The Spanish congress of the European association of pulmonologists and thoracic surgeons, held in 2009, confirmed the international classification of spontaneous pneumothorax in which catamenial (menstrual) pneumothorax was identified. Different from usual pneumothorax, its reason is not because of bleb disease in the lungs, but rather, caused by menstrual cycle in women. The cause was partly studied and explained by several theories. By the first of them, congenital defects (holes, fenestrations) in the diaphragm allow air to get into pleural space because of increased permeability of the fallopian tubes during menstruation. The second hypothesis, the same mechanism is considered, but it has been supposed that a hole in the diaphragm can be caused by endometriosis. The third theory, endometriosis of a pulmonary parenchyma can create leak of air during menstruation. The fourth theory, significance is attached to production of F2 prostaglandin, which is a powerful broncho- and vasoconstriction agent, causing ruptures of alveoli in women in the period of the woman's menstrual cycle.

Two groups of patients were identified: with a defect in the diaphragm and without. Existence of such defects is described in 50% of cases. Having a wide clinical experience in the field of thoracic surgery, we, for the first time in practice, diagnosed catamenial pneumothorax in patients with the recurrence course of the disease.

Key words : Spontaneous pneumothorax, Bülau drain, Video-assisted minithoracotomy

Case Report

The 2009 Spanish Congress of the European Association of Pulmonologists and Thoracic Surgeons confirmed the international classification of spontaneous pneumothorax in which catamenial (menstrual) pneumothorax was identified. Unlike usual cases of pneumothorax, catamenial pneumo­thorax is not caused by pulmonary blebs, but is caused by the menstrual cycle in women.¹

Several theories have been given to explain the cause of catamenial pneumothorax. One theory attributes the cause to congenital defects (holes, fenestration) in the diaphragm that allow air to enter the pleural space because of increased permeability of the fallopian tubes during menstruation. The same mechanism is considered in another theory, but attributes the holes in the diaphragm to endo­metriosis.^2,3 In a third theory, endometriosis of a pulmonary parenchyma can create air to leak during menstruation. The fourth theory attributes catamenial pneumothorax to a hormonal cause, with significance attached to production of F2 prostaglandin, a powerful bronchiolar constriction and vasoconstriction agent that causes subsequent alveolar rupture during the menstrual cycle.

We describe our first case of catamenial pneumo­thorax in a patient with a recurrent disease course. The 32-year-old woman was admitted to our thoracic surgery clinic in 2011 with complaints of cough and shortness of breath. According to the patient’s medical history, the patient had 2 prior episodes of pneumothorax on the right side, which had been treated by a Bülau drain. A clear connection of development of pneumothorax with the menstrual cycle was identified, with a radiographic image showing partial pneumothorax on the right side. Pathologic shadows of the lung were not revealed (Figure 1).

After diagnosis, the woman underwent video-assisted right-side minithoracotomy. During the surgical procedure, a fall of one-quarter of lung volume with usual pink color was revealed; other defects and pathologic neoplasms on visceral pleura were not detected. Basal lung inspection showed multiple, linear fenestrations (3.0 × 0.5 cm) on the internal side of the diaphragm. Defects were covered with mucous, and through them, the liver surface was visible. A water test showed air bubbles coming through the defects of the diaphragm. An inspection of the diaphragmatic pleura showed it to be edematous and injected by vessels (Figure 2).

Because of the multiple defects, a pleurodesis with talc was performed, and the pleural cavity was drained. The patient’s postoperative course was uneventful. The lung drainages were removed on the third day, and the patient was discharged on the sixth day after treatment (Figure 3).

Conclusions

In conclusion, for women with recurrent pneumo­thorax developing during menses, it is important to consider catamenial pneumothorax, which has own features of pathogenesis and demands a different diagnostic approach and treatment.

References:

1. Vodička J, Špidlen V, Klečka J, Šafránek J, Šimánek V, Fichtl J. Catamenial pneumothorax - case studies from our department in a ten-year period [in Czech]. Rozhl Chir. 2012;91(10):554-557.
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2. Elia S, De Felice L, Varvaras D, Sorrenti G, Mauriello A, Petrella G. Catamenial pneumothorax due to solitary localization of diaphragmatic endometriosis. Int J Surg Case Rep. 2015;12:19-22.
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3. Capov I, Wechsler J, Krynská J, Dusa J, Jedlicka V. Catamenial pneumothorax--case report [in Czech]. Rozhl Chir. 2001;80(9):456-458.
   PubMed