CP

Catamenial Pneumothorax

Dr. Mahesh ChaudharyPhase-B, RadiologyBSMMU

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Patients particulars:

Name: Momtaz SultanaAge: 34 yearsSex: FemaleOccupation: School TeacherAddress: Dhaka

Presenting Complaints:

Sudden onset of chest pain on the left side for 2 days.Shortness of breath for 2 days.Dry cough for 2 days.

No history of fever, hemoptysis, hematemesis or trauma.

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.

For these symptoms she was treated by gynecologists on the basis of dysmenorrhea or menorrhagia for last 4 years.

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Personal HistoryMarried for last 10 years No history of pregnancy: G0P0No children

Menstrual HistoryIrregular cycle (30-40 days) with dysmenorrheaAssociated with chest pain, SOB and backache

Respiratory system: There was a restricted chest wall movement on the left side. Vocal fremitus absent on the left side

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FINAL DIAGNOSIS:

Catamenial Pneumothorax

Pneumothorax

Accumulation of air in the pleural space

Pathophysiology: Disruption of visceral pleura Trauma to parietal pleura

Pleuritic pain, dyspnea (in 80-90%)

Traumatic Pneumothorax

(a) Penetrating trauma

(b) Blunt trauma:Pathophysiology: ruptured alveoli 1. Rib fracture2. Increased intrathoracic pressure against closed glottis3. Bronchial fracture: fallen lung sign

(c) Iatrogenic: tracheostomy, central venous catheter, thoracic irradiation

fallen lung sign = hilum of lung below expected level within chest cavity

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Spontaneous PneumothoraxPrimary spontaneous (80%)Cause: rupture of subpleural blebs

Age: 20-40 years;M:F = 8:1Young tall stature menMostly in smokers

Secondary spontaneous (20%) Air-trapping disease Pulmonary infectionsGranulomatous disease Malignancy Connective tissue disorder PneumoconiosisVascular disease Catamenial [Greek: kata , = according to; men= month]

Cause: rupture of subpleural blebs in apical region of lung

(a) Air-trapping disease: spasmodic asthma, diffuse emphysema, Langerhans cell histiocytosis, lymphangiomyomatosis, tuberous sclerosis, cystic fibrosis, Chronic obstructive pulmonary disease is the most common predisposing disorder of secondary spontaneous pneumothorax

(b) Pulmonary infections: lung abscess, necrotizing pneumonia, hydatid disease, pertussis, acute bacterial pneumonia, S. aureus, Pneumocystis carinii pneumonia

(c) Granulomatous disease: tuberculosis, coccidioidomycosis, sarcoidosis, berylliosis

(d) Malignancy: primary lung cancer, lung metastases esp. osteosarcoma, pancreas, adrenal, Wilms tumor

(e) Connective tissue disorder: scleroderma, rheumatoid disease, Marfan syndrome, EhlersDanlos syndrome

(f) Pneumoconiosis: silicosis, berylliosis

(g) Vascular disease: pulmonary infarction

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Types of PneumothoraxOpen : 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

Pathophysiology: intrapleural pressure exceeds atm. pressure in lung during expiration (check-valve mechanism) When collection of gas is constantly enlarging, resulting compression of mediastinal structures it can be life-threatening and is known as a tension pneumothorax.

Tension hydropneumothorax: air-fluid level in pleural space on erect CXR 10

Pneumothorax size:

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

ComplicationsLoculated or Encysted pneumothorax ~subpleural pulmonary cavity, cyst or bullaPleural adhesions Haemopneumothorax PyopneumothoraxRe-expansion Pulmonary edema

Rupture of pleural adhesion haemo pneumothoraxInfected subleural lesion pyo pneumothorax12

Catamenial Pneumothorax (CP)

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

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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.

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

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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.

Additionally, respiration causes the right hemi diaphragm to contract against the liver, known as the piston effect, which potentially allows for endometrial implantation and/or migration across the diaphragm.

Left sided implants: direct seeding of endometrial tissue along with venous drainage.

Finally, although congenital diaphragmatic hernias are far more common on the left side, congenital diaphragmatic defects, particularly fenestrations, are known to occur more commonly on the right, leading to the right-sided predominance of TES

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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.

Hormonal : high levels of prostaglandin from thoracic endometrial implants cause vascular and bronchiolar vasoconstriction, leading to ischemic injury and ultimately causing alveolar rupture17

Diagnosis:

X-ray chest PA viewCT scan of ChestHormone level of gonadotropin hormonesVideo-Assisted Thoracoscopic Surgery (VATS)

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 presentExpiratory chest radiograph

lung becomes smaller and volume of pleural air is unchanged .. Hence more conspicuous19

CTIdentifies 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

USG Normal lung: seashore sign

normal lung ---interface with pleura shows lung sliding with vertical comet tails running down from the pleural surface.

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USG :barcode /stratosphere sign:

In pneumothorax, this sliding is absent and so are the comet tail artifacts from the pleura. This is due to air in between the parietal and visceral pleura, preventing lung from sliding.22

Lung point sign

Visualising the junction between sliding lung and absent sliding is known as the lung point sign and is near 100% specific for pneumothorax Not found in all pneumothorax cases (sensitivity is around 65%) especially large pneumothoraces where the lung is collapsed and there is globally absent sliding. 23

Treatment: Pneumothorax

Asymptomatic small rim pneumothorax (