Catamenial Pneumothorax in terms of Radiology

1. Catamenial Pneumothorax
Dr. Mahesh Chaudhary
Phase-B, Radiology
BSMMU

2. Patient’s particulars:
Name: Momtaz Sultana
Age: 34 years
Sex: Female
Occupation: School Teacher
Address: Dhaka

3. Presenting Complaints:
1. Sudden onset of chest pain on the left side for 2 days.
2. Shortness of breath for 2 days.
3. Dry cough for 2 days.
No history of fever, hemoptysis, hematemesis or trauma.

4. Past History
She has history of episodes of similar symptoms at every
30-40 days duration for last 4 years.
The SOB & chest pain were always followed by menstruation.

5. Personal History
Married for last 10 years
No history of pregnancy: G0P0
No children
Menstrual History
Irregular cycle (30-40 days) with dysmenorrhea
Associated with chest pain, SOB and backache

6. FINAL DIAGNOSIS:
Catamenial Pneumothorax

7. Pneumothorax
 Accumulation of air in the pleural space
Pathophysiology: Disruption of visceral pleura
Trauma to parietal pleura
 • Pleuritic pain, dyspnea (in 80-90%)

8. Traumatic Pneumothorax
(a) Penetrating trauma
(b) Blunt trauma:
 Pathophysiology: ruptured alveoli
1. Rib fracture
2. Increased intrathoracic pressure against closed glottis
3. Bronchial fracture: fallen lung sign
(c) Iatrogenic:
tracheostomy, central venous catheter, thoracic irradiation

9. Spontaneous Pneumothorax
Primary spontaneous (80%)
 Cause:
rupture of subpleural blebs
Age: 20-40 years;
M:F = 8:1
 Young tall stature men
 Mostly in smokers
Secondary spontaneous (20%)
 Air-trapping disease
 Pulmonary infections
 Granulomatous disease
 Malignancy
 Connective tissue disorder
 Pneumoconiosis
 Vascular disease
 Catamenial
[Greek: kata , = according to; men= month]

10. Types of Pneumothorax
 Open : chest wound
air move in & out of pleural space during respiration
 Closed : intact thoracic cage
no air movement
 Valvular: enter during inspiration & doesn't exit
 Tension : (clinical diagnosis)
higher in barotrauma

11. Pneumothorax size:
Surgical rule:
pneumothorax >25% requires
chest tube drainage
Air resorb from the pleural space
at a rate of approximately 1.5% /
day.

12. Complications
 Loculated or Encysted pneumothorax
~subpleural pulmonary cavity, cyst or bulla
 Pleural adhesions
 Haemopneumothorax
 Pyopneumothorax
 Re-expansion Pulmonary edema

13. Catamenial Pneumothorax (CP)
CP is defined as recurrent pneumothorax (at least two episodes)
occurring between the day before and within 72 hours after the
onset of menstruation.

14. Epidemiology:
 Incidence of 3-6 % among all the pneumothoraxes in women.
 Involves right-side (85-95%) or can be left-sided or bilateral.
 Associated with diaphragmatic perforations and/or thoracic
endometriosis syndrome.

15. TES is the presence of endometrial tissue in or around
the lung & consists of 4 distinct clinical entities:
1. Catamenial pneumothorax (CP),
2. Catamenial hemothorax,
3. Hemoptysis &
4. Pulmonary nodules or implants.
Thoracic endometriosis syndrome (TES)

16. Why right?
 Physiologically, peritoneal fluid moves in a clockwise
fashion from the pelvis along the right paracolic
gutter to the subphrenic space.
 Endometrial tissue located within the peritoneum
likely follows the same directional flow, landing more
commonly on the right hemi diaphragm.
 Once there, the falciform ligament prevents further
travel of tissue to the left.

17. Theories for CP
 Ingression of air via diaphragmatic fenestrations
from the vagina to the peritoneum
 Hormonal: Rupture of pre-existing pleural blebs/
alveoli during menstruation by increase in PG-F2.
 Sloughing of Pleural or parenchymal endometrial
implants in the lung.

18. Diagnosis:
1. X-ray chest PA view
2. CT scan of Chest
3. Hormone level of gonadotropin hormones
4. Video-Assisted Thoracoscopic Surgery (VATS)

19. Chest radiograph
 Visceral pleural edge seen as a very thin, sharp white line
 No lung markings are seen peripheral to this line
 Peripheral space is radiolucent compared to adjacent lung
 The lung may completely collapse
 Mediastinum shift (+)– if tension pneumothorax is present
 Expiratory chest radiograph

20. CT
 Identifies even small pneumothoraces not visible in CXR
 Differentiates bullous disease from intrapleural air
 CT guided drain in complicated or inaccessible pneumothorax:
Posterior location or tethered lung

21. USG Normal lung: seashore sign

22. USG :barcode /stratosphere sign:

23. Lung point sign

24. Treatment: Pneumothorax
 Asymptomatic small rim pneumothorax (<2 cm): no treatment with
follow up radiology to confirm resolution
 Pneumothorax with mild symptoms (no underlying lung condition):
needle aspiration in the first instance
 pneumothorax in a patient with background chronic lung disease or
significant symptoms: intercostal drain insertion (small drain using the
Seldinger technique)

25. TREATMENT: CP
Medical :
Hormonal therapy (GnRH analogue)
Surgical: VATS
 Pleurodesis
 Repair of diaphragmatic defects with an artificial mesh
Treatment are usually medical in conjunct to surgical alleviation of the
disease.

26. Thank you….
Have a good day!!