Catamenial Pneumothorax

Catamenial Pneumothorax The Roles of Diaphragmatic Defects and Endometriosis - B. SIMON SLASKY - RALPH D. SIEWERS - JAMES W. LACKY - ALBERT ZAJKO - JOHN A. BURKHOLDER Abstracts Recurring spontaneous pneumothorax in women, concurrent with the onset of menstruation, was first described in 1958. It was later called “catamenial pneumothorax.” Since 1958, 59 such cases have been reported in the medical literature in English. The present authors describe four additional cases which emphasize the role that fenestrations and endometriosis of the diaphragm play in the pathogenesis of the disorder. Case 1, a 38-year-old woman, gravida 3, para 2, had an 11-month history of recurrent right chest and back pain. Each episode was related to the onset of menses, and a right pneumothorax was documented on six occasions. The patient was menstruating when admitted, but her physical examination was otherwise unremarkable. Chest radiography showed no pneumothorax. A diagnostic pneumoperitoneum caused a 20 per cent right pneumothorax and the development of symptoms. Tho-racotomy was performed with excision of a localized area containing multiple perforations in the membranous part of the right hemidiaphragm. Dry sponge pleurodesis was performed also. Histology showed multiple small perforations with local histiocytic infiltrations but no evidence of endometriosis. The patient has been asymptomatic for 3 years since the operation. Case 2, a 35-year-old woman, gravida 3, para 3, had a 2-year history of right chest, shoulder, and arm pain. Each episode was related to the beginning of menses. A right pneumothorax was documented on several occasions. The patient was menstruating when examined. Decreased breath sounds were heard over the right hemithorax, and chest radiography confirmed a small pneumothorax. Thoracotomy revealed a cluster of 2− to 3-mm perforations in the right diaphragm, with one area of hyperpigmentation. The involved part of the diaphragm was excised, and dry sponge pleurodesis was performed. Histology showed areas of spindle-shaped endometrial stromal cells associated with abundant hemosiderin pigment deposits. No endometrial glands were found. This was interpreted as consistent with, but not diagnostic of, endometriosis. The patient has been asymptomatic for 2 years since the operation. Case 3, a 30-year-old woman, gravida 2, para 2, hao a 1-year history of recurrent right chest and shoulder pain related to the onset of menses. A right pneumothorax was documented twice. Physical examination was unremarkable except for the fact that the patient was menstruating at the time. Chest radiography revealed a small right pneumothorax which was resolved after a few days. Diagnostic pneumoperitoneum caused recurrence of symptoms and a small right pneumothorax. Transabdominal tubal ligation was performed. The patient has been asymptomatic for 1.5 years since the operation. Case 4, a nulliparous 36-year-old woman, had recurrent right chest pain for 4 years, always at the onset of menses. Pneumothoraces were confirmed by radiography on many occasions. These were always treated expectantly and never required a chest tube. There was no hemoptysis and no associated dyspnea. She complained of a sensation of bubbling across the lower right chest. The patient was menstruating at the time of examination. A right thoracotomy was performed, with excision of an area in the right diaphragm containing multiple small (2 to 3 mm) defects. These perforations were surrounded by hemosiderin pigment. Dry sponge pleurodesis was performed, and histology showed areas of hemosiderin, hemorrhage, and cells suggestive of endometrial stroma. No endometrial glands were seen. This was interpreted as consistent with, but not diagnostic of, endometriosis. The patient has had no recurrent pneumothoraces during her 12-month postoperative course.