A Case of Catamenial Pneumothorax with Diaphragmatic Fenestrations

doi:10.1016/j.jemermed.2009.05.023

The Journal of Emergency Medicine

Volume 43, Issue 1, July 2012, Pages e1-e3

https://doi.org/10.1016/j.jemermed.2009.05.023 Get rights and content

Abstract

Background: Considerable controversy exists with regards to the physiopathogenesis of catamenial pneumothorax. The rarity of catamenial pneumothorax makes understanding of its pathophysiology and verification of etiological mechanisms difficult. Objective: To contribute evidence to the knowledge base on the pathogenesis of catamenial pneumothorax. Case Report: We describe a case of catamenial pneumothorax with images that substantiate the pore hypothesis as a cause of recurrence of air in the pleural cavity in this patient. Conclusion: Our case report contributes evidence that transperitoneal migration of endometrial implants may occur through diaphragmatic fenestrations. Surgical options may be more viable to prevent recurrent pneumothoraces in such patients.

Introduction

The phenomenon of catamenial pneumothorax was first described in 1958 by Maurer and colleagues (1). It is recurrent pneumothorax that occurs during the first 3 days of menses. It has been definitely linked to the presence of concurrent endometriosis. It has been hypothesized that the endometrial tissue can spread to the thorax either by the transperitoneal or hematogenous route (2). The former depends upon diaphragmatic pores and may result in catamenial pneumothorax. Hematogenous spread, on the other hand, results in deposits of endometriotic tissue in the pulmonary parenchyma, and the patient usually presents with cyclical hemoptysis associated with menstruation.

The monthly periodicity of pneumothorax and hemoptysis has been associated with surges of hormonal activity in women. It is notoriously absent in patients on oral contraceptives or those who have anovulatory cycles. Although diaphragmatic fenestrations have been noted in 19–33% of cases, a pulmonary source of air leak has not been identified (3). It has been hypothesized that pleural endometrial tissue absorbed from such fenestrations may lead to air leaks when the endometriotic tissue breaks down during menstruation. However, there is no conclusive evidence in the literature to support this theory. We report a case of catamenial pneumothorax with interesting histopathological findings.

Section snippets

Case Report

A 38-year-old woman was referred to our service with a diagnosis of recurrent right-sided pneumothoraces (Figure 1A). She had presented to the Accident & Emergency Department (ED) a day earlier with acute onset of dyspnea. On examination, she was found to be in acute respiratory distress. Chest auscultation revealed absent air entry on the right side. A provisional diagnosis of tension pneumothorax was confirmed when her symptoms were alleviated after needle pleurocentesis in the right second

Discussion

Congenital abnormality is a described cause of catamenial pneumothorax, as in the Maurer and Crutcher hypothesis (1, 4). They believed that the extrusion of mucus plug occluding cervix during menstrual flow is responsible for air entry in the thorax via the peritoneal cavity during menses. The distribution of peritoneal stomata has been hypothesized to have a right-sided predominance, as per the pore hypothesis (5). However, there is considerable controversy on whether the pathogenesis of

Conclusion

Our case report indicates that, even with a poorly understood pathogenesis, it is possible for endometriotic implants to migrate transperitoneally. Neglect of diaphragmatic examination may lead to recurrent pneumothoraces. There is a need to reevaluate treatment options (medical vs. surgical) for this condition. As an alternative to the standard prescription of oral contraceptive, we believe that there is a need to build a standardized surgical treatment protocol for patients who present with

References (13)

T.J. Yeh
Endometriosis within the thorax: metaplasia, implantation, or metastasis?
J Thorac Cardiovasc Surg
(1967)
E.J. Carter et al.
Catamenial pneumothorax
Chest
(1990)
R.R. Crutcher et al.
Recurrent spontaneous pneumothorax associated with menstruation
J Thorac Cardiovas Surg
(1967)
T. Peikert et al.
Catamenial pneumothorax
Mayo Clin Proc
(2005)
E.R. Maurer et al.
Chronic recurring spontaneous pneumothorax due to endometriosis of the diaphragm
JAMA
(1958)
L. Allen
The peritoneal stomata
Anat Rec
(1936)

There are more references available in the full text version of this article.

