You are presented a case of a 35-year-old woman who presents with intermittent
right-sided chest pain, shortness of breath, and hemotysis of one years duration.
Multiple ER visits including workups for pneumonia and autoimmune disease have failed
to reveal the cause of her pulmonary symptoms.
She was diagnosed as having an irritable bowel syndrome at the age of 30 after years
of intermittent bloating and abdominal pain. She has had heavy menses and dysmenorrhea since adolescence. Her Past Medical History, Review of Systems, Family History, and Epidemiologic history
are otherwise unremarkable .
Except for mild tenderness in her right lower quadrant her physical examination is described as being normal.
Her CBC, electrolytes, liver chemistries, and urinalysis are normal. She could not
produce a sputum sample for analysis. Her chest x-ray shows a small right-sided pleural
effusion but is otherwise interpreted as being normal.
DIAGNOSIS: Thoracic endometriosis - ectopic endometrial tissue involving the diaphragm,
pleura, and lung parenchyma and manifesting as catamenial chest pain, pleural effusions,
and hemoptysis.
Endometriosis affects about 10% of reproductive-age women and can present in other
extrapelvic sites including the bowel and the brain. In some series, extra-uterine
endometriosis is the most common misdiagnosed disorder in emergency rooms, resulting
in extensive and expensive diagnostic investigations.
The diagnosis of thoracic endometriosis is established by tissue biopsy. Management
options include hormonal suppression (GnRH agonists, oral contraceptives), surgical
excision of endometrial implants, or a combination of both.