MRI features of pleural endometriosis after catamenial haemothorax

Picozzi G, Giulia Picozzi, Beccani D, Davide Beccani, F. Innocenti, Innocenti F, Florio Innocenti, Michela Grazzini, Grazzini M, Mario Mascalchi, Mascalchi M
BMJ case reports · 2009 · vol. 2009 , pp. bcr0920080903 · doi:10.1136/bcr.09.2008.0903 · PMID:21686570 · PMC3030108 · W1982919467
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This case report describes MRI findings of pleural endometriosis in a patient with catamenial hemothorax, showing resolution after surgical treatment for endometriosis.

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This case report describes a 43-year-old woman with a history of pelvic endometriosis who presented with catamenial haemothorax, where initial video-assisted thoracoscopy and pleural fluid cytology failed to provide a diagnosis. Subsequent chest MRI performed during menstruation revealed a distinctive lesion in the right costophrenic angle characterized by homogeneous high signal intensity on T1- and T2-weighted images, which resolved after the patient underwent hysterectomy and oophorectomy. The authors highlight that while VATS is often non-diagnostic for this condition, MRI features coinciding with menses can support the diagnosis of thoracic involvement when clinical suspicion is high. This paper is centrally about endometriosis — specifically the rare thoracic manifestation known as pleural endometriosis presenting as catamenial haemothorax.

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Abstract

A 43-year-old multiparous woman with a history of pelvic endometriosis and myocardial infarction presented with acute onset of right hemithorax pain and dyspnoea coinciding with dysmenorrhoeic menstruation. A chest CT confirmed the presence of a right hydropneumothorax which was drained. A video-assisted thoracoscopy was unremarkable but at a subsequent menses, an MRI chest demonstrated a lesion in the right costophrenic angle. The patient underwent a hysterectomy and oophorectomy for treatment of endometriosis. Six months later, she was free of thoracic symptoms and a repeat MRI scan showed resolution of the right pleural abnormality.
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Abstract

A 43-year-old multiparous woman with a history of pelvic endometriosis and myocardial infarction presented with acute onset of right hemithorax pain and dyspnoea coinciding with dysmenorrhoeic menstruation. A chest CT confirmed the presence of a right hydropneumothorax which was drained. A video-assisted thoracoscopy was unremarkable but at a subsequent menses, an MRI chest demonstrated a lesion in the right costophrenic angle. The patient underwent a hysterectomy and oophorectomy for treatment of endometriosis. Six months later, she was free of thoracic symptoms and a repeat MRI scan showed resolution of the right pleural abnormality.

Background

This case describes the rare presentation of thoracic endometriosis and discusses the diagnostic utility of MRI in this condition CASE PRESENTATION A 43-year-old multiparous woman with a history of pelvic endometriosis and myocardial infarction presented with acute onset of right hemithorax pain and dyspnoea coinciding with dysmenorrhoeic menstruation. INVESTIGATIONS A non-contrast enhanced chest CT scan (fig 1) showed a right haemopneumothorax with floating clots within the fluid, which was drained. A video-assisted thoracoscopy (VATS) guided random pleural biopsy sample was negative. Magnetic resonance imaging (MRI) of the chest coinciding with menses 4 months later showed an oval-shaped lesion with homogeneous high signal intensity in T1- and T2-weighted images in the right posterior costodiaphragmatic recess (fig 2A, B). TREATMENT Owing to the relative contraindication for hormone therapy related to the coronary artery disease, the patient underwent a hysterectomy and oophorectomy for treatment of endometriosis. OUTCOME AND FOLLOW-UP Six months after her hysterectomy and oophorectomy she was free of thoracic symptoms and an MRI scan showed the disappearance of the right pleural abnormality.

Discussion

Pleural endometriosis typically presents in young women within 72 h of onset of menstruation as cata-menial pneumothorax, haemothorax or both. The diagnosis of thoracic endometriosis is usually based on clinical grounds but is often delayed. Cytological examination of the pleural fluid is usually not helpful and VATS is often negative.1,2 Although no pathological proof was available, the diagnosis of pleural endometriosis in our case was supported by the typical clinical presentation, the history of pelvic endometriosis, the MRI features distinctive of pleural endometriosis3 and the disappearance of the pleural MRI finding after surgical treatment of endometriosis. LEARNING POINTS VATS is often non-diagnostic in patients with catamenial haemo-thorax or haemopneumothorax. The MRI appearance of a pleural-based lesion exhibiting homo-geneous high signal in T1- and T2-weighted images is distinctive of pleural endometriosis. MRI after drainage of the pleural effusion and coinciding with menses could support the diagnosis of pleural endometriosis in women with catamenial haemothorax or haemopneumothorax. Acknowledgments This article has been adapted with permission from Picozzi G, Beccani D, Innocenti F, Grazzini M, Mascalchi M. MRI features of pleural endometriosis after catamenial haemothorax. Thorax 2007;62:744. Footnotes Competing interests: None.

References

- 1.Joseph J, Sahan SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 1996; 100: 164–70 [DOI] [PubMed] [Google Scholar] - 2.Johnson MM. Catamenial pneumothorax and other thoracic manifestations of endometriosis. Clin Chest Med 2004; 25: 311–9 [DOI] [PubMed] [Google Scholar] - 3.Cassina PC, Hauser M, Kael G, et al. Catamenial hemoptysis: diagnosis with MRI. Chest 1997; 111: 1447–50 [DOI] [PubMed] [Google Scholar]

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