HIV AS A RED HERRING IN SANGUINOUS PLEURAL EFFUSION SECONDARY TO THORACIC ENDOMETRIOSIS

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: Hemothorax is most commonly due to trauma and iatrogenic causes. However, spontaneous hemothorax and bloody effusions occurring independent of trauma may be secondary to malignancy, infection, rheumatologic, or vascular diseases. We present the case of a young woman with a complex bloody effusion and a medical history that lends itself to a particularly wide differential. CASE PRESENTATION: A 30 year old HIV positive woman from Ghana disclosed two weeks of cough and dyspnea during outpatient follow up with infectious disease. She denied fever, chills, sick contacts and hemoptysis, but endorsed intermittent right flank and shoulder pain. CXR showed complete whiteout of the right lung field and she was sent to the ED. On evaluation she was neither hypoxic, tachycardic, nor tachypneic. She was afebrile and without leukocytosis, though a microcytic anemia was noted. CT-TAP showed a large right pleural effusion, collapse of the right lung, leftward mediastinal shift, as well as intraperitoneal fluid and uterine fibroids. A chest tube was placed and drained 1500ml of sanguinous fluid. Fluid studies indicated an exudative effusion with pleural/serum hematocrit of 5/26.6%, failing to meet criteria for a true hemothorax . Bacterial and mycobacterial cultures were sterile, and cytology showed only hemosiderin laden macrophages. At time of discharge the etiology of the effusion was as of yet undetermined. Outpatient OBGYN evaluation included TVUS confirming fibroids and pelvic ascites and the patient endorsed dysmenorrhea and 5 years of failed attempts to conceive, collectively highly suggestive of endometriosis. At follow up with interventional pulmonology the patient’s pleural effusion had reaccumulated and thoracentesis yielded 1600ml. Cytology and immunohistochemistry were performed and PAX8, ER, and CD10 immunostains returned positive, suggesting presence of endometrial cells in the pleural space, consistent with thoracic endometriosis. DISCUSSION: In our HIV positive patient from a TB endemic region, malignant and infectious etiologies were of particular concern. Conversely, endometriosis has a prevalence of approximately 10%, the prevalence of thoracic endometriosis syndrome (TES) is uncertain but exceedingly rare, and only 14% of TES cases involve hemothorax or sanguinous effusion independent of pneumothorax. Additionally, the typical presenting symptoms of TES, cough, dyspnea, and chest pain are nonspecific. However, right sided laterality of effusion and concomitant pelvic pathology is where TES begins to stand out amongst the differentials. As with all manifestations of TES, hemothorax or bloody effusion has a predilection for right sided laterality greater than 80% of the time, and virtually all cases have concomitant pelvic involvement. CONCLUSIONS: In women of childbearing age with spontaneous hemothorax or bloody effusion, TES is a rare albeit important differential for consideration. Reference #1: Patrini D, Panagiotopoulos N, Pararajasingham J, Gvinidanidze L, Iqbal Y, Lawrence DR. Etiology and management of spontaneous haemothorax. Journal of Thoracic Disease. 2015;7(3):520-6. Reference #2: Martinez FJ, Villanueva AG, Pickering R, Becker FS, Smith DR. Spontaneous hemothorax. Report of 6 cases and review of the literature. Medicine. 1992;71(6):354-68. Reference #3: Joseph J, Sahn S. Thoracic endometriosis syndrome: New observations from an analysis of 110 cases. The American Journal of Medicine. 1996;100(2):164-70. DISCLOSURES: No relevant relationships by Jared Mickelson, source=Web Response No relevant relationships by Randal Rovinski, source=Web Response