Mycoplasma pneumoniae is recognized as an important and frequent cause of community-acquired respiratory illness in school-aged children [4]. The clinical course of mycoplasma pneumonia is typically mild and self-limited. Pleural effusion is not a common feature of M. pneumoniae, and when it occurs there is usually a small amount of effusion which does not require chest tube insertion [6]. We report here on a child with M. pneumoniae infection complicated by necrotizing pneumonitis (NP) who presents with respiratory distress secondary to massive pleural effusion.A 7-year-old -previously healthy -girl presented to our hospital with a 10-day history of fever and cough. Shortness of breath developed on the day before admission. Antibiotics had not been administered by mouth previously, and no known allergy to drug or food was elicited. Upon arrival to our Emergency Department, she appeared to be acutely ill with respiratory distress. Her body temperature was 39.5°C, pulse rate was 163 beats/min, respiratory rate was 50/min with a blood pressure of 107/55 mmHg. Tachypnea with subcostal retraction was present, and examination of the chest revealed dullness to percussion, with decreased breath sounds to auscultation over the left lower lung field. A chest roentgenogram showed consolidation of the left lower lobe and partial atelectasis of left upper lobe with massive pleural effusion. Complete blood cell counts and biochemical examination revealed a white blood cell count of 17,600/μl with 89% neutrophils and 5% lymphocytes and an increased C-reactive protein level of 337.8 mg/l (normal: <5 mg/l). A chest ultrasonography with diagnostic thoracocentesis was performed, and yellow, not turbid fluid was aspirated. Analysis of the pleural effusion showed white blood cells at 980/mm 3 (neutrophils: 54%; lymphocytes: 29%; monocytes: 11%), red blood cells at 70/mm 3 , protein at 3.6 g/ dl, glucose at 105 mg/dl and lactate dehydrogenase at 2,002 U/l. No organisms were found on Gram-and acid faststained smears. The latex agglutination test of the pleural fluid for Streptococcus pneumoniae, Haemophilus influenzae type b and group B Streptococcus was negative.Empiric ceftriaxone (100 mg/kg body weight per day) was prescribed, but spiking high fever and pleural effusion with respiratory distress persisted for 1 week. Cultures for bacteria, Mycobacterium tuberculosis, fungi and viruses were all negative. A computed tomography (CT) of the chest was performed for further evaluation, and the scan revealed consolidation of the left lower lobe with multiple low attenuation areas and a massive pleural effusion with left lung entrapment (Fig. 1a). Subsequent video-assisted thoracic surgery (VATS) with pleural decortication was performed, and a chest tube was placed with effective drainage of the pleural effusion. Initially, the cold hemagglutinin titer was 1:4 and the complement-fixation immunoglobulin G (IgG) titer for M. pneumoniae was 1:160. One week later, the tests were repeated; the second time the cold hemagglutinin titer was 1:16 a...

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