PLEURAL ENDOMETRIOSIS: AN ATYPICAL CAUSE OF HEMOPTYSIS

Objectives: Introduction
Endometriosis is a benign, inflammatory disease characterized by the presence and growth of dysfunctional endometrial tissue outside the uterus and is often associated with reactive fibrosis. Typically confined to the pelvis, endometriosis is frequently associated with pelvic pain, dysmenorrhea, and infertility. Outside of the pelvis, endometrial tissue has been documented to implant within the lung parenchyma and both parietal and visceral pleura within the thoracic cavity. Clinical manifestations of thoracic endometriosis include catamenial pneumothorax, hemothorax and hemoptysis, collectively termed thoracic endometriosis syndrome (TES). We present a case of thoracic endometriosis in a 43-year-old female with a history of hemoptysis and dyspnea with loculated pleural effusion found after gynecologic surgery.

Case Report
A 43-year-old female with no significant past medical history was transferred to the emergency department at our academic institution from an outside hospital for evaluation and management of a newly discovered adnexal mass and anemia. The patient endorsed several recent syncopal events and intermittent hemoptysis. The patient subsequently underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pathology of the adnexal mass demonstrated benign leiomyoma. During the hospital stay, a left pneumothorax was noted after placement of a left subclavian central venous catheter and treated with tube thoracostomy. Computer tomographic (CT) imaging of the chest was obtained due to initial non-expansion of the left lung and a loculated fluid collection noted in the right hemithorax. After resolution, the patient was discharged and scheduled for follow-up with thoracic surgery.

Repeat CT imaging was obtained prior to follow-up and demonstrated a large, persistent multiloculated right pleural fluid collection with an associated 2.6 x 1.2 cm enhancing nodule within the right hemithorax. The patient subsequently underwent right thoracotomy and decortication. The nodule was removed and on final pathology was identified as endometrial tissue within the parietal pleural tissue. The patient did well post-operatively and was discharged home.

Discussion
Thoracic endometriosis is a medical problem that is frequently undiagnosed and encountered by the practicing surgeon. Sharp clinical acumen is required to have an appropriate index of suspicion to suspect and diagnose TES. Recognizing key symptoms such as catamenial dyspnea and hemoptysis in reproductive aged women is essential to establish early detection. Early diagnosis reduces disease progression and late complications, such as reactive loculated effusions, and allows for minimally invasive techniques to achieve tissue diagnosis and initiation of appropriate medical management.

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