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Few incidences of adult patients with rapidly progressing empyema complicated by bronchopleural fistula related to Streptococcus anginosus have been documented. A 53-year-old male with a history of smoking 20 packs/year. He was admitted with 5 days history of worsening cough, respiratory distress, fever, headache, and pleuritic chest pain. Thoracic ultrasound was done, showing septated right-sided pleural effusion, confirming empyema. After decortication, pus culture showed heavy growth of Streptococcus anginosus. The drug susceptibility test revealed susceptibility to penicillin, erythromycin, cephalosporin, and piperacillin/tazobactam. The patient was successfully treated with piperacillin/tazobactam and early open thoracotomy decortication surgery was performed and discharged within 11 days. Although the number of empyema cases infected with Streptococcus anginosus is low, patients should be managed early depending on accurate diagnosis using the right antibiotics, optimal drainage, and surgical intervention if necessary. Further knowledge and research on the clinical presentation and the pathogenesis of thoracic Streptococcus anginosus are needed to have better clinical outcomes in future cases. The specific classification of empyema is suggested using lung ultrasound for the best management options.