SERIAL CASES

C ATA M E N I A L P N E U M O T H O R A X
F. Suwandinata1, B. Arjunadi2
Family Maternity Hospital, Jakarta, Indonesia
2
Persahabatan General Hospital, Jakarta, Indonesia
1

INDONESIAN SESSION, 18TH NOVEMBER 2

3RD EUROPEAN CONGRESS ON
ENDOMETRIOSIS
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BUDAPEST, HUNGARY

RSUP Persahataban
The Government General Hospital Class
A
Located in East Jakarta
Bed capacity of 600 beds
Accredited for 16 fields of health care
National referral hospitals (top referral)
for respiration

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Introduction
Definition
Catamenial pneumothorax: Recurrent pneumothorax (at
least 2 periods) occur in between 1 day prior and 72
hours after menstruation

Alifano M, Jablonski C, Kadiri H, Falcoz P, Gompel A, Camilleri-Broet S, Regnard JF

Catamenial and non-catamenial, Endometriosis-related or
Non-endometriosis-related Pneumothorax Referred for Surgery.
Am J Respir Crit Care Med, 2007

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX,

2016

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Case 1
41
Ony.o.,
19thP2
August 2015
Referred to endocrinological subunit
Chief complaint:
Severe dyspnoea since 1 week
Recurrent dyspnoea every menstrual periods
Recurrent chest pain every menstrual periods
Worsening dysmenorrhoea since 3-4 years

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Previous history

198
9

201
4

201
5

treatment for 9 months and

decleared fully recovered in
1989

anti-tuberculosis

pulmonologist

Pulmonary
Tuberculosis
Underwent anti-tubercolosis

Underwent WSD (Water

Sealed Drainage)
Pneumothorax
insertion, treated with

New
symptoms
Referred by

therapy category II
2 weeks after recurrent
Pneumothorax and
reinserted WSD for 2
weeks
She had Pleurodesis

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Physical
examination
Compos Mentis
Fully alert
Vital sign with in normal limit
Thorax examination:
Vesicular sound weak on the right
lung
No rhonchi or rhales

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Transvaginal US

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Primary Assessment

Right lung pneumothorax, secondary due to

susp pulmonary tuberculosis, dd/
catamenial endometriosis

Plan : WSD Insertion

Plan : Further examination with Thorax CT
Thoracotomy exploration to perform
surgical pleurodesis

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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CT-Scan
125
100
75

CT-Scan:

50
25
0

2007

2008
Region 1

2009

2010

Region 2

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

Active pulmonary
tuberculosis,
bronchiectasis, right
hydro-pneumothorax
and pericardial
effusion.
A catamenial
pneumothorax could
not be excluded

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Progression
4th September 2015

Worsening of the dyspnoea

Thorax > worsening of Pneumothorax with
air fluid appearance

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Thoracotomy Procedure

On exploration found adhesion on superior lobe and

inferior lobe of right lung, performed adhesiolysis and
found laceration on mediana lobe, performed primary
suture

On diaphragm area found multiple nodules in centrum

tendineum with sign of spotting and fibrosis,
performed nodules resection histopathology
examination

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Histopathological examination result:

Unspecified chronic inflammation with 1st
Inject
focal bleeding typically for endometriosis

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Case 2
40 y.o. P4, came on 21st August 2015
Shortness of breath
occured 3 x in every menstrual periods
Chest pain

2014 History of pneumothorax

2014 Water Seal Drainage with Pleurodesis

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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CT Scan

Complete collapse of
right lung

Pneumothorax on whole
right hemithorax

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Primary Assessment

Right lung pneumothorax

Plan : WSD insertion

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

No Improvement

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Thoracotomy Procedure

On diaphragm area found multiple pores in centrum

tendinum

Continued with chemical and mechanical pleurodesis

histopathology

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Histopathological Result
Endometriosis
spot

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Case 3
30Dyspnoea
since 3 daysdepartment (16th March 2016)
y.o., P0, emergency
Recurrent chest pain for the last 2 menstrual cycle
Recurrent dysmenorrhoea for 2 consecutive menstrual
cycle
Sub-fertility, ovulation hyper stimulation with
clomiphene citrate

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Case 3

201
3

Pneumothorax

Got Water Sealed Drainage

201
3

Tuberculosis

201
6

Dyspnoe

She was diagnosed as

pulmonary Tuberculosis
and underwent therapy
of anti-tuberculosis for 6
months, and declared
fully recover on 2013

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Case 3
Patient fully
alert
Physical
examination
Vital sign normal, high respiratory rate
Thorax examination: weakness of vesicular sound in the
right lung, no rhales and rhonchi
Gynecological examination: normal
Chest X-Ray (March 2016): Right pneumothorax
Sputum microbiological check: negatif
F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Primary Assesment

Right lung pneumothorax, secondary due to suspucted

pulmonary tuberculosis

Plan : WSD insertion

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

Worsening

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VATS Procedure

On exploration found multiple nodules in

Diaphragma, performed nodules resection
histopathology test

On median lobe found bullae, performed bulectomy

with Stappler

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Histopathological
Result

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Discussion
Thoracic endometriosis syndrome (TES):
The presence of endometrial tissue in or around the lung
catamenial pneumothorax (CP)
catamenial hemothorax (CHx)
hemoptysis
pulmonary nodules
Clinical diagnosis
Clinical sign is the key to diagnosis of TES.
Reproductive age
Chest pain, dyspnea, or cough around menstrual cycle
F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

Diminished/ absent breath sounds

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Discussion
Thoracic endometriosis syndrome (TES):

CT imaging: diaphragmatic endometrial implants as

hypo-attenuating areas or identify single or multiple
pulmonary nodules, nonspecific but may sometimes be
represented as a focal ground glass opacity or
consolidation

Magnetic resonance imaging: endometrial implants will

be hyper-intense

Bronchoscopy not helpful because most pathologic

features are located in the peripheral lung

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Discussion
Thoracic endometriosis syndrome (TES):

CT imaging: diaphragmatic endometrial implants as

hypo-attenuating areas or identify single or multiple
pulmonary nodules, nonspecific but may sometimes be
represented as a focal ground glass opacity or
consolidation

Magnetic resonance imaging: endometrial implants will

be hyper-intense

Bronchoscopy not helpful because most pathologic

features are located in the peripheral lung

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Discussion
Thoracic endometriosis syndrome (TES):

Treatment:

Suppression of ovarian estrogen secretion:

Oral contraceptives

Progesterone agents

Danazol

Gonadotropin-releasing hormone (GnRH) agonists

Video-assisted thorascopic surgery:

Resection of areas of the lung and diaphragm where

endometrial implants are present

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Discussion
Prevalence of Tuberculosis very high in Indonesia

Pneumothorax would be treated mostly for

Tuberculosis
Water Sealed Drainage is the emergency
treatment for the pneumothorax
F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Summary
Catamenial pneumothorax is a rare and complex
condition
Diagnosis is often delayed or missed by clinicians
Clinical signs are cyclical chest pain, dyspnea and/or
hemoptysis
F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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Thank You

F. SUWANDINATA, B. ARJUNADI, CATAMENIAL PNEUMOTHORAX, 2016

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