Catamenial pneumothorax caused by endometriosis in the visceral pleura

Catamenial pneumothorax is a rare clinical entity of unknown etiology. The most well known hypothesis is passage of air from the genital tract through endometrial fenestrations in the diaphragm. Although some reports are associated with diaphragmatic endometriosis, few have been confirmed endometrial implants in the visceral pleura. We describe a very rare case of catamenial pneumothorax caused by ectopic endometriosis in the visceral pleura confirmed histopathologically in a woman 1-year after hysterectomy.     

An experience of surgical treatment for catamenial pneumothorax with diaphragmatic and pulmonary endometriosis]

A case of catamenial pneumothorax with diaphragmatic and pulmonary endometriosis is presented. A 43-year-old, married woman had three times of recurrent right pneumothorax during the period from January to July on 1990. Each episode was apparently related to the onset of the menstruation suggesting catamenial pneumothorax. Right thoracotomy revealed a perforation of the diaphragm and five black spots on the visceral pleura. Involved portion both diaphragm and lung were excised. Microscopic examination of the excised specimens showed endometrial stroma in the diaphragm and subpleural layer of the lung. Although it has been postulated that intrathoracic endometriosis is a possible cause of the pneumothorax, very few cases have been reported in which pulmonary or pleural endometriosis was demonstrated histologically. Surgical and pathologic findings are documented discussing the relationship of both conditions in this report.     

Catamenial pneumothorax due to diaphragmatic endometriosis confirmed by histological examination; report of a case

We reported a case of catamenial pneumothorax caused by diaphragmatic endometriosis that was histologically confirmed. A 49-year-old female who had recurrent chest pain and cough appearing on the day preceding each menstruation from 5 years ago. These episode suggested catamenial pneumothorax. Thoracotomy revealed the characteristic appearances of catamenial pneumothorax such as blueberry spots and multiple small holes on the central tendon of the right diaphragm. But there were no lesions on the visceral pleura of the lung. Partial resection of the diaphragm including these lesions were performed. Histological examination showing positive for estrogen receptor and progesterone receptor confirmed the presence of endometrial tissue on the diaphragm. The patient has been well controlled by therapy with gonadotropin releasing hormone, without recurrence of catamenial pneumothorax.     

Life-threatening endometriosis-related hemopneumothorax

Catamenial pneumothorax is a relatively rare condition, generally of mild to moderate severity. We report the case of a 29-year-old woman who experienced an episode of life threatening right-sided hemopneumothorax in association with menses. She had already been operated on for recurrent pneumothorax. Treatment of the current episode included urgent tube thoracostomy and iterative thoracotomy, together with lung wedge resection, parietal pleurectomy, and partial diaphragmatic excision. Pathologic examination revealed endometrial implants massively involving the diaphragm, the pleura, and the lung parenchyma. The present report shows that endometriosis-related pneumothorax may be extremely severe. The multiple localizations of endometrial implants in this case may provide a support to the different pathogenic theories of endometriosis-related pneumothorax.     

Video assisted thoracic surgery for the treatment of catamenial pneumothorax

Video assisted thoracic surgery (VATS) was applied in 3 cases of pneumothorax combined with pathologic changes in the diaphragm (two cases of catamenial pneumothorax and one case of suspected catamenial pneumothorax). Case 1, 39-year-old woman, was preoperatively diagnosed as catamenial pneumothorax in the right lung. Thoracoscope was inserted through the 5th intercostal anterior axillary line and the lesion with the pathologic changes in the central tendon of the diaphragm was incised and sutured with Endo-GIA and Endo-STAPELAR. Case 2, 42-year-old woman, was confirmed to have pathologic changes in the central tendon after insertion of thoracoscope through the 5th intercostal anterior axillary line. Minithoracotomy of 50 mm in size was added close to the center of the diaphragm and direct incision and suture of that part were performed. Case 3, 47-year-old woman, underwent thoracoscopy through the 5th intercostal mid-axillary line and bulla in the S2 interlobar surface was incised with Endo-GIA. In this case, the diaphragm was partially incised through additional minithoracotomy because some lesions were detected on that part. VATS can fully be carried out for pathologic changes in the diaphragm in catamenial pneumothorax. Since catamenial pneumothorax may be complicated with another pathologic changes in the diaphragm (Case 1) or in the visceral pleura (Case 3), the whole thoracic cavity, including diaphragm and visceral pleura, should be carefully observed under thoracoscopy. Application of minithoracotomy-associated thoracoscopic surgery is a useful method in the case to whom catamenial pneumothorax is definite or suspected.     

