Catamenial Hemothorax Diagnosis Obscured by Vats Biopsy

Abstract

Hemothorax is most commonly caused by trauma, but can also result from iatrogenic injury, rupture of pleural adhesions, neoplasm, complication of anticoagulation, aneurysmal rupture, rupture of pulmonary vascular malformations, endometriosis, and exostoses. A recurrent right-sided hemothorax, with a temporal relation to menses, in a young female distinguishes thoracic endometriosis from other etiologies. Video assisted thoracoscopic Surgery (VATS) is thought of as the definitive diagnostic procedure for the diagnosis of thoracic endometriosis. We present a case of a young female with a recurrent right sided hemothorax, whose diagnosis was obscured by two negative pleural biopsies obtained via VATS. CASE PRESENTATION:A 36-year-old female with a history of pulmonary embolism s/p anticoagulation, presented with recurrent dyspnea on exertion, pleuritic chest pain, and a bleeding umbilical mass, worsened by menses. She had a history of three years of recurrent right-sided hemorrhagic pleural effusions of unknown etiology. She had undergone right pleurectomy via VATS two years prior. The biopsy showed pleural tissue with mesothelial cell hyperplasia and chronic inflammation. A repeat VATS was performed one year later, with conversion to open thoracotomy, and biopsy of a nodule demonstrated a foreign body reaction, most likely to talc. No endometrial tissue was found. Patient underwent thoracoscopic decortication at this time. During her work up, the patient had been trialed on Depo Provera, without improvement. Biopsy of her umbilical mass demonstrated endometriosis and the presumptive diagnosis of thoracic endometriosis syndrome was made, with plans to start the patient on GnRH antagonist therapy.DISCUSSION: Catamenial hemothorax can result from ectopic endometrial tissue implantation directly in the pleural cavity or from abdominal implantations that bleed into the pleural cavity in a retrograde manner. In both cases, disease manifestation fluctuates temporally with menses. For this reason, VATS biopsies may have limited ability to rule out thoracic endometriosis in the workup of hemothorax. McCann et al. further elaborate on the limitations of VATS in diagnosis of catamenial hemothorax by identifying a decrease in diagnostic yield when a biopsy is performed outside of menstruation which they attribute to degradation and autolysis of the proliferative tissues approximately 48 hours after menstruation.CONCLUSIONS: This case illustrates the use VATS biopsy can be misleading in diagnosing catamenial hemothorax due to the various implantation sites and the temporal fluctuations of ectopic endometrial tissue.