CATAMENIAL CONUNDRUM: A CASE OF PULMONARY EMBOLISM IN A PATIENT WITH CATAMENIAL PNEUMOTHORAX

Abstract

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Endometriosis is a common condition affecting about 10% of reproductive-age women, in which ectopic endometrial tissue is found outside of the uterine cavity [1]. While it most commonly affects the pelvis, rarely endometrial tissue can also be found in the chest, often presenting as catamenial pneumothorax [2]. There have also recently been reports of systemic effects of endometriosis such as supporting a pro-inflammatory and prothrombotic state, increasing the risk for deep vein thrombosis (DVT) and pulmonary embolism (PE) [3]. CASE PRESENTATION: A 32 year old woman with endometriosis presented to the hospital with several weeks of pleuritic chest pain, nausea, vomiting, and inability to tolerate oral intake. Several months prior, she was diagnosed with thoracic endometriosis after a hospitalization for chest pain and discovery of bilateral pneumothoraces and pleural effusions, necessitating bilateral chest tube placement. Her consequent outpatient course was complicated by an unprovoked DVT, for which she was started on apixaban. She was admitted to the hospital the next month for worsening dyspnea and underwent computed tomography angiography of the chest and was found to have a left lower lobe subsegmental pulmonary embolism and loculated bilateral pneumothoraces, leading to video-assisted thoracoscopic surgery with decortication, pleural biopsy, and chemical pleurodesis for catamenial pneumothorax, with improvement in symptoms (Image 1). Anticoagulation (AC) was switched from oral apixaban to enoxaparin injections 1.5mg/kg daily, with a plan for clinic follow up for further AC management. DISCUSSION: Extrathoracic involvement is a rare and challenging presentation of endometriosis, often necessitating invasive interventions, and associated with recurrence rates of up to 14% (4). Our patient presented the challenge of requiring AC for her PE while managing bleeding risk in the setting of endometriosis, all while being unable to tolerate oral medications due to nausea and vomiting associated with endometriosis. In such patients, injectable, quickly reversible options for AC such as enoxaparin should be considered. CONCLUSIONS: There have been several studies suggesting that endometriosis supports a prothrombotic state, making it imperative to remember this dual challenge when treating endometriosis patients, and to have a low threshold for suspecting PE in any patient with persistent chest discomfort even after treatment of catamenial pneumothorax. Management should be individualized, with attention to the effect of related systemic complications such as nausea and vomiting precluding oral medication success to prevent potentially devastating consequences. REFERENCE #1: Shafrir AL, Farland LV, Shah DK, et al. Risk for and consequences of endometriosis: A critical epidemiologic review. Best Pract Res Clin Obstet Gynaecol. 2018;51:1-15. REFERENCE #2: Mecha E, Makunja R, Maoga JB, et al. The Importance of Stromal Endometriosis in Thoracic Endometriosis. Cells. 2021;10(1):180. Published 2021 Jan 18. REFERENCE #3: Ding D, Liu X, Guo SW. Further Evidence for Hypercoagulability in Women With Ovarian Endometriomas. Reprod Sci. 2018;25(11):1540-1548. DISCLOSURES: No relevant relationships by Teressa Ju, source=Web Response No relevant relationships by Gina Villani, source=Web Response No relevant relationships by Angelina Voronina, source=Web Response