Introduction:
Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by the presence of Philadelphia chromosome, which is defined by BCR::ABL1 fusion oncogene. CML can be associated with pleural infections, increased risk of infection and coagulation abnormalities. Stage 3 empyema requires surgical decortication but can lead to significant hemorrhage. Thoracic packing is an established damage control technique in management of thoracic trauma cases, however there is scant literature of its role in hematologic malignancy associated empyema surgery.

Aim:
We describe a 29-year-old female, who presented with fever, pleuritic chest pain and dyspnea, and was newly diagnosed with CML. Imaging revealed a large loculated organized left empyema (Stage 3), which required surgical intervention.

Case study:
Thoracotomy and decortication was done. Surgery was complicated by diffuse raw surface oozing, postoperative sepsis and coagulopathy. This led to massive hemorrhage requiring re-exploration and intrathoracic packing. This was followed by recovery in surgical intensive care unit. Packs were removed after 72 h, revealing complete hemostasis. Over the next few days, patient recovered fully and was started on systemic treatment of CML.

Discussion:
CML can predispose an individual to increased risk of infection and bleeding. Decortication in the setting of CML can increase the risk of bleeding furthermore. Thoracic packing significantly lowers the mortality when compared to prolonged attempts at definitive hemostasis.

Conclusions:
This appears to be the first detailed report of CML-associated empyema with septic coagulopathy requiring thoracic packing after decortication. Early re-exploration and packing can be lifesaving in diffuse bleeding unresponsive to conventional hemostasis.