Late Recurrence of Empyema More Than a Decade after Window Thoracostomy: Secondary <i>Aspergillus</i> Infection Superimposed on Prior MRSA Empyema, Successfully Managed by Stepwise Surgical and Endobronchial Definitive Closure

<b><i>Background:</i></b> Fungal empyema is uncommon and has worse short-term outcomes than bacterial disease, particularly when a bronchopleural fistula (BPF) sustains contamination. <b><i>Case:</i></b> A previously healthy male developed BPF and methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) empyema after right upper lobectomy at age 17, managed by open-window thoracostomy (OWT). An apical residual space persisted and formed a fungus-ball-like nodule. At age 30, he re-presented with fever and nodule growth, with elevated <i>Aspergillus</i> IgG; voriconazole was started. <b><i>Management:</i></b> Computed tomography-guided catheter placement and re-OWT exposed air leaks and recurrent MRSA. Staged fistula control with endobronchial Watanabe spigots, <i>n</i>-butyl-2-cyanoacrylate, and cavity-side suturing achieved cessation. <b><i>Outcome:</i></b> After irrigation, sterilized cultures, negative-pressure therapy preceded latissimus dorsi flap obliteration. He was discharged on postoperative day 149 without recurrence. <b><i>Conclusions:</i></b> A stepwise plan-source control, fistula control, sterilization, and obliteration-can achieve durable cure in mixed <i>Aspergillus</i>-MRSA empyema with BPF after prior OWT.