IMAGES IN THORAX

MRI features of pleural endometriosis after catamenial haemothorax

Giulia Picozzi¹, Davide Beccani¹, Florio Innocenti², Michela Grazzini², Mario Mascalchi³

¹ Radiodiagnostic Section, Department of Clinical Physiopathology University of Florence, Italy
² Respiratory Unit, Pistoia Hospital, Pistoia, Italy
³ Radiodiagnostic Section, Department of Clinical Physiopathology University of Florence, Italy

Correspondence to:
Correspondence to:
Professor Mario Mascalchi
Radiodiagnostic Section, Department of Clinical Physiopathology, University of Florence, Viale Morgagni 50134, Florence, Italy; m.mascalchi{at}dfc.unifi.it

Pleural endometriosis typically presents in young women within 72 h of onset of menstruation as cata-menial pneumothorax, haemothorax or both. A 43-year-old multiparous woman with a history of pelvic endometriosis and myocardial infarction presented with acute onset of right hemithorax pain and dyspnoea coinciding with dysmenorrhoeic menstruation. A non-contrast enhanced chest CT scan (fig 1) showed a right haemopneumothorax with floating clots within the fluid, which was drained. A video-assisted thoracoscopy (VATS) guided random pleural biopsy sample was negative. Magnetic resonance imaging (MRI) of the chest coinciding with menses 4 months later showed an oval-shaped lesion with homogeneous high signal intensity in T1- and T2-weighted images in the right posterior costodiaphragmatic recess (fig 2A, B). Owing to the relative contraindication for hormone therapy related to the coronary artery disease, the patient underwent a hysterectomy and oophorectomy for treatment of endometriosis. Six months later she was free of thoracic symptoms and an MRI scan showed the disappearance of the right pleural abnormality.

View larger version (26K): in this window | in a new window | PowerPoint for Teaching   Figure 1  Non-contrast enhanced chest CT scan at presentation showing (A) right haemopneumothorax in the lung parenchyma and (B) evidence of slightly hyperdense floating clots (arrows) within the pleural fluid.

 

View larger version (39K): in this window | in a new window | PowerPoint for Teaching   Figure 2  Non-contrast enhanced MRI scan of the chest and upper abdomen showing an oval-shaped well-defined lesion in the right posterior costodiaphragmatic recess abutting the pleura. The lesion (arrow) exhibits homogeneous high signal intensity in (A) the coronal T1-weighted spin echo image and (B) the axial T2-weighted fast spin echo images without fat suppression.

 

The diagnosis of thoracic endometriosis is usually based on clinical grounds but is often delayed. Cytological examination of the pleural fluid is usually not helpful and VATS is often negative.^1,2 Although no pathological proof was available, the diagnosis of pleural endometriosis in our case was supported by the typical clinical presentation, the history of pelvic endometriosis, the MRI features distinctive of pleural endometriosis³ and the disappearance of the pleural MRI finding after surgical treatment of endometriosis.

1. Joseph J, Sahan S A. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 1996;100:164–70.[CrossRef][Medline]
2. Johnson M M. Catamenial pneumothorax and other thoracic manifestations of endometriosis. Clin Chest Med 2004;25:311–9.[CrossRef][Medline]
3. Cassina P C, Hauser M, Kael G, et al. Catamenial hemoptysis: diagnosis with MRI. Chest 1997;111:1447–50.[Medline]

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