230 A Rare Case of Catamenial Pneumothorax (CP) in a Middle-Aged Patient with Liver Herniation

Abstract

Abstract Catamenial pneumothorax (CP) is the recurrent accumulation of air in the pleural cavity in reproductive-age women without concomitant respiratory disease. We report a forty-year-old lady with no past medical history first presented to her local hospital with haemoptysis, severe chest pain, recurrent spontaneous pneumothorax, and dyspnoea, coinciding with menstruation. In addition to a right-sided pneumothorax, in this admission, the chest radiograph showed a right-sided nodule overlying the right hemithorax, and CT showed multiple right-sided ‘pleural’ nodules on the diaphragmatic side. She underwent a single-port VATS procedure which revealed herniation of the liver through a centrally located diaphragmatic defect, together with the adhesion of the superior lobe to the parietal pleura. The diaphragm was repaired using multiple stitches, followed by buttressing and plication to cover further and reinforce the fixed portion, and a pleurectomy was undertaken to prevent recurrent pneumothorax. The aetiology of CP remains obscure. However, physiologic hypotheses, the migration theory, the metastatic or lymphovascular microembolisation theory, and the transgenital-transdiaphragmatic passage of air theory are mentioned in other literature. Radiological investigations such as CXR and CT scans showed pneumothorax or pleural nodule evidence, and Investigative inspection of the pleural diaphragmatic surface at thoracoscopy often reveals defects (termed fenestrations) as well as small endometrial deposits. These deposits have also been seen on the visceral pleural surface among women undergoing routine surgical treatment for recurrent pneumothorax. The most effective treatment strategy is early surgical repair and resection of the diaphragm and the affected lung with pleurodesis and hormonal therapy to achieve amenorrhoea.