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A 70-year-old man with prior colon adenocarcinoma presented with 1 week of persistent hiccups, 1 day of fever and acute dyspnoea. Other than colon cancer surgery more than 10 years earlier, he had no recent abdominal procedures, no immunocompromising condition and no history of intravenous drug use. Chest radiography and CT demonstrated a massive left pleural effusion that enlarged rapidly within 24 hours, along with multiple hypodense splenic lesions (figure 1A). Diagnostic thoracentesis yielded frank pus.