Recurrent Pneumothorax Due to Diaphragmatic Endometriosis: A Case Report

Endometriosis most commonly involves the pelvis. The most common extrapelvic location of endometriosis is the thorax. Thoracic endometriosis can manifest itself as pneumothorax, hemothorax, hemoptysis, pulmonary nodules, or thoracic pain, but the most common presentation is catamenial pneumothorax. Catamenial pneumothorax symptoms usually begin 24 hours before to 72 hours after the onset of menstruation. A CT scan of the chest can identify pneumothorax, pleural effusion, pleural or parenchymal nodules, and blebs, but MRI is better at detecting diaphragmatic defects. In many cases, the diagnosis is made incidentally when the patient undergoes surgery for recurrent pneumothorax. Treatment requires managing the presenting feature and secondary prevention of recurrence, which can involve surgical resection of visible blebs and pleurodesis, resection of visible endometrial implants, closure or repair of diaphragmatic defects if needed, and hormonal suppressive therapy after the diagnosis is confirmed.



This video demonstrates the case of a forty-one-year-old woman who was a smoker. She had a history of two previous episodes of right pneumothorax that underwent chest drainage in the previous year. The patient went to the emergency room because of complaints of dyspnea, cough, and thoracic pain in the right hemithorax aggravated with deep breathing. A chest x-ray revealed a large right pneumothorax and a chest tube was inserted in the right pleural cavity with full lung expansion after chest tube placement. A CT scan of the chest showed a couple of blebs in the apical right lung and no suspected diaphragmatic lesions. 

The patient underwent surgery by right uniportal video-assisted thoracic surgery (VATS). Some adhesions were seen from the lung to the diaphragm and they were released with electrocautery. Some purple-brownish lesions were found in the diaphragm that were suspicious of endometriosis. The part of the diaphragm that had the lesions was excised with an automatic suture machine. Several blebs in the middle lobe and superior lobe were also excised. Mechanical pleurodesis was then performed through pleural abrasion and talc powder was used for chemical pleurodesis. A 24 French chest tube was left in the pleural cavity. 

The patient was discharged home two days after the surgery and the hospital stay was uneventful. Anatomopathological evaluation revealed emphysema lesions in the lung and diaphragmatic lesions with glands and stroma with characteristics compatible with endometriosis spots. When questioned, the patient mentioned she was menstruating on all three episodes of pneumothorax. She was then sent to gynecology to start hormonal therapy.

Thoracic endometriosis should always be suspected in reproductive-age women with history of catamenial pneumothorax, especially those who have proven pelvic endometriosis. The treatment involves a multidisciplinary team with pulmonologists, thoracic surgeons, and gynecologists.

References

1. Marjański T, Sowa K, Czapla A, Rzyman W. Catamenial pneumothorax - a review of the literature. Kardiochir Torakochirurgia Pol. 2016 Jun;13(2):117-21. doi: 10.5114/kitp.2016.61044. Epub 2016 Jun 30. PMID: 27516783; PMCID: PMC4971265
2. Elia S, De Felice L, Varvaras D, Sorrenti G, Mauriello A, Petrella G. Catamenial pneumothorax due to solitary localization of diaphragmatic endometriosis. Int J Surg Case Rep. 2015;12:19-22. doi: 10.1016/j.ijscr.2015.05.012. Epub 2015 May 7. PMID: 25981153; PMCID: PMC4486100
3. Gil Y, Tulandi T. Diagnosis and Treatment of Catamenial Pneumothorax: A Systematic Review. J Minim Invasive Gynecol. 2020 Jan;27(1):48-53. doi: 10.1016/j.jmig.2019.08.005. Epub 2019 Aug 8. PMID: 31401265.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.