Cited by (7)

Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Noncatamenial Symptoms
2022, Journal of Minimally Invasive Gynecology
Citation Excerpt :
The final exclusion was made of cases in which the patient's symptomatology was not presented clearly or endometriosis was an incidental operative finding. The final exclusion yielded 240 articles and 480 patients for inclusion in this review (Fig. 1) [7–246]. The patients were categorized for assessment into 2 groups depending on whether the presentation of their symptoms was catamenial (n = 419) or noncatamenial (n = 61).
This review aimed to categorize thoracic endometriosis syndrome (TES) according to whether the presenting symptoms were catamenial and to evaluate whether such a categorization enables a better management strategy.
An electronic search was conducted using the PubMed/Medline database.
The following keywords were used in combination with the Boolean operators AND OR: “thoracic endometriosis syndrome,” “thoracic endometriosis,” “diaphragm endometriosis,” and “catamenial pneumothorax.”
The initial search yielded 445 articles. Articles in non-English languages, those whose full texts were unavailable, and those that did not present the symptomatology clearly were further excluded. After these exclusions, the review included 240 articles and 480 patients: 61 patients in the noncatamenial group and 419 patients in the catamenial group. The groups differed significantly in presenting symptoms, surgical treatment techniques, and observed localization of endometriotic loci (p <.05).
This review points out the significant differences between patients with TES with catamenial and noncatamenial symptoms. Such categorization and awareness by clinicians of these differences among patients with TES can be helpful in designing a management strategy. When constructing management guidelines, these differences between patients with catamenial and noncatamenial symptoms should be taken into consideration.
Non-traumatic diaphragmatic rupture with liver herniation due to endometriosis: A rare evolution of the disease requiring multidisciplinary management
2019, Journal of Gynecology Obstetrics and Human Reproduction
Citation Excerpt :
The following descriptors were used on PubMed/MEDLINE database: “diaphragmatic endometriosis”, “diaphragmatic rupture”, “thoracic endometriosis”. We identified 12 cases reported, considering only the articles in English [4–10]. Characteristics of the 12 cases are reported in the Table 1.
A 35 year old woman with chronic pelvic endometriosis suffered from right scapular pain. MRI imaging showed a right diaphragmatic rupture with liver herniation. Surgical procedure was performed by thoracotomy. The liver was put back into the abdomen, endometriosis was resected from the diaphragm, interrupted non absorbable suture of the diaphragm was performed and an absorbable mesh was placed. Endometriosis was confirmed on histological analysis of the resected diaphragm. To study this pathology, we performed a systematic review of the literature and found 12 similar cases of diaphragmatic rupture due to endometriosis. Right diaphragm is often involved and rupture is always located on the tendinous portion. Symptoms are mainly cyclic right scapular pain and cathamenial pneumothorax. MRI should be performed in case of suggestive symptoms and a systematic exploration of the diaphragm should be performed at laparoscopy for an early treatment of the lesions to prevent progression to rupture.
Recurrent catamenial pneumothorax. Case report
2020, Revista Peruana de Ginecologia y Obstetricia
Clinical presentation and treatment of catameinal pneumothorax and endometriosis-related pneumothorax
2018, Expert Review of Respiratory Medicine
Catamenial pneumothorax since introduction of video-assisted thoracoscopic surgery: A systematic review
2017, Wiener Klinische Wochenschrift
Pleural endometriosis: Findings on magnetic resonance imaging
2012, Jornal Brasileiro de Pneumologia

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Clinical Communications: AdultsA Case of Catamenial Pneumothorax with Diaphragmatic Fenestrations

Abstract

Introduction

Section snippets

Case Report

Discussion

Conclusion

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovas Surg

Mayo Clin Proc

Chronic recurring spontaneous pneumothorax due to endometriosis of the diaphragm

JAMA

The peritoneal stomata

Anat Rec

Clinical Communications: Adults
A Case of Catamenial Pneumothorax with Diaphragmatic Fenestrations