View Abstract

A3219 - Recurrent Pneumothorax in a Woman of Reproductive Age
Author Block: D. O. Rillera1, R. R. Guarin2, E. V. Tamayo3, P. P. Rozul4, N. Bambalan1; 1Pulmonary Medicine, University of Perpetual Help Dalta Medical Center, Las Piñas City, Philippines, 2University of Perpetual Help Dalta Medical Center, Alabang Zapote Las Pinas, Philippines, 3University of Perpetual Help Dalta Medical Center, Las Pinas City, Philippines, 4Medical Center, University of Perpetual Help DALTA, Las Pinas, Philippines.
Catamenial pneumothorax is a clinical entity that is often underdiagnosed due to lack of disease awareness, variations in size, and number of lesions relative to the timing of menstruation, and incomplete search for lesions.
A case of 35-year-old-female, presenting with one-year history of recurrent monthly hemoptysis, accompanied by shortness of breath. Chest imaging was noted with 40% right sided pneumothorax, Chest tube thoracotomy done resulting into re-expansion and was eventually removed prior to discharge. However, pneumothorax recurred and VATS revealed multiple fenestrations on his diaphragm ranging from 5-8 mm in diameter. Though histopathology revealed no endometriosis, she was started on gonadotropin releasing hormone (GnRH) agonist to induce amenorrhea resulting into non-recurrence of pneumothorax.
Catamenial pneumothorax is a rare entity and occurs only in 3-6% of spontaneous pneumothorax, was described as a spontaneous recurrent pneumothorax of menstruating woman occurring within 24-72 hours.1 Endometrial tissue from retrograde menstruation migrates through the thoracic cavity either by pelvic seeding or lymphovascular spread. These tissues cause necrosis and sloughs off, creating diaphragmatic fenestrations which allows some endometrial tissues to travel and implant themselves in the pleura resulting into air leaks and pneumothorax.
Patient with catamenial pneumothorax may present with shortness of breath, cough and recurrent episode of scapular or thoracic pain during menstruation, which is highly specific for thoracic endometriosis syndrome.2 Diaphragmatic fenestrations may or may not be present and once biopsied, endometrial tissue may or may not be found. Thus, even in the absence of endometrial deposits or visible fenestrations, catamenial pneumothorax should be suspected in women with a history of recurrent pneumothorax, pelvic endometriosis, breathlessness, and right upper back pain during menstruations. 3
Recurrence rate drops if surgical management combined with hormonal treatment like GnRH agonist for patients with catamenial and or endometriosis related pneumothorax.
Although the occurrence is rare, we need to maintain a high degree of clinical alertness and include catamenial pneumothorax in the differential diagnosis among menstruating women with recurrent pneumothorax. When menarche has started, physicians should elicit history of right scapular pain during menstruation which is highly specific for thoracic endometriosis.
References
1.
Alifano M, et al. Catamenial and non-catamenial, endometriosis-related or non-endometriosis-related pneumothorax referred for surgery. Am J Respir Crit Care Med 2007;176:1048-53.
2.
Rousset-Jablonski C, et al. Catamenial pneumothorax and endometriosis-related pneumothorax: clinical features and risk factors. Hum Reprod. 2011 Sep;26(9):2322–9.
3.
Visouli A, Zarogoulidis K, et al. Catamenial pneumothorax. Journal of Thoracic Disease. 2014;6(Suppl 4):S448-S460.