CASE 14432 Published on 06.04.2017

Catamenial pneumothorax: A rare diagnosis


Chest imaging

Case Type

Clinical Cases


Sanjeet Kumar Shah1, Mahesh Chaudhary2, Sharzia Asma–Ul Hosna3 Md. Delwar Hossain4, Manabendra Biswas5

(1) Resident, MS (Cardiovascular and Thoracic Surgery), Phase-B, BSMMU
(2) Resident, MD (Radiology and Imaging), Phase-B, BSMMU
(3) Consultant Radiologist, Department of Radiology, LABAID Hospital, Dhaka
(4) Assistant Professor, Department of Thoracic Surgery, NIDCH
(5) Associate Professor, Department of Thoracic Surgery, NIDCH
*BSMMU= Bangabandhu Sheikh Mujib Medical University (Dhaka)
*NIDCH= National Institute of Diseases of Chest and Hospital (Dhaka)

Bangabandhu Sheikh Mujib Medical University;
Shahbagh 0088 Dhaka, Bangladesh;

34 years, female

Area of Interest Lung ; Imaging Technique Conventional radiography
Clinical History
A 34-year-old female patient presented with sudden onset of shortness of breath and left-sided chest pain for 2 days. She had a history of multiple episodes of similar symptoms every 30-40 days for the past 4 years and it was always followed by menstruation. A chest radiograph was performed.
Imaging Findings
The frontal chest radiograph revealed a left-sided pneumothorax for which Tube-thoracostomy was done. A previous radiograph showed a dense homogeneous opacity in the right middle and lower zone obliterating the right heart border and right dome of the diaphragm suggesting right-sided pleural effusion with chest tube drain in situ.
Catamenial pneumothorax (CP) is defined as recurrent pneumothorax (at least two episodes) occurring between the day before and within 72 hours after the onset of menstruation. It may affect up to one-third of women with spontaneous pneumothoraces [1]. It is encountered in 3-6% of spontaneous pneumothorax cases among menstruating women [2]. There is right side preponderance [3, 4, 5]. It usually involves the right side (85-95%) and can be left-sided or bilateral [2]. It is associated with diaphragmatic perforations and/or thoracic endometriosis [2].

Thoracic endometriosis syndrome (TES) is the presence of endometrial tissue in or around the lung. Although endometriosis in general can affect up to 15% of women in their reproductive years, TES remains an exceedingly rare condition [6, 7].

TES occurs almost exclusively in the right hemithorax (approximately 95% of cases) [8, 9]. Although congenital diaphragmatic hernias are far more common on the left side, congenital diaphragmatic defects, particularly fenestrations, are known to occur more commonly on the right, leading to the right-sided predominance of TES [10].
CP is responsible for only 2.5% to 5% of cases of women with spontaneous pneumothorax [11, 12] even though it accounts for 73% of the cases of TES [6]. The first case of CP was described by Maurer et al. [13] in 1958, but the term catamenial pneumothorax was not introduced until 1972. [14] CP is typically defined as spontaneous and recurrent pneumothorax occurring within 72 hours from the onset of menstruation. [8, 11] According to Karpel et al, [15] the number of recurrent pneumothoraces can range from 2 to 42 per patient.

Three theories have developed to explain this entity. The first is transdiaphragmatic passage, or movement, of air from the vagina to the peritoneum via the fallopian tubes, and subsequently to the thorax via diaphragmatic fenestrations. This is thought to occur during the menstrual cycle when the cervical mucus plug is absent. [5, 7, 13]. The
second is air leakage triggered by sloughing of the endometrial implants located on the pleura. [5, 7] The third proposes a hormonally mediated mechanism in which high levels of prostaglandin from thoracic endometrial implants cause vascular and bronchiolar vasoconstriction, leading to ischaemic injury and ultimately causing alveolar rupture and
subsequent air leakage. [5] Another theory that has been proposed as a cause of catamenial pneumothorax is the spontaneous ruptures of blebs.

Teaching points
Whenever a female patient in the reproductive age group present with chest pain or recurrent pneumothorax; it's worthwhile to record an elaborated mensuration history and evaluate for catamenial pneumothorax.
Differential Diagnosis List
Catamenial pneumothorax
Primary spontaneous pneumothorax
Iatrogenic pneumothorax
Final Diagnosis
Catamenial pneumothorax
Case information
DOI: 10.1594/EURORAD/CASE.14432
ISSN: 1563-4086