Diaphragmatic endometriosis-associated pneumothorax triggered by abortion; report of a case

The patient was a 36-year-old woman. She had previously undergone surgery for hysteromyoma and endometriosis. At 8 week of pregnancy, the fetus's heart stopped beating, and the woman underwent abortion. On the same day, she began experiencing difficulty in breathing in the evening. After 4 days, she was referred to our hospital with dyspnea. Chest X-ray finding showed a right pneumothorax. Tube toracotomy was performed, and the right lung re-expanded immediately. Two months later, pneumothorax recurred without any association with the menstruation cycle. Thoracoscopic surgery was performed. No lesion was detected in the lung or visceral pleura, but a small hole and some thinned areas were noted in the diaphragm. Partial resection of the diaphragm was performed. Microscopic examination revealed endometriosis and localized lymphocyte infiltration in the resected diaphragm. It was suggested that the recurrence of pneumothorax without menstruation was caused by the thinning of the diaphragm due to endometriosis.     

Spontaneous pneumothorax in a patient with dendriform pulmonary ossification: report of a case

We report herein the rare case of a patient with dendriform pulmonary ossification (DPO) who developed spontaneous pneumothorax. A 33-year-old male with a history of bronchial asthma presented with pneumothorax of the left lung. An intraoperative inspection revealed no findings of bullae in the entire left lung, but inflammatory pleural changes were identified on the interlobular surface of the left lower lobe. In addition, hard, twig-like configurations were clearly palpable in the subpleural parenchyma and were resected. A histological examination showed acicular bone formations containing myeloid tissue and marrow fat in the lung. DPO was thus diagnosed, and the bony spines were considered to have caused a rupture of the elastic fiber layer of the visceral pleura. DPO may thus have been directly responsible for the pneumothorax in this case.     

Chronic spontaneous pneumothorax due solely to a pleurovisceral membrane. A case report.

The case of a 28-year-old male with a neglected and protracted spontaneous pneumothorax is reported. The condition was diagnosed 45 days after the onset of symptoms. The affected lung had completely collapsed and was unexpandable. Subsequent thoracotomy revealed a firm membrane covering the visceral pleura as the sole explanation of the persistent pulmonary collapse. This variety of chronic pneumothorax seems to be rare. The lung expanded completely after decortication.     

Catamenial pneumothorax

We report 3 cases of catamenial pneumothorax, with review of the literatures. Case 1: A 38-year-old female had recurrent right-sided pneumothorax in February 2001. Videothoracoscopic visualization showed multiple small fenestrations in central tendon of diaphragm. A partial diaphragmatic resection including the lesions was performed. She received hormone therapy postoperatively. Case 2: A 40-year-old female with past history of ovarian endometriosis had recurrent right-sided pneumothorax in 1993. During the operation, multiple diaphragmatic fenestrations and bullae of right middle and lower lobes were identified. The lesions were resected and postoperative hormone therapy was performed for 6 months. In 1997, right-sided pneumothorax recurred. She underwent surgical procedure due to prolonged air leakage from the right lung. During the operation, a diaphragmatic fenestration and bulla of apex of right upper lobe of the lung were visualized. Diaphragm was reefed and bulla was resected. After that, she had no recurrence of pneumothorax. Case 3: A 39-year-old female had recurrent right-sided pneumothorax in 2003. Under video-assisted thoracoscopic surgery, multiple fenestrations of central tendinous diaphragm were identified. Diaphragmatic partial resection was performed. Postoperatively, she received hormone therapy for 6 months. After hormone therapy, she suffered from recurrent pneumothorax, and underwent an operation. During the operation, she had endometriosis of visceral pleura without diaphragmatic fenestration. Once again, she received postoperative hormone therapy. Catamenial pneumothorax is a rare disease, and the definite etiology has not been clarified. A combination of both surgical and hormone therapy is useful for treatment.     

