Case: Hemoptysis in a young female

Q: 26 years old female presented with hemoptysis. Patient has a previous history of right-sided pneumo-pleural fistula a year ago, which was resolved with chest tube insertion. Bronchoscopy was promptly performed, and the right-sided bronchial tree appeared hyperemic with a friable mucosa. No active source is identified, and cold saline lavage appears to be sufficient. CT chest showed a right-sided focal area of ground-glass opacification. Bronchial artery angiography is reported as no active bleeding but just an "arterial blush". The most probable diagnosis in light of history and presentation is?

Answer: Thoracic endometriosis

Hemoptysis is not common in thoracic endometriosis. Patients who present with hemoptysis are usually younger than patients without hemoptysis (mean age 27 vs 34 years). Hemoptysis is usually catamenial, minor, and right-sided. Massive hemoptysis is rare. Despite typical history, it would be prudent to rule out malignancy by biopsy and pathology.

The thorax is the most frequent site of extra-pelvic endometriosis. Without a histological diagnosis, it should be referred to as 'probable thoracic endometriosis'. Patients with frequent symptomatic presentation require further surgical intervention with blebectomy, pleurodesis, and hormonal suppression. In resistant and debilitating cases, pleurectomy or hysterectomy with bilateral salpingo-oophorectomy (BSO) may be needed.

Cataminal pneumothoraces refer to episodes of pneumothorax corresponding to the menses of the patient; otherwise, they should be called noncataminal pneumothoraces.

See references for further reading.

#pulmonary

#thoracic-surgery

References:

1. Fukuda S, Hirata T, Neriishi K, et al. Thoracic endometriosis syndrome: Comparison between catamenial pneumothorax or endometriosis-related pneumothorax and catamenial hemoptysis. Eur J Obstet Gynecol Reprod Biol 2018; 225:118.

2. Channabasavaiah AD, Joseph JV. Thoracic endometriosis: revisiting the association between clinical presentation and thoracic pathology based on thoracoscopic findings in 110 patients. Medicine (Baltimore) 2010; 89:183.

3. Nezhat C, Main J, Paka C, et al. Multidisciplinary treatment for thoracic and abdominopelvic endometriosis. JSLS 2014; 18.

4. Kim CJ, Nam HS, Lee CY, et al. Catamenial hemoptysis: a nationwide analysis in Korea. Respiration 2010; 79:296.

5. Alifano M, Jablonski C, Kadiri H, et al. Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery. Am J Respir Crit Care Med 2007; 176:1048.

6. Wang HC, Kuo PH, Kuo SH, Luh KT. Catamenial hemoptysis from tracheobronchial endometriosis: reappraisal of diagnostic value of bronchoscopy and bronchial brush cytology. Chest 2000; 118:1205.

7. Tsuboshima K, Kurihara M, Okumura G, et al. Postoperative hormonal therapies reduce the recurrence of thoracic endometriosis-related pneumothorax. Eur J Cardiothorac Surg 2023; 64.