A Rare Case of Cyclical Hemothorax: Thoracic Endometriosis Syndrome

Abstract

Endometriosis is a common condition in which endometrial cells and stroma are deposited in extrauterine sites. Its prevalence has been estimated to be 10% of reproductive age females. It is commonly found in the pelvis; however, it may be found in the abdomen, thorax, brain, or skin. Thoracic involvement is a relatively rare presentation of this common disease. Thoracic endometriosis commonly presents as pneumothorax in 73% of patients. A rarer presentation of thoracic endometriosis is hemothorax (<14%) or hemoptysis (7%). Thoracic endometriosis is an uncommon cause of a pleural effusion. We present a case of 28-year-old African American female with no other medical conditions. She presented to the hospital with worsening right-sided pleuritic chest pain, dyspnea, and menorrhagia. She had been complaining of pleuritic chest pain for 5 years, the onset of which corresponds to the start of her menstrual cycle and is relieved with cessation of menses. Initial laboratory studies revealed a severe microcytic anemia with normal coagulation profile. Chest X-ray showed small right pleural effusion and suspicious for airspace disease. A computed tomography (CT) of chest was ordered for further clarification and identified large right pleural effusion. CT-guided thoracentesis removed 500 ml of serosanguinous fluid consisting of blood elements. There can be multiple sites involved with endometriosis and can present with wide range of symptoms that occur periodically with menses in young woman. The history and pleural fluid findings of this case are suggestive of Thoracic Endometriosis Syndrome. The diagnosis of this is often missed or delayed by clinicians, which can result in recurrent hospitalization and other complications. As internists we should be suspicious of atypical presentations of endometriosis and treat them early before complications develop. This case also highlights the importance of suspecting atypical etiologies for pleural effusion.

Endometriosis: A Clinicopathological Study in a Tertiary Care Hospital

“…EM affects an estimated 89 million women of reproductive age worldwide. 9 Discovered more than 100 years ago at the beginning of the 20th century, with the common name "adenomyosis externa," it is Thomas Cullen who deserves the credit. The term "endometriosis" was first used by John A. Sampson when observing bleeding of the lesions in the ovary while operating on women at the time of menstruation.…”

“…5 In 1860, Karl Von Rokitanski was the first to identify EM histologically under the microscope. 6,9 Various theories have been proposed in the etiopathogenesis for EM. Retrograde menstruation with regurgitation of endometrial cells into the peritoneal cavity still stands as the best explanation for most ectopic implants.…”

Thoracic Endometriosis With Catamenial Hemoptysis and Hemothorax: Long-Term Follow-Up After GnRH-a Treatment

“…Patients at initial workup are found to have pneumothorax (73%), hemothorax (14%), hemoptysis (7%), and pulmonary nodules (6%). 2 While the diagnosis of thoracic endometriosis syndrome (TES) is often delayed, especially when the temporal relationship between recurrent symptoms and menstruation is not recognized. 3 In our opinion, extensive and repeat surgeries are not good options.…”

“…5 Qianwei Zhen, BD 1 However, most patients acquire resistance against ALK inhibitors through different molecular mechanisms. 2 Analysis of circulating tumor DNA can be useful for the detection of resistant mutations. 3 We report here the case of a 70-year-old patient with ALK-positive NSCLC treated with crizotinib as part of the ALTA-1L trial.…”

Hemothorax and Hemorrhagic Ascites: A Rare Presentation of Endometriosis

“…1 Although it is typically confined to the pelvis, rare manifestations involving the thorax, abdomen or pericardium have been documented. [2][3][4][5] Even more rare is the concurrent presence of endometriosis-associated hemorrhagic pleural effusion and ascites, which can prove a diagnostic challenge. We describe a case of hemothorax and hemorrhagic ascites in a woman with shortness of breath and abdominal pain.…”