Unsuspected lung cancer accompanied by catamenial pneumothorax.

A 45-year-old nonsmoking woman with repeated coughing and dyspnea on effort was admitted to our hospital diagnosed with right-sided pneumothorax on chest X-ray. Chest computed tomography showed neither bullae nor nodules. Chest drainage failed to completely reexpand the lung, necessitating video-assisted thoracic surgery. Thoracoscopy showed pleural thickening in the apical segment without bullae or air leakage, dark-brown pigmentation of the diaphragm, and an unsuspected small nodule about 5 mm in diameter on the diaphragmatic surface of the right lower lobe. Pneumothorax was treated by mechanical abrasion of parietal pleura and upper lobe wedge resection. The lower lobe and nodule were wedge-resected using staplers. The nodule was bronchioloalveolar carcinoma of Noguchi's type B. To improve curability and check for diaphragmatic lesions, right posterolateral thoracotomy was conducted on post-video-assisted thoracic surgery day 28. Aggressive intraoperative lymph node exploration yielded no remarkable histological findings. Nonanatomical lower lobe wedge resection was done and the diaphragm with pinhole-like perforations was partially resected. The resected lung showed no cancerous tissue. Endometrial tissue was histologically confirmed in the resected diaphragm. The patient has remained asymptomatic in 14-month follow-up. This is, to our knowledge, the first lung cancer accompanied by catamenial pneumothorax.     

Endometriosis externa thoracalis

The incidence of endometriosis is between eight and 15 percent among sexually mature women, with peaks being in the third and fourth decades of age. External thoracic endometriosis is associated with implantation of endometrial tissue into lung, pleura, bronchial system, and diaphragm. Major indicators symptoms of thoracal endometriosis include haemoptysis, thorax pain, recurrent spontaneous pneumothorax, and haemorrhagic pleural effusion, with all these manifestations being temporally coordinated with menstruation. Bronchoscopy and radiography are used for diagnosis, while surgery, hormonal treatment, and radiotherapy are used for therapeutic action. One patient with systemic endometriosis is reported in greater detail in this paper.     

An unusual pleural cyst in a child presenting as a pseudo-pneumothorax. Case report

This case highlights an unusual pleural cyst in a 3-year-old child that simulated a pneumothorax on chest radiograph. The child presented with mild respiratory distress and the 'pneumothorax' failed to respond to pleural intubation. At thoracotomy, a 10 cm air-filled cyst was found attached to the visceral pleura by a narrow pedicle. This was transfixed and divided, with removal of the cyst. Postoperatively, the lung expanded and the child recovered without any sequelae. Histological examination of the cyst showed it to be lined with mesothelial cells. It is suggested that this cyst arose from a mesothelial inclusion cyst or sub-mesothelial pleural tissue, which communicated with the peripheral lung tissue.     

Catamenial pneumothorax: chest X-ray sign and thoracoscopic treatment

We report the case of a 25-year-old woman with recurrent right-sided catamenial pneumothorax. At thoracoscopy, the diaphragm presented several violet implants with holes. The presence of diaphragmatic endometrial implants was confirmed at pathologic examination. Re-review of the preoperative chest x-ray film showed 8 x 5 and 1 x 1 mm bubbles at the level of the right diaphragm associated with the homolateral pneumothorax, thus suggesting that passage of air from the genital tract through the diaphragm was responsible for the pneumothorax. This may further clarify the pathogenesis of catamenial pneumothorax which remains controversial in the literature.     

A case of multiple synchronous localized fibrous tumor of the pleura.

We report a patient with two synchronous distinct masses in the same hemithorax both of which got the diagnosis of benign localized fibrous tumor of the pleura. The plain chest X-ray was rather obscured due to a large left-sided pleural effusion, but her subsequent computerized chest tomography revealed a heterogeneous hypodense soft tissue mass, which was pleural in origin, sitting on the diaphragm bathed in fluid. At thoracotomy, we detected two distinct masses in the left hemithorax, both arising from the visceral pleura via their vascular pedicles.     

Catamenial pneumothorax.

