A Case of Treatment-Resistant Catamenial Disease: Insufficiency in Mainstay Treatment Options

Introduction:Thoracic endometriosis syndrome (TES) is characterized by presence of ectopic endometrial tissue within the thoracic cavity, mainly the lung parenchyma and pleura. TES presents as catamenial pneumothorax (CP), catamenial hemothorax (CH), pulmonary nodules or hemoptysis. Hormonal therapy is considered first line treatment followed by operative thoracoscopy for removal of ectopic endometrial implants. Description:A 37-year-old G4P0040 female presented to the emergency department (ED) with worsening shortness of breath for 5 days. Associated symptoms included cough and right-sided chest pain localized to the lateral right mid-lower rib cage. Her past medical history is significant for hypertension, obesity, iron deficiency anemia, severe endometriosis and TES manifesting as recurrent, right sided pleural effusions, CPs and CHs requiring surgical treatment. Her current medications include leuprolide 11.25mg injection/30 days, norethindrone and ferrous sulfate daily. She appeared in distress with a BP of 166/102. Physical examination revealed tachypnea, accessory muscle usage, and respiratory distress. Chest x-ray and CT were consistent with findings for right tension hemothorax. CBC revealed Hb of 5.7g/dl. She was initially started on BiPAP and a tube thoracostomy was performed to place a chest tube. She was transfused 4 units pRBC and admitted to the ICU for further monitoring. Leuprolide was administered to prevent recurrence of hemothorax, and patient was discharged after resolution of symptoms confirmed by imaging. Conclusion:This unique case illustrates the insufficiency in surgical and hormonal mainstay treatments. Novel treatments and multidisciplinary team approach should be used in conjunction to effectively treat TES and prevent disease relapse.