1.5-year-old previously healthy patient was referred from tertiary care to us with complaints of fever and cough for one week and respiratory distress for two days. The patient was initially managed by a general physician with supportive treatment, but due to worsening of symptoms, the patient visited another tertiary care hospital where she was admitted; a baseline workup was performed, and oxygen was provided with a noninvasive high-low nasal cannula along with broad-spectrum antibiotics. The workup revealed pleural effusion; therefore, the patient was referred to us for further management, which was consistent with respiratory distress with swelling and erythema on the left side of the chest wall extending inferiorly from the xiphoid process to the midclavicular line and superiorly up to the subclavicular region with decreased air entry on the left side of the chest. Laboratory workup revealed leukocytosis with white blood count of 58.9k/µL with a left shift 74% neutrophils, 0.1% eosinophil’s, 6.1% monocytes, 19.7% lymphocytes, hemoglobin 9.9 g/dL, platelet count 703 K/µL, C-reactive protein 150.94 mg/L, procalcitonin 4.01 ng/mL and blood gas with pH 7.47, partial pressure of carbon dioxide 34.80 mm Hg, partial pressure of oxy-gen 185 mm Hg, bicarbonate 24.7meq/L and base excess 1.5 meq/L. Chest X-ray findings were consistent with complete left hemithorax whiteout with a contralateral mediastinal shift, as obvious in fig1. Computed tomography of the chest was performed, consistent with gross left-sided pleural effusion with an enhanced pleural margin suggestive of empyema, large collection with an enhancing margin in the left lateral chest wall, and smaller fluid collection in the paramediastinal location consistent with Empyema Necessitans (EN), as shown in figure 1b & 1c. The patient was admitted to the pediatric intensive care unit, intubated, and continued on mechanical ventilation for increased work of breathing. The broad-spectrum antibiotics ceftriaxone and vancomycin were continued. The cardiothoracic surgery team was taken onboard, and left posterolateral thoracotomy and decortication were performed under general anesthesia with more than 500 ml purulent fluid drained and two chest tubes placed. The post-procedure patient went into SIRS, which was managed with inotropes, fluid resuscitation, and adjustment of ventilatory support. Cultures revealed MRSA.  Pleural fluid for the AFB smear and gene-xpert were negative. An echocardiogram, which was negative for vegetation, was performed. IV ceftriaxone was discontinued, and vancomycin was switched to intravenous linezolid. Post-procedure radiography showed resolution of the pleural effusion, as shown in fig 1d and 1e. Chest tubes were removed on 7^th postoperative day. The patient was treated with one week of IV antibiotics (4 days of ceftriaxone and vancomycin and 3 days IV linezolid) followed by oral linezolid for 4 weeks. The patient’s hospital course remained uneventful, and Patient was discharged in stable condition on oral antibiotics on postoperative day 9.