Consistent clinical features of catamenial pneumothorax are its recurrent nature, repeated involvement of the right hemithorax, and a temporal relationship to the onset of menstruation. A personal case with endometrial implants and defects of the the diaphragm is presented. A review of the entire 41 cases reported in the literature reveals that the syndrome is more common than previously believed; there is a definite relationship with endometriosis; and the air allowing the pneumothorax does not appear to enter the chest by way of the genital tract, as originally postulated.     

A case report of thoracic endometriosis – A rare cause of haemothorax

IntroductionThe presence of endometrial tissue in airways, pleura and lung parenchyma is called thoracic endometriosis syndrome (TES). It is a rare pathology, and typically consists of catamenial pneumothorax, haemothorax, haemoptysis, and pulmonary nodules. We report a case of a 36-year-old woman with thoracic endometriosis causing catamenial haemothorax.ConclusionsThe diagnosis of thoracic endometriosis is complicated and often delayed. TES should be suspected in a reproductive age woman with exacerbating symptoms during the menstruation.Treatment may be medical and surgical.     

A case of simultaneous bilateral spontaneous pneumothorax after the Nuss procedure

We present a case of simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication formed from Nuss procedure for pectus excavatum. A 17-year-old man with a history of Nuss operation complained chest pain and dyspnea. A chest roentgenogram demonstrated a tiny bilateral pneumothorax and two metallic bars inserted at the Nuss procedure. Computed tomography revealed furthermore a bulla in the apex of the left lung. The bilateral pneumothorax critically deteriorated after 4 days from onset and urgent bilateral chest drainages were performed. Nevertheless the drainages the full expansion of both lungs was not obtained and air leakage only from left side was continued. A video-assisted left bullectomy was performed 9 days after the tube insertion. The two bars penetrating anterior mediastinal pleura were thought to be a cause of the simultaneous bilateral spontaneous pneumothorax.     

Pneumothorax at menses caused by concomitant diaphragmatic endometriosis and a leaking bulla: a case report

Menses-associated pneumothorax has largely been attributed to thoracic endometriosis. We report a case of a 37-year-old woman who presented with a right pneumothorax during menses and was found, on thoracoscopy, to have diaphragmatic endometriosis causing fenestrations in the tendinous diaphragm and a pulmonary bulla. A water-seal test demonstrated an air leak from the bulla. The patient then underwent a video-assisted thoracoscopic resection of the bulla and the involved portion of the diaphragm. Pathologic examination of diaphragmatic lesions demonstrated endometrial glands. The patient was treated with chemical pleurodesis and hormonal suppression of her endometriosis. She is currently symptom-free at 12?months of follow-up.     

Experience with invasive thymoma presenting pleural dissemination

A 61-year-old man was admitted to Showa University Hospital because of a myasthenia gravis. Chest computed tomography revealed a mediastinal invasive tumor. During surgery, invasion to the pericardium and dissemination on the left visceral pleura and the left diaphragm were observed. Extended thymo-thymectomy and partial resection of the pericardium, left lung, and diaphragm were performed. Incomplete resection was achieved because of the dissemination on the diaphragm. Chemotherapy using ADOC and radiotherapy for mediastinum and left diaphragm were done. Four years after surgery, neither recurrence of the tumor nor myasthenia gravis was observed.     

Pneumothorax and insertion of a chest drain

A pneumothorax occurs when the visceral or parietal pleura is breached and air enters the pleural space. This leads to loss of the negative intrapleural pressure and lung collapse. Pneumothoraces may be classified into ‘simple’, ‘tension’ or ‘open’ according to the underlying pathophysiology. A chest radiograph is essential in diagnosis and management. Tension pneumothorax is a medical emergency, relieved initially with needle thoracentesis, but treated definitively with a chest drain. The latter is inserted in all cases where aspiration is unsuccessful in controlling symptoms in a simple pneumothorax. A thoracic surgical opinion should be sought if there is persistent air leak from the drain or the lung fails to re-expand after three days.A chest drain is used to drain air, blood, fluid or pus from the pleural space. Proper attention should be paid to patient preparation, which should include full asepsis, appropriate patient positioning, and application of National Patient Safety Agency recommendations. A chest drain is usually inserted under local anaesthesia in the ‘safe triangle’ in the lateral chest wall using blunt dissection. The drains should not be clamped in cases of pneumothorax, and the drainage bottle should always be kept below the level of the patient’s chest.