Medical thoracoscopy (or pleuroscopy) is a valuable diagnostic tool in patients with pleural pathology, being minimally invasive, inexpensive and relatively easy to learn. Complications may occur, depending on the complexity of the case, and mainly include broncho-pleural fistulas, chest infections, arrhythmia, severe hemorrhage due to blood vessel injury, and air or gas embolism. Death is very rare. The present report describes the peculiar case of a 72-year-old woman affected by a pleural empyema who suddenly and unexpectedly died during medical thoracoscopy. On autopsy, three small perforations of the right lung were found, without involvement of major vessels or bronchial ramifications. After a brief overview of medical thoracoscopy and its complications, the fatality and its possible pathophysiological mechanisms are analyzed through a review of the literature.