Recurrent catamenial hemopneumothorax caused by diaphragmatic endometriosis not identified by chest X-ray or CT scan: a case report and literature review

Thế Trường Mạc, Dinh Dat Van, Thị Phương Lan Đoàn, Hoan My Pham, Gia Khanh Ngo
In: European Journal of Case Reports in Internal Medicine · 2026 · doi:10.12890/2026_007519 · W7222957182
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Video-assisted thoracoscopic surgery diagnosed and treated diaphragmatic endometriosis causing catamenial hemopneumothorax in a patient with negative chest imaging, confirming the utility of VATS for definitive management.

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This case report and literature review describes a 44-year-old woman with recurrent catamenial hemopneumothorax that was not identified by standard chest X-ray or CT imaging. Video-assisted thoracoscopic surgery revealed diaphragmatic endometriosis, characterized by dark-red nodules and a diaphragmatic defect, which was subsequently resected and repaired. The authors emphasize that early recognition of the temporal link between thoracic symptoms and menstruation is critical for diagnosis when radiological findings are nonspecific. This paper is centrally about endometriosis — specifically thoracic endometriosis syndrome involving diaphragmatic lesions causing catamenial hemopneumothorax.

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Abstract

Introduction: Thoracic endometriosis syndrome (TES) is a rare extrapelvic manifestation of endometriosis. Catamenial hemopneumothorax secondary to diaphragmatic endometriosis is particularly uncommon and remains a diagnostic challenge because of its nonspecific clinical and radiological findings. Early recognition of the temporal relationship between thoracic symptoms and menstruation is essential for timely diagnosis and management. Case description: A 44-year-old woman presented with recurrent right-sided hemopneumothorax occurring within 72 hours of menstruation onset. Chest radiography and computed tomography demonstrated right pleural effusion and pneumothorax but failed to identify the underlying cause. Because of recurrence, video-assisted thoracoscopic surgery (VATS) was performed. Intraoperative findings included approximately 500 ml of old blood in the pleural cavity, multiple dark-red nodules on the right hemidiaphragm, and a 1-cm diaphragmatic defect. The affected diaphragmatic tissue was resected using an endoscopic stapler, followed by diaphragmatic repair and pleurodesis. Histopathological examination confirmed diaphragmatic endometriosis. The postoperative course was uneventful, and no recurrence was observed during a 3-month follow-up period. Conclusion: Diaphragmatic endometriosis should be considered in women of reproductive age presenting with recurrent hemopneumothorax, particularly when episodes coincide with menstruation. VATS plays a pivotal role in both diagnosis and treatment by enabling direct visualization of diaphragmatic lesions, definitive histopathological confirmation, and simultaneous surgical management.
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Keywords

Thoracic endometriosis syndrome, diaphragmatic endometriosis, catamenial hemopneumothorax, video-assisted thoracoscopic surgeryAbstract

Introduction

Thoracic endometriosis syndrome (TES) is a rare extrapelvic manifestation of endometriosis. Catamenial hemopneumothorax secondary to diaphragmatic endometriosis is particularly uncommon and remains a diagnostic challenge because of its nonspecific clinical and radiological findings. Early recognition of the temporal relationship between thoracic symptoms and menstruation is essential for timely diagnosis and management. Case description: A 44-year-old woman presented with recurrent right-sided hemopneumothorax occurring within 72 hours of menstruation onset. Chest radiography and computed tomography demonstrated right pleural effusion and pneumothorax but failed to identify the underlying cause. Because of recurrence, video-assisted thoracoscopic surgery (VATS) was performed. Intraoperative findings included approximately 500 ml of old blood in the pleural cavity, multiple dark-red nodules on the right hemidiaphragm, and a 1-cm diaphragmatic defect. The affected diaphragmatic tissue was resected using an endoscopic stapler, followed by diaphragmatic repair and pleurodesis. Histopathological examination confirmed diaphragmatic endometriosis. The postoperative course was uneventful, and no recurrence was observed during a 3-month follow-up period.

Conclusion

Diaphragmatic endometriosis should be considered in women of reproductive age presenting with recurrent hemopneumothorax, particularly when episodes coincide with menstruation. VATS plays a pivotal role in both diagnosis and treatment by enabling direct visualization of diaphragmatic lesions, definitive histopathological confirmation, and simultaneous surgical management.

References

- Nezhat C, Nicoll LM, Bhagan L, Huang JQ, Bosev D, Hajhosseini B, et al. Endometriosis of the Diaphragm: Four Cases Treated with a Combination of Laparoscopy and Thoracoscopy. J Minim Invasive Gynecol. 2009;16(5):573–80. doi:10.1016/j.jmig.2009.06.012. - Korom S, Canyurt H, Missbach A, Schneiter D, Kurrer MO, Haller U, et al. Catamenial pneumothorax revisited: Clinical approach and systematic review of the literature. J Thorac Cardiovasc Surg. 2004;128(4):502–8. doi:10.1016/j.jtcvs.2004.04.039. - McKee DC, Mansour T, Wasson MN. Thoracic and diaphragmatic endometriosis: an overview of diagnosis and surgical treatment. Curr Opin Obstet Gynecol. 2022;34(4):204–9. doi:10.1097/GCO.0000000000000792. - Ciriaco P, Muriana P, Carretta A, Ottolina J, Candiani M, Negri G. Catamenial Pneumothorax as the First Expression of Thoracic Endometriosis Syndrome and Pelvic Endometriosis. J Clin Med. 2022;11(5):1200. doi:10.3390/jcm11051200. - Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med. 1996;100(2):164–70. doi:10.1016/s0002-9343(97)89454-5. - Aissa S, Benzarti W, Alimi F, Gargouri I, Salem HB, Aissa A, et al. Catamenial pneumothorax revealing diaphragmatic endometriosis: a case report and revue of literature. Pan Afr Med J. 2017;27:112. doi:10.11604/pamj.2017.27.112.8007. - Bobbio A, Canny E, Lupo AM, Lococo F, Legras A, Magdeleinat P, et al. Thoracic Endometriosis Syndrome Other Than Pneumothorax: Clinical and Pathological Findings. Ann Thorac Surg. 2017;104(6):1865–71. doi:10.1016/j.athoracsur.2017.06.049. - Dong B, Wu CL, Sheng Y liang, Wu B, Ye GC, Liu YF, et al. Catamenial pneumothorax with bubbling up on the diaphragmatic defects: a case report. BMC Womens Health. 2021;21:167. doi:10.1186/s12905-021-01318-0. - Ganesan PR, Kang D, Khan Z, Milteer HB. Diaphragmatic Endometriosis Presenting as Recurrent Catamenial Pneumothorax: A Case Report. Cureus. 15(9):e45179. doi:10.7759/cureus.45179. - Koh E, Nakazawa T, Nakajima Y. Catamenial pneumothorax with histologically proven diaphragmatic endometriosis successfully managed by combined surgical resection and hormonal therapy: A four-year recurrence-free case. Respir Med Case Rep. 2025;58:102323. doi:10.1016/j.rmcr.2025.102323.

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