Clinical Communications: AdultsA Case of Catamenial Pneumothorax with Diaphragmatic Fenestrations
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
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Cited by (7)
Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Noncatamenial Symptoms
2022, Journal of Minimally Invasive GynecologyCitation 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).
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 ReproductionCitation 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.
Recurrent catamenial pneumothorax. Case report
2020, Revista Peruana de Ginecologia y ObstetriciaClinical presentation and treatment of catameinal pneumothorax and endometriosis-related pneumothorax
2018, Expert Review of Respiratory MedicineCatamenial pneumothorax since introduction of video-assisted thoracoscopic surgery: A systematic review
2017, Wiener Klinische WochenschriftPleural endometriosis: Findings on magnetic resonance imaging
2012, Jornal Brasileiro de Pneumologia