A CURIOUS CASE OF CYCLICAL PNEUMOTHORAX

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Spontaneous pneumothorax is classified as primary or secondary based on whether underlying lung disease is present. Secondary spontaneous pneumothorax usually occurs due to underlying obstructive lung disease or infections, however less common causes should also be considered and a thorough history should be obtained. CASE PRESENTATION: A 48-year- old otherwise healthy woman with a history of endometriosis presented with right shoulder pain that started after doing push-ups at the gym. She denied chest pain and shortness of breath and was hemodynamically stable. Right pneumothorax was incidentally found on chest x-ray, which was thought to be spontaneous in origin. She was managed conservatively without chest tube placement. However, she returned to the hospital four weeks later with dyspnea and chest pain. On further questioning, she reported a long-standing history of dysmenorrhea accompanied by shortness of breath and mid-sternal, non-exertional chest pain. She noted that all symptoms occurred usually 2-3 days after onset of menstruation. Computed Tomography (CT) of the chest revealed pleural nodularity suggestive of endometrial implants. Empiric treatment with leuprolide, a gonadotropin receptor agonist, was initiated for presumed thoracic endometriosis, after which she did not have recurrence of symptoms. DISCUSSION: Catamenial pneumothorax is a syndrome of recurrent pneumothoraxes occurring in association within 48 to 72 hours of menses. It is encountered in 3-6% of spontaneous pneumothorax cases among women of reproductive age. Its pathogenesis remains poorly understood; some of the proposed mechanisms include acquired diaphragmatic fenestration caused by endometriosis, micro embolization and peritoneal pleural migration of endometrial tissue, and prostaglandin F2 causing bronchiolar constriction and alveolar rupture of the lungs leading to pneumothorax. Diagnosis requires establishing a temporal relationship between pneumothoraxes and menstruation. High resolution CT (HRCT) of the chest is one of the main imaging modalities to support the diagnosis. Management of a catamenial pneumothorax is identical to that of pneumothorax of any etiology. Small asymptomatic or mildly symptomatic pneumothoraxes may be managed conservatively while large ones require tube thoracostomy. Long-term treatment of recurrent catamenial pneumothoraxes involves either suppression of ovulation or ablation of the pleural space to interrupt the pattern of recurrence. Surgical management is performed when medical treatment fails and consists of endometrial tissue removal through video-assisted thoracoscopic surgery (VATS) or open surgery. CONCLUSIONS: Neglect of the menstrual history may prevent and/or delay diagnosis, leading both to an underestimation of the true incidence of this disorder and to a delay in initiation of appropriate therapy. Reference #1: Catamenial pneumothorax caused by thoracic endometriosis. Paolo Maniglio MD, Enzo Ricciardi MD, Federica Meli MD, Salvatore Giovanni Vitale MD, Marco Noventa MD, Amerigo Vitagliano MD, Gaetano Valenti MD, Valentina Lucia La Rosa, MD, Antonio SimoneLaganà MD, Donatella Caserta MD. Reference #2: Catamenial pneumothorax: retrospective study of surgical treatment. Patrick Bagan MD, Françoise Le Pimpec MD, Barthes MD, aJalal Assouad MD, Redha Souilamas MD, Marc Riquet MD, PhD. DISCLOSURES: No relevant relationships by Nikita Fernandes, source=Web Response No relevant relationships by Lakshmi Priyanka Mahali, source=Web Response No relevant relationships by Jonathan Ross, source=Web Response