Catamenial pneumothorax in Ghana: case report and literature review
Isaac Okyere1,&, Paul Sedem Komla Glover2, Paa Kobina Forson2, Perditer Okyere3, Delali Blood-Dzraku4
1Department of Surgery, School of Medicine and Dentistry, College of Health Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital, Kumasi, Ghana, 2Department of Emergency Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana, 3Department of Internal Medicine, School of Medicine and Dentistry, College of Health Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital, Kumasi, Ghana, 4MedFocus International, N0.39 Sam Nujoma Road, North Ridge, Accra, Ghana
Isaac Okyere, Department of Surgery, School of Medicine and Dentistry, College of Health Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital, Kumasi, Ghana
Catamenial pneumothorax is a rare condition that is often misdiagnosed. It is defined as spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. Etiology is unknown but could be linked to endometriosis. Pleural ablation via thoracoscopy and hormonal therapy are mainstay treatment options to avoid recurrence. We present a case of a young adult female who experienced gradual painless abdominal distention that resolved spontaneously after each menses twelve years post menarche. She was first seen at a peripheral facility where laparotomy undertaken was negative for suspected ectopic pregnancy. However, a bleeding omental mass was noticed and a biopsy taken. Histopathology reported it as an endometriotic tissue. The patient subsequently had recurrent cyclical chest pains and breathlessness leading to the diagnosis of catamenial pneumothorax. She had chemical pleurodesis done with sterile talc after chest tube drainage and has been well over two years now.
Spontaneous pneumothorax associated with menstruation is called catamenial
pneumothorax. It is defined as spontaneous pneumothorax occurring
within 72 hours before or after onset of menstruation. It is a rare condition
is often misdiagnosed and usually associated with endometriosis.
We report a case of a young woman with recurrent catamenial pneumothorax
chest tube drainage, sterile talc pleurodesis and hormonal therapy.
Recurrent nature of the condition causes significant morbidity. Correct
will lead to effective treatment and prevention of recurrence.
Patient and observation
A 25 year old nursing student presented to the Emergency Department
with right sided pleuritic chest pain and exertional dyspnoea.
Patient had menarche at 12 years and has been well until she started
painless abdominal distension when she was 21 years. This was not
associated with any gastrointestinal symptoms and therefore was
initially managed as
dysmenorrhea. In April 2011, she became dizzy, severely lethargic
and disoriented during her menses. She was initially seen at a
peripheral hospital where
she had a laparotomy after an ultrasound done confirmed a haemoperitoneum
though a urine pregnosticon test was negative. At laparotomy the
ovaries, fallopian tubes and uterus were found to be normal but
a bleeding mass was
noticed on the omentum which was excised for histopathology which
reported an endometriotic tissue. Subsequently, patient was well
and had no repeated
symptoms until March 2015 when she experienced heaviness in the
right chest with easy fatigability and dyspnoea during her menses.
A right haemothorax
was diagnosed and a chest tube inserted draining 2 litres of coffee-ground
coloured fluid over 48 hours at the same peripheral hospital. She
was subsequently referred to do a Chest CT Scan for specialist
care after being started on
oral contraceptive pills (OCPs). Her past medical and surgical
history was only significant for an epigastric hernia repair in
2007. Patient was not
sexually active at the time she first had symptoms. Her usual menstrual
cycle was 28 days with a moderate bleed lasting 5-6 days without
dysmenorrhea. The menstrual cycle got changed in 2011 to 3 days
of heavy bleed with clots
and dysmenorhoea. The cycle became normal when she was started
on OCPs. She had no family history of any bleeding disorder or
vitals on presentation were stable including SpO2 of 94% on room
air however there was decreased chest expansion and absent breath
sounds over the right
hemithorax. The CAT scan and chest x-ray showed massive right pneumothorax
with right lung collapse as shown in Figure
1 and Figure 2.
Subsequently, tube thoracostomy was done using a size 28 FG chest
tube which was inserted in the 4thintercostal space midpoint between
the anterior axillary
line and the mid-axillary line draining gush of air. Chemical pleurodesis
with 4 grams of sterile talc diluted to 50mls with normal saline
was administered into the pleural space via the chest tube using
a 60cc bladder syringe.
The chest tube was removed after 48 hours following full lung expansion
confirmed clinically and radiologically as shown Figure
3. She was then discharged for gynaecology follow up. She is doing
well without recurrence for over two years.
Catamenial pneumothorax is recurrent accumulation of air in the pleural
cavity in women of reproductive age without concomitant respiratory diseases.
The sine qua non criterion is the occurrence of the pneumothorax in the
period of 72 hours before or after the menses. Additional criteria include
characteristic pleural lesions, right-sided occurrence and coexistence of
endometriosis . The features in the above definition
were consistent with the findings in the case. It has always been considered
a rare cause of primary spontaneous pneumothorax with a reported incidence
of 2.8-5.6% . This is probably the first reported
case from Kumasi, Ghana as far as we know. Tettey et al. in 
report the first of such cases in Accra in 2005 with a subsequent review
of twelve cases by same Tettey et al. in 2013 in Ghana .
