대한흉부영상의학회 Weekly Chest Cases

Case No : 1058 Date 2018-02-05

Courtesy of Ho Young Park, MD., Eun Jin Chae, MD. / Asan Medical Center, University of Ulsan College of Medicine
Age/Sex 48 / F
Chief ComplaintRight pleuritic chest pain, dyspnea 2 days ago

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2017-8-1

Diagnosis With Brief Discussion

Diagnosis: Catemenial Pneumothorax
Radiologic Findings: Fig 1. Chest PA shows 1st episode of right pneumothorax and atelectasis of right lower lobe (2017-08-01)
Fig 2. Chest PA shows 2nd episode of right pneumothorax and atelectasis of right lower lobe (2017-09-01)
Fig 3. Chest PA shows 3rd episode of right pneumothorax and atelectasis of right lower lobe (2018-01-08)
Fig4. Lung window setting of chest CT scan shows right pneumothorax. There is no parenchymal lesion in both lungs.
Fig 5. Thorough history from the patient revealed that her symptoms began during menses at each episode. Catamenial pneumothorax was clinically suspected. Explorative VATS was performed. Intraoperative finding showed multiple pores at the right diaphragm, suggesting catamenial pneumothorax. The result of excisional biopsy of the diaphragm was mild chronic inflammation and no endometriotic tissue was documented.
Brief Review: Catamenial pneumothorax (CP) is a spontaneous recurring pneumothorax that occurs in women and is correlated with menses. CP was generally considered a rare entity. Its incidence in large epidemiological studies is only 3-6%. It is believed that CP is underdiagnosed and the incidence of CP has been often underestimated. CP involves the right side in the vast majority of cases. It can be left sided or rarely may be bilateral.
CP etiology is most likely multifactorial in origin involving a combination of different mechanisms. Currently, three different mechanisms have been proposed, namely: (1) transdiaphragmatic passage of peritoneal air, originating from the genital tract, through the fallopian tubes; (2) sloughing of endometrial implants from the visceral pleura, with subsequent air leakage; and (3) alveolar rupture due to prostaglandin-induced bronchiolar constriction or obstruction by bronchiolar endometrial implants. Transdiaphragmatic passage of air is currently the most widely accepted hypothesis, although it cannot explain every case. Cervical mucus plug liquefaction during the menstrual period allows passage of external air through the uterine cavity into the peritoneal one. Air may then reach the pleural space through diaphragmatic fenestrations, helped by negative intrathoracic pressure, implying the occurrence of pneumoperitoneum as an intermediate step.
The typical clinical presentation of CP involves spontaneous pneumothorax during or preceding menses, usually manifested with pain, dyspnea and cough.
Although there are generally no specific diagnostic imaging criteria, CT remains the first-line imaging method, as it can rule out other diagnoses and map the lesions for surgery if necessary. Diaphragmatic implants may appear as hypo-attenuating areas on CT, sometimes associated with an iso-attenuated component, depending on the size and blood content. Other rare imaging findings include pneumoperitoneum co-existing with right pneumothorax, small diaphragmatic defects, nodular appearance of the diaphragm on chest X-ray and CT corresponding to partial intrathoracic liver herniation.
Characteristic operative findings include diaphragmatic defects, and/or spots or nodules (usually endometrial implants) on the diaphragm, and/or the visceral and/or the parietal pleura.
Endometriosis tissue may or may not be found in the characteristic lesions. The spots and nodules are usually found to be endometrial implants. Endometrial tissue has been also found at the edges of the diaphragmatic defects, which may represent cyclical breakdown of endometrial implants. However, macroscopic evidence of thoracic endometriosis and furthermore histologically proven thoracic endometriosis is not revealed in all cases of catamenial pneumothorax.

