Actam, subcutaneous enoxaparin(65 mg twice daily) was commenced, and a 6 French pigtail tube thoracostomy was performed under ultrasound guidance (Fig. 1b). Turbid yellow fluid was drained and results of the analysis are shown in Table 2. After 3 days, suboptimal clinical and radiologic resolution resulted in transfer to our institution under the respiratory physicians where intrapleural enzyme therapy was commenced with alteplase (10 mg in 50 mL of saline, 12-hourly) and dornase alfa (Roche AG, Basel, Switzerland)) (5 mg in 50 mL of saline 12-hourly).Fig. 1 a Chest radiograph 1-phenyl-4-(4,4,5,5-tetramethyl-1,3,2-dioxaborolan-2-yl)-1H-pyrazole on presentation at hospital. b Chest radiograph after initial pigtail drain insertion. c Portable chest radiograph during medical emergency call. d Transverse contrast-enhanced computed tomography image on presentation to hospital ?lung window. e Pulmonary embolus in division of right pulmonary artery. f Computed tomography angiogram following medical emergency team callVun and Lance Journal of Medical Case Reports (2015)9:Page 3 ofTable 2 Pleural fluid analysispH Albumin Total protein Lactate dehydrogenase Glucose Cytology 7.8 14 g/L 42 g/L 3570 U/L PubMed ID:https://www.ncbi.nlm.nih.gov/pubmed/8711135 pressure 70 mmHg systolic) and respiratory distress. Drainage had become sanguineous and then ceased, presumably due to obstruction of the small-bore drainage tube. An examination revealed hypovolemic shock and a chest X-ray demonstrated complete opacification of the left hemithorax with mediastinal deviation toward the right (Fig. 1c). His hemoglobin level dropped to 91 g/L, and our patient was transferred to the intensive care unit (ICU) and was transiently responsive to fluid boluses. An urgent CT angiogram demonstrated collapse of the left upper and lower lobes due to a massive pleural effusion, but no contrast extravasation to indicate active bleeding (Fig. 1f ). A 32 French tube thoracostomy was performed in intensive care, resulting in the oncotarget.13387 immediate drainage of over 3000 mL of sanguineous fluid. Our patient remained unstable and was transferred to the operating theater for left thoracotomy and exploration for bleeding. A posterolateral thoracotomy was performed through the fifth intercostal space. On PubMed ID:https://www.ncbi.nlm.nih.gov/pubmed/9544797 entering the pleural 3-Fluoro-2-(trifluoromethyl)aniline cavity, a further 3600 mL of blood was immediately evacuated with cell salvage. The pleural cavity was then explored systematically. Anteriorly, a small adhesion from the superior segment of the lower lobe appeared to have torn and was bleeding and was controlled with point diathermy. The lung appeared inflamed, hyperemic and a small abscess cavity was noted in the lower lobe, which was evacuated. The entirety of the pleural cavity was then examined directly and with the assistance of vidoeoscope. This revealed widespread hyperemic pleural surfaces, which bled on contact. No focal cause for massive hemorrhage could be found. Pleural biopsy would later show fibrous and fibrinous pleuritis thickened with abundant inflammatory granulation tissue. Following copious washout the incision was closed with two drains and our patient was returned to the ICU.A total of 2500 mL of cell-salvaged blood was returned to the patient. Despite aggressive correction of coagulopathy, the.