Recent studies suggest that this incidence in reality is around 30% ,
probably due to increased awareness. According to Marjanski T and his team
, the etiopathogenesis of catamenial pneumothorax
is explained by the following theories: physiological, migrational, microembolic-metastatic
and the diaphragmatic theory of air "passage" as shown in Table
1, but none of them can fully explain the different manifestations
of thoracic endometriosis syndrome (TES) which include catamenial pneumothorax,
catamenial haemothorax, catamenial haemoptysis, pulmonary nodule, catamenial
pneumomediastinum and isolated chest pain .
Endometriosis seems to play the most important role in the development of catamenial
pneumothorax. Catamenial pneumothorax is found to be associated with 31-50% of
pelvic endometriosis [1
] as was found in this patient. The
pneumothorax can progress to tension pneumothorax which is potentially fatal.
Treatment options for catamenial pneumothorax include: aspiration where air is
removed manually by way of a catheter or needle (catheter or needle thoracocentesis).
A similar approach is the use of a one-way Heimlich valve. The second option
is tube thoracostomy which involves the passage of a chest tube/chest drain into
the pleural space with application of suction and water seal drainage until the
lung re-expands. The third option is chemical sclerosis or pleurodesis where
a chemical agent or sclerosant is inserted through the chest tube after chest
drainage to cause chronic inflammation and scarring of the pleural surfaces promoting
adhesions to form between the lung and chest wall, thereby discouraging future
collapses. Chemical pleurodesis used alone to treat catamenial pneumothorax,
without other surgical repairs and/or hormonal therapy has been found to have
a significant failure rate [5
]. The fourth option is endometrial
suppression hormonal therapy which involves the use of progestins and gonadotropin
releasing hormone agonists (GnRH) most commonly, to induce chemical menopause
]. This is done after chest drainage.
Our patient underwent chest tube drainage and chemical pleurodesis as the mode
of management. The sixth option is the use of thoracoscopy/Video-assisted thoracic
surgery (VATS) which utilizes a fiber optic scope to visualize the lung, pleura
and diaphragm. Diaphragm repair, bleb resection and pleurodesis can all be done
during this procedure [2
]. Then pleural abrasion which is
mechanical pleurodesis involves abrading or "scrubbing" of the pleural surfaces
during thoracoscopy or thoracotomy, so that resulting inflammation will form
adhesions between the lung and pleural surfaces. Literature shows that pleurodesis
used as a singular treatment, without other surgical repair or hormonal therapy,
has a high failure rate [8
]. Our patient has been free from
recurrence after two years, having had the chest tube insertion and pleurodesis.
Another surgical option is thoracotomy with pleurectomy. Thoracotomy is performed
to view the lung, diaphragm and pleura directly by opening the lung cavity. A
pleurectomy is the removal of the pleura, which is designed to encourage adhesion
of the lung directly to the chest wall. During thoracotomy, diaphragmatic perforations
or fenestrations repair using polymesh can also be done [7
This procedure was introduced in 2003 and involves a vicryl-type mesh which is
placed over the entire diaphragm, to cover any small fenestrations that may not
be seen by the surgeon [7
]. The Vicryl material allows for
tissue in-growth forming substantial scar tissue over the diaphragm. Recent articles
indicate that this procedure is being used in Europe and US, and has been found
to be especially successful when used in conjunction with hormonal therapy [8
The other minimally invasive option is dual laparoscopic diaphragm evaluation
and repair. Understanding the complex nature of this condition, thoracic surgeons
and gynecologists utilize a dual laparoscopic procedure, whereby both the anterior
and posterior of the diaphragm are evaluated for endometrial progression. This
tandem approach reportedly improves chances of successful repair, when lesions
are removed from both sides. Lastly a bilateral salpingo-oophorectomy through
laparotomy or laparoscopy to remove both ovaries to induce surgical menopause,
thereby limiting estrogen production and suppressing endometrial implants from
] is also effective. Cessation of the menstrual
cycle has shown to be an effective treatment for catamenial pneumothorax, as
long as immediate estrogen replacement is withheld [9
for the management of catamenial pneumothorax, a chest tube should be inserted
after clinical assessment. This is followed with chemical pleurodesis and continued
with hormonal therapy. This combinational therapy is relatively effective in
less resource centres.
Catamenial pneumothorax should be suspected in every young woman presenting with pneumothorax or haemopneumothorax during menses. Diagnosis should be confirmed. Chest tube drainage releases the air and allows lung re-expansion. Chemical pleurodesis combined with hormonal therapy for at least six months may be adequate and effective in less resource centres. Surgery combined with hormonal therapy is the best option.
The authors declare no competing interests.
All authors have read and agreed to the final version of this manuscript and have equally contributed to its content and to the management of the case.
We are grateful to the patient who consented for the publication of the case and to the doctors and the nurses at the Accident and the Emergency Centre of the Komfo Anokye Teaching Hospital, Kumasi, Ghana and to Ms Sonia and her team at the Emergency Medicine Research Unit at the Komfo Anokye Teaching Hospital, Kumasi-Ghana.
Table and figures
Table 1: theories for the development of thoracic foci of endometriosis
Figure 1: chest x-ray showing massive right pneumothorax with right lung collapse and minimal effusion
Figure 2: the CAT scan showing massive right pneumothorax with right lung collapse and minimal effusion
Figure 3: a repeat chest x-ray after 48 hours showing adequate re-expansion
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