 \[[@B5]\] described a case of EN secondary to methicillin-resistant *S. aureus* (MRSA). This patient developed a rounded painful swelling of the left upper chest after he tripped and fell. Mizell et al. \[[@B13]\] also described a case of EN secondary to MRSA in a patient with diabetes and cirrhosis. Unlike this case, our patient did not have any risk factors such as immunosuppression, diabetes, chest trauma, or thoracic surgery. We theorize that our patient\'s infection started as a skin and soft tissue infection due to MSSA in the left antecubital fossa with subsequent bacteremia and seeding of his tricuspid valve, followed by embolic phenomenon to his lungs which led to a parapneumonic effusion and ultimately direct extension through the chest wall to the pectoralis muscle, as seen in [Figure 1](#fig1){ref-type="fig"}. EN commonly spreads to the subcutaneous tissues of the chest wall and can also involve spread to other sites such as the esophagus, breast, retroperitoneal, peritoneal, pericardial, and paravertebral regions. The resultant subcutaneous abscess may eventually rupture through the skin \[[@B13]\].

In terms of diagnosing EN, plain radiographs are often nonspecific and at times can even be normal. At best, plain radiographs may suggest a soft tissue density in the chest wall. Chest CT is best at assessing the extent of infection out of the thoracic cavity. Chest CT will classically reveal an empyema (often a relatively well-demarcated collection) with extension through the chest wall into an extrathoracic compartment. Accompanying rib destruction may be present \[[@B5]\].

Management options for EN include drainage (open or closed) of the pleural space to expand the lung and mitigate risks of fibrosis. Appropriate antibiotic therapy is also a mainstay of treatment \[[@B4]\]. The addition of gentamicin to nafcillin or oxacillin was previously recommended for treatment of complicated right-sided IE due to MSSA. However, recent data suggest that the risks of nephrotoxicity from gentamicin outweigh the