{"paper_id":"e0c5f12c-687a-4404-a8c0-4dabca12a061","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nEndometriosis is a benign condition in which endometrial stroma \nand glands are found outside the uterus. 1 The mean age at diagnosis \nvaries from 25 to 35years old 2,3 and the most common affected areas \nare the uterosacral ligaments, the rectouterine and vesicouterine \nexcavations, the uterine tubes, the sigmoid colon and the round \nligaments.4 Pleural endometriosis is a rare form of endometriosis \nand its incidence among general population is still unknown. It was \nobserved in less than 1% of the women who have had surgery due \nto a suspicion of pelvic endometriosis and in 3% to 6% of women \nwho have presented spontaneous pneumothorax. We report a case \nof a patient who presented catamenial hemothorax related to pleural \nendometriosis.5,6\nCase\nA 40year-old nulligravid female patient presented to the emergency \nroom with a 2month history of progressive dispnea associated to right \nthoracic pain. The patient was submitted to a relieve thoracocentesis \nwith drainage of 1.5liter of hematic liquid and then she was transferred \nto our service. Chest radiography revealed unlimited opacities in \nlower lobe of the right lung associated to ipsilateral costophrenic \nangle obliteration. Thus, the patient was submitted to exploratory \nthoracotomy which showed bloody pleural effusion. Pleural biopsy \nwas compatible with the dignosis of pleural endometriosis. On physical \nexam patient presented pulmonary auscultation with diminished \nvesicular murmur on lower third of right hemithorax. On gynecologic \nexam we observed endometrial implant on the posterior comissure of \nthe vagina as well as thickness of uterosacral ligaments. Transvaginal \nultrasound revealed a lesion on the right ovary measuring 4cm in \nlength and CA 125 level was 113.6. The patient is currently under \ntreatment with desogestrel and the pulmonary simptoms have been \nstable.\nDiscussion\nExtrapelvic endometriosis is a associated to a variety of symptoms \nwhich depend on the affected organs. 7 Thus, physical findings are \nrelated to the location and extension of the disease. 8 Diagnosis is \nmore accurate during menstruation. 9 In our report we suspected of \npleural endometriosis due to the cyclic pleural effusion and to the \nbloody fluid that was drained during the thoracocentesis procedure. \nThoracic endometriosis can be defined as presence of endometrial \nstroma and/or glands in the lung parenchyma and/or pleura, airways \nand diaphragm. Some procedures, such as thoracic tube aspiration, \nthoracotomy and bronchoscopy, can be used to identify endometrial \nimplants.10\nSymptoms tend to be cyclic and to be worsened during \nmenstruation. Clinical manifestations varies according to the affected \nareas. Thus, when endometrial implants occur in the pleura the \npatient may present catamenial pneumothorax or hemothorax. When \nthe lung parenchyma is affected the patient may present catamenial \nhemoptysis or assymptomatic lung nodules.11,12 As we observed in our \npatient, pleural implants are more frequent on the right side, possibly \ndue to cogenital defect of the right diaphragmatic hemi-cupula and the \ncontinuous fluid flow from pelvis to abdominal right upper quadrant. \nThey can present as a unique or as multiple implants and its length \nvaries from 1mm to some centimeters. Usually pleural implants are \nred colored. However they can also present in diferent shades of grey, \nincluding white. During bronchoscopy these implants can be seen in \nthe tracheaobrochial tree.13\nAlthough some risk factors for pelvic endometriosis have been \ndescribed, such as short menstual cycles, nulliparity, early menarche \nand late menopause, it is still unknown if they increase the risk of \nthoracic impairment. 14 The most common complementary test is \nthe chest radiography which might reveal frequent changes such as \npneumothorax, hemothorax with or without mediastinal deviation and \nparenchymatous nodules. 10 CT must be performed in symptomatic \npatients with normal chest radiography. Ca 125 level can also be \nMOJ Womens Health. 2017;5(6):313‒314. 313\n©2017 Lopes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nPleural endometriosis associated with catamenial \nhemothorax: a case report\nVolume 5 Issue 6 - 2017\nEdinari N de S Lopes, Lia CV da C Damasio, \nEdmund C Baracat, Allana Karine L Riberio \nSra, Janine L de M LJ Lopes Sra, Dennyse de \nMG Albuquerque\nDepartment of Gynecology, Universidade Federal do Piauí, \nBrazil.