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Disorders of the Pleura |

Near Fatal Presentation of Bilateral Catamenial Massive Pneumothorax Caused by Diaphragmatic Endometriosis

Waseem Hajjar, MD
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King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia


Chest. 2014;146(4_MeetingAbstracts):476A. doi:10.1378/chest.1992093
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Abstract

SESSION TITLE: Pleural Disease Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Catamenial pneumothorax is a rare clinical condition, It is defined as spontaneous pneumothorax that occurs within 48-72 hours before or after the onset of menstruation. The etiology is not completely clear, but in most cases it is associated with thoracic and intra-pleural endometriosis with a diaphragmatic fenestrations.

CASE PRESENTATION: We describe in this report a case of a near fatal presentation of bilateral massive catamenial pneumothorax in a 28-years old female who presented to the emergency department complaining of severe dyspnea, cyanosis, and bilateral severe chest pain. Chest x ray confirmed bilateral massive pneumothorax, which was treated by immediate insertion of bilateral chest tubes. She is known case of pelvic endometriosis on hormonal therapy, and she gave a vague history of recurrent chest pain and cough appearing related to her menstruation for the last few years. She was treated successfully by staged thoracic surgical exploration which showed bilateral multiple diaphragmatic fenestrations and the diagnosis confirmed histologically as endometriosis with the presence of endometrial implants on the upper aspect of the both diaphragms.

DISCUSSION: Catamenial pneumothorax is a rare clinical condition that may be difficult to diagnose. It is defined as spontaneous pneumothorax that occurs within 48-72 hours before or after the onset of menstruation. It occurs in the right lung in most of the cases. We describe in this report a case of near fatal presentation of bilateral massive catamenial pneumothorax caused by bilateral diaphragmatic endometriosis which was treated surgically and the diagnosis confirmed histologically in a 28-years old female who presented to the emergency department complaining of severe shortness of breath, cyanosis, and bilateral severe chest pain. She is known case of pelvic endometriosis on hormonal therapy, and she gave a vague history of recurrent chest pain and cough appearing related to her menstruation for the last few years. Chest x ray confirmed the presence of bilateral massive pneumothorax. Immediate bilateral chest tubes inserted which allowed the lungs to inflate partially and to relieve the symptoms gradually. In the next few days she continued to have active air leak and the lungs remained partially collapsed despite low grade negative suction applied on the chest tubes, due to these reasons and the acute presentation of bilateral massive pneumothorax decision made to offer her surgery in the form of staged procedures of video assisted thoracoscopy however this converted to thoracotomy However, the exact pathogenic mechanism and optimal management of catamenial pneumothorax remain unclear. This article discusses the common issues related to catamenial pneumothorax pathogenic mechanisms, symptoms, diagnostic and the optimal surgical and medical management, During video-assisted thoracoscopic surgery, inspection of the diaphragmatic surface is essential where multiple diaphragmatic perforations or fenestrations are seen. Plication of the involved area alone can be successful. In complicated cases, hormonal suppression therapy is a helpful adjunct. Surgery to repair and strengthen the diaphragm and/or resect nodules or bullae also has a role, supplemented by mechanical pleurodesis or pleurectomy to prevent further pneumothorax or effusions. The main risk is recurrence, and thus the current usual practice is to combine surgery, immediately followed by hormone therapy focusing on GnRH analogues

CONCLUSIONS: this case report demonstrates the evidence that transperitoneal migration of endometrial implants may occur through diaphragmatic holes fenestrations. Surgical intervention in this case presentation is the only option to prevent recurrent pneumothoraces in such patients.

Reference #1: Acta Clin Belg. 2011 Sep-Oct;66(5):376-8. Why a chest physician should be interested in abdominal pain. Bostoen S1, Van Raemdonck D, Dooms C.

Reference #2: J Emerg Med. 2012 Jul;43(1):e1-3. doi: 10.1016/j.jemermed.2009.05.023. Epub 2009 Aug 13. A case of catamenial pneumothorax with diaphragmatic fenestrations. Makhija Z1, Marrinan M.

Reference #3: Asian Cardiovasc Thorac Ann. 2009 Jan;17(1):70-2. doi: 10.1177/0218492309102507. Diaphragmatic fenestrations in catamenial pneumothorax: a management strategy. Rafay M1, El-Bawab H, Kurdi W, Al Kattan K.

DISCLOSURE: The following authors have nothing to disclose: Waseem Hajjar

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