Clinical image
A 67-year-old male smoker presented with a 3-day history of severe progressive acute respiratory distress (pulse, 120 beats/min, respiration, 40 breaths/min, and oxygen saturation, 72%). Physical examination revealed left tracheal deviation, decreased right chest wall movement, and diminished breath sounds. We suspected tension pneumothorax and scheduled an emergency needle decompression. Pre-procedural lung ultrasound showed fluid accumulation in the right chest; chest radiography revealed large pleural effusion without pneumothorax (Fig. 1a); and chest computed tomography showed massive, loculated pleural effusion with gas (Fig. 1b). What is your diagnosis?