\nCorrespondence: Edinari Lopes, Universidade Federal do \nPiauÃ, Rua Pe Cirilo Chaves, Bairro Dos Noivos, T eresina-Piauã, \n1515, Brasil, T el +55(86)994653030, \nEmail edinarinunes@hotmail.com\nReceived: August 01, 2017  | Published: August 21, 2017\nAbstract\nPleural endometriosis is a rare condition that leads to anxiety and suffering on \naffected patients. We suspect of pleural endometriosis when pulmonary symptoms \nare associated with the menstrual cycle. We report a case of a 40year-old nulligravid \npatient who presented dispnea and thoracic pain during menstruation. The diagnosis \nwas confirmed based on biopsy performed during exploratory thoractomy procedure.\nKeywords: gynecology, endometriosis, hemothorax\nMOJ W omen’s Health\nCase Report\n Open Access\n\n\nPleural endometriosis associated with catamenial hemothorax: a case report\n314\nCopyright:\n©2017 Lopes et al.\nCitation: Lopes ENS, Damasio LCVC, Baracat EC, et al. Pleural endometriosis associated with catamenial hemothorax: a case report. MOJ Womens Health. \n2017;5(6):313‒314. DOI: 10.15406/mojwh.2017.05.00140\nelevated in those patients but this measure has low sensitivy and \nspecificity.15,16 Initial treatment for pleural endometriosis associated \nwith pleural effusion consists in urgent thoracic drainage. Significative \nhemorrhage is rare in patients with endometriosis, however, if more \nthan 20mL/kg is drained, urgent thoracotomy and segmentectomy \nof the endometrial implants must be performed. 17 Following these \nprocedures patient must receive hormonal therapy in order to \nsuppres ovarian steroidogenesis, which include oral contraceptives, \nprogestagen, danazol and GnRH agonist drugs. It is recommended \nthat the treatment lasts at least 6months. 10 Briefly we reported a rare \ncase of pleural endometriosis associated with catamenial hemothorax \nof which description and literature review allow other health \nprofessionals to be alert regarding this condition, its proper dignosis \nand treatment.\nAcknowledgements\nNone.\nConflict of Interests\nThe authors declare that they have no conflict of interests.\nReferences\n1. Fritz MA. Leon Speroff. Endocrinologia, ginecologia e infertilidade. \n2015;29:1259. \n2. Kuohung W, Jones GL, Vitonis AF, et al. Characteristics of patients with \nendometriosis in the United States and the United Kingdom. Fertil Steril. \n2002;78(4):767–772. \n3. Hediger ML, Hartnett HJ, Louis GM. Association of endometriosis with \nbody size and figure. Fertil Steril. 2005;84(5):1366–1374.\n4. Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin \nNorth Am. 1997;24(2):411–440.\n5. Guo SW, Wang Y . The prevalence of endometriosis in women with chronic \npelvic pain. Gynecol Obstet Invest. 2006;62(3):121–130.\n6. Viganò P, Parazzini F, Somigliana E, et al. Endometriosis: epidemiology \nand aetiological factors. Best Pract Res Clin Obstet Gynaecol . \n2004;18(2):177–200.\n7. Fritz MA. Leon speroff: endocrinologia. Ginecologia e infertilidade . \n2015;29:1272. \n8. Vercellini P, Trespidi L, De Giorgi O, et al. Endometriosis and pelvic pain: \nrelation to disease stage and localization. Fertil Steril . 1996;65(2):299–\n304.\n9. Koninckx PR, Meuleman C, Oosterlynck D, et al. Diagnosis of deep \nendometriosis by clinical examination during menstruation and plasma \nCA-125 concentration. Fertil Steril. 1996;65(2):280–287.\n10. Alifano M, Jablonski C, Kadiri H, et al. Catamenial and noncatamenial, \nendometriosis-related or nonendometriosis-related pneumothorax referred \nfor surgery. Am J Respir Crit Care Med. 2007;176(10):1048–1053.\n11. Barbosa BC, Marchiori E, Zanetti GMR, et al. Peneumotorax catamenial. \nRadiol Brasil. 2015;48(2):128–129.\n12. Costa F, Matos F. Endometriose torácica. Rev Port Pneumol. 2008;14:427–\n435.\n13. Channabasavaiah AD, Joseph JV . Thoracic endometriosis: revisiting \nthe association between clinical presentation and thoracic pathology \nbased on thoracoscopic findings in 110 patients. Medicine (Baltimore) . \n2010;89(3):183–188.\n14. Jose JV . Thoracic endometriosis: Pathogenesis, epidemiology, and \npathology. Up To Date; 2017.\n15. Rousset P, Rousset-Jablonski C, Alifano M, et al. Thoracic endometriosis \nsyndrome: CT and MRI features. Clin Radiol. 2014;69(3):323–330.\n16.  Tsunezuka Y , Sato H, Kodama T, et al. Expression of CA125 in thoracic \nendometriosis in a patient with catamenial pneumothorax. Respiration. \n1999;65(5):470–472.\n17.  Sevin ç S, Unsal S, Ozt ürk T, et al. Thoracic endometriosis syndrome \nwith bloody pleural effusion in a 28 year old woman. J Pak Med Assoc . \n2013;63(1):114–116.","source_license":"CC0","license_restricted":false}