For treatment, partial diaphragmatic resection and/or resection of visceral pleural implants, and pleurodesis, are frequently performed. In addition, hormonal treatment (GnRH) immediately after surgery is now suggested for all patients with proven CP.
References: 1. Visouli AN, Darwiche K, Mpakas A e al. Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature. J Thrac Dis. 2012;4:17-31
2. Rousset P, Rousset-Jabloski C, Alifano M et al. Thoracic endometriosis syndrome: CT and MRI features. Clinical Radiology. 2014;69:323-330
Keywords: Pleura, Others,

No. of Applicants : 98

▶ Correct Answer : 59/98, 60.2%

- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- Hyogo Prefectural Amagasaki General Medical Center , Japan TOMOAKI OTANI
- Showa university Northern Yokohama Hospital , Japan KOTA WATANABE
- Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
- Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
- Niigata University , Japan ATSUSHI UEHARA
- Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
- NIMS, Hyderabad , India AMIT DADHANIA
- Gifu University Hospital , Japan TOMOHIRO ANDO
- , Korea (South) HANKYUL KIM
- McGill University Health Center , Canada Alexandre Semionov
- The University of Tokyo Hospital , Japan Yusuke Watanabe
- , Korea (South) SUYON CHANG
- Chonnam National University Hospital , Korea (South) MOON GYEONG IL
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Other , Korea (South) HEE SEOK CHOI
- Freelance resident in Reunion Island , Reunion Fabien HO
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Beaulieu clinic Geneva , Switzerland gilles GENIN
- The Jikei university , Japan TAKU GOMI
- Onomichi municipal hospital , Japan Hirofumi Mifune
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Yonsei University, Wonju Severance Christian Hospital , Korea (South) JUYEON LEE
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Gifu University Hospital , Japan Yo Kaneko
- Samsung Medical Center , Korea (South) MIN YEONG KIM
- Okayama Red Cross Hospital , Japan KAZUAKI MUNETOMO
- Kurashiki Central Hospital , Japan TORU KONISHI
- , United Kingdom KRISHNA PRASAD PREMNATH BELLAM
- The University of Tokyo Hospital , Japan RYO KUROKAWA
- Medicheck health care , Korea (South) Chae hun Lim
- Other , Korea (South) JIN YOUNG KIM
- CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Yonsei University,Severance Hospital , Korea (South) KYUNGSUN NAM
- Kyemyung University Dongsan Hospital , Korea (South) NAM YEOKYOUNG
- Multimagem Diagn泥sticos , Brazil PEDRO PAULO TEIXEIRA E SILVA TORRES
- Wuhan Union Hospital , China QIGUANG CHENG
- , Korea (South) YOUNG EUN BAHN
- The University of Tokyo Hospital , Japan TAKU TAJIMA
- Yujin Yamazaki Hospital , Japan MASASHI TAKAHASHI
- University of New South Wales , Australia RASHID HASHMI
- Escola Paulista de Medicina , Brazil RENATO MASSON DE ALMEIDA PRADO
- District TB centre, kasaragod,India , India rikhy krishnan
- Korea university medical center, guro hospital , Korea (South) Lee kyu chong
- Fortis hospital , Mohali , India SHALEEN RANA
- Kizawa Memorial Hospital , Japan Shoji Okuda
- Teikyo University Hospital , Japan KAORU SUMIDA
- Kyoto Prefectural University of Medicine , Japan TADASHI TANAKA
- , Korea (South) TAE SUN KANG
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
- Private sector , Greece VASILIOS TZILAS
- Hamamatsu university school of medicine , Japan YUKI HAYASHI
- Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
- University of Utah , United States AKIHIKO SAKATA
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 6/98, 6.1%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- MD , India DEEPANDER SINGH RATHORE
- Mallinckrodt Institute of Radiology , United States Naganathan BS Mani
- Azienda Ospedaliera di Cremona , Italy Pietro Sergio
- MBAL BURGAS , Bulgaria VLADISLAV BOYANOV RUSINOV
- Radiology resident , India SITHANTHA SEELAN

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1058 Date 2018-02-05

Discussion

No. of Applicants : 98