Catamenial Pneumothorax: The Missing Link

Pneumothorax is a collapsed lung due to presence of air in the pleural cavity. In the absence of trauma, it is categorized as either primary or secondary spontaneous type. Primary spontaneous pneumothorax has no association with any pulmonary disease; secondary spontaneous pneumothorax (SSP) is caused by underlying lung disease. Catamenial pneumothorax is a SSP that occurs during perimenstruation thought to be associated with thoracic endometriosis. Less than 300 cases have been reported to date. No formal registry or guide for proper diagnosis and treatment algorithm is available. We are reporting a case of catamenial pneumothorax with recurrent symptomatology who suffered for 10 years due to the lack of association between timing of menstruation and spontaneous pneumothorax.A 29-year-old African American woman presented with one day history of persistent left-sided chest pain, accompanied by nonproductive cough, and increased shortness of breath at rest; she finished her menses three days prior. She had a chest tube inserted for spontaneous pneumothorax 10 years ago. Preliminary report of chest x-ray did not suggest evidence of pneumothorax; however, due to previous history of spontaneous pneumothorax, chest computerized tomography (CT) scan was pursued revealing a moderate size left pneumothorax. It also showed multiple bilateral pulmonary cysts and two small separate foci of pleural based tissue mass lesions adjacent to the diaphragm. Patient stated that she developed left upper back pain 4-5 separate incidences within the 10-year span of her first diagnosed pneumothorax. Chest x-rays were done during those occurrences but did not reveal any pneumothorax. At one point, patient was even sent for physical therapy with suspected muscle strain. She then recalled experiencing these symptoms toward the end of her menstruation. A thoracostomy tube was inserted; patient did well without supplemental oxygen. After two days, chest tube was removed, and patient was discharged home but did not follow up as outpatient. Six months later, she experienced another pneumothorax, and was then treated with pleurodesis. As far as we know, patient did not have any other episodes since that procedure.We present a case of catamenial pneumothorax with recurrent suffering that was misdiagnosed for 10 years. Despite appropriate menstrual history during medical interview, it is paramount to associate the possibility of this rare pneumothorax to menstruation to avoid this missed diagnosis. Formalizing a worldwide registry will standardize the way to enhance research into the true cause(s) and proper treatment algorithm for this rare, but possibly life-threatening, disorder.