessitatis caused by Serratia marcescens natural phenotype AmpC , she presented an adequate response with drainage + decortication and antibiotic therapy with Clindamycin + Cefepime. Patient with a history of primary immunodeficiency type chronic granulomatous disease, with a mass of 2 weeks evolution, 8 x 6 cm in the posterior wall and 10 x 8 cm in the anterior wall of the left hemithorax, in whom TAC was used to diagnose necrotizing pneumonia and empyema necessitatis, caused by Aspergillus flavus and treatment with voriconazole .The management of this case was a challenge due to the underlying disease, and because it also had bone infection associated with osteomyelitis and spondylitis. However, after antifungal treatment and prolonged antibiotic and also surgical drainage presented satisfactory evolution. Discussion Empyema necessitatis is a complication of pleural empyema that is characterized by the extension of purulent fluid through the parietal pleura into the chest wall. The pathology has a good prognosis, the treatment involves the drainage of the abscess and the appropriate antimicrobial therapy. Despite the decrease in incidence, this condition should be considered as a complication present in pneumonias with empyema or parapneumonic effusion in children, immunocompromised patients are still at a higher risk, but can be present in patient previously healthy. It´s important to think about this because of early diagnosis and management would prevent the development of complications.
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