{"paper_id":"ecd7693c-d581-44b0-998d-116b6b4608d3","body_text":"Endometriosis usually involves the pelvic organs and surrounding peritoneum. Thoracic\nendometriosis syndrome (TES) is a rare extra-pelvic involvement of the pleura or lung. It\nshould be considered in a reproductive-age female presenting with anemia, shortness of\nbreath, and pleural effusion. Management involves medical and surgical interventions to\nsuppress endometrial activity.\n\nA 21-year-old female with no significant past medical history presented to the emergency\nroom with progressive abdominal distension and bloating for 9 months. She also had\nright-sided upper abdominal cramps. In the last month, she also started having progressive\nshortness of breath on exertion. Her menstruation had been regular, but she had noticed new\ncramps associated with vomiting and rectal pain during her menstruation. She also\nexperienced progressive shortness of breath with exertion in the month prior to arrival. She\nwas afebrile, blood pressure 113/91, heart rate 106, and oxygen saturation 97% on room air.\nHer physical examination was consistent with decreased breath sounds and dullness to\npercussion on the right side of the lung, along with distended abdomen with shifting\ndullness. She had a hemoglobin of 5.4 g/dL with a hematocrit of 20.8%. A chest x-ray showed\nmassive right pleural effusion with only a small amount of residual aeration of the right\nlung apex and a normal left lung. Computed tomography (CT) of the chest, abdomen, and pelvis\ndemonstrated massive right pleural effusion with a mediastinal shift along with a moderate\namount of abdominal and pelvic ascites ( Figure 1 ). She was given 2 units of packed red blood cells and underwent\nthoracentesis with the removal of 1250 mL of serosanguinous fluid which was consistent with\nan exudate as per light’s criteria. The total cell count of pleural fluid was\n788/mm 3 , and 64% were histiocytes, with plenty of red blood cells (RBCs). Her\ncytology showed hemorrhagic fibrinous material and reactive mesothelial hyperplasia\nsuggestive of endometriosis. She also developed an iatrogenic pneumothorax for which she\nbriefly had a chest tube placement. Subsequent diagnostic laparoscopy revealed dense\nadhesions in her pelvis, and the pathology was consistent with endometriosis. She received\nleuprolide acetate and norethindrone and is scheduled to follow-up as an outpatient with\nOB/Gyn.\n(a) Computed tomography of the chest showing a large right pleural effusion with\nleftward mediastinal shift. (b) Intra-abdominal laparoscopic view of the liver with\nsurrounding hemorrhagic ascites.\n\nEndometriosis is defined as the presence of endometrial-like glands and stroma outside the uterus. \n 1 \n  Pelvic endometriosis affects 5% to 15% of reproductive-age women. \n 2 \n  A rare progression of endometriosis is TES, and it is also the most frequent form of\nextra abdominopelvic endometriosis. 1 , 3  TES\npresents around the age of 34.2 ± 6.9 years, while pelvic endometriosis symptoms precede\nthis by 5 to 7 years. \n 4 \n  Of women diagnosed with TES, 50% to 84% have associated pelvic lesions; however, the\npercentage of women with pelvic disease prior to a TES diagnosis is largely unknown. \n 4 \n  In TES, functional endometrial tissue is found in the pleura, lung parenchyma, and\nairways, and may include clinical presentations such as catamenial pneumothorax, catamenial\nhemothorax, catamenial hemoptysis, and lung nodules. \n 5 \n  The pathophysiology of TES is likely multifactorial; however, the most prominent\ntheory is retrograde menstruation which suggests that endometrial cells move in a retrograde\nfashion through the fallopian tubes and into the peritoneal cavity where they implant on\nvarious surfaces. \n 1 \n  Patients typically develop symptoms 24 to 48 hours after the onset of menstruation,\nwith chest pain being the most common symptom, followed by dyspnea and hemoptysis. \n 5 \n  An updated review of 110 TES cases also found that pneumothorax was the most common\nclinical presentation (72%), while hemothorax occurred in 12% of cases and were mostly right sided. \n 6 \n  Diagnosis is based on clinical grounds; however, imaging such as chest X-ray and\nchest CT scans are useful. \n 5 \n  CT scan is the first-line imaging method since it can rule out other diagnoses and\nmap the lesions if surgery is required. \n 3 \n  Video laparoscopy (VL) is the gold standard for the diagnosis of diaphragmatic\nendometriosis, and video-assisted thoracoscopic surgery (VATS) is the gold standard for\nthoracic endometriosis. \n 1 \n  TES involves medical and surgical management. Medical treatment involves suppression\nof the ectopic endometrium. Gonadotropin-releasing hormone (GnRH) agonists, such as\nleuprolide, may be useful peri-operatively. 5 , 7  Although new GnRH antagonists can also be\nadministered, add-back treatment should be added to this therapy to reduce menopausal\nsymptoms. 1 , 8  Furthermore, VATS allows\nfor surgical management which can involve fulguration of lesions, sharp dissection, wedge\nresection, and even lobectomy. \n 1 \n  In this case, the patient underwent diagnostic laparoscopy with simultaneous VATS,\nand was placed on elagolix and leuprolide, along with norethindrone. Currently her symptoms\nremain controlled with leuprolide and norethindrone, and has continued to follow with\nthoracic surgery with no further pleural or parenchymal lung disease.","source_license":"CC0","license_restricted":false}