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Recurrent Pneumothorax Dennis Scurry, Jr., MD, Harry C. Press, Jr., MD, and Oswald G. Warner, MD Washington, D.C.
Clinical History A 36-year-old gravida 3, para 3, black female was awakened from sleep by a sharp pain located anteriorly in her lower chest wall and radiating to her back. She had a three-year history of such frequent chest pains, often at monthly intervals and always concurrent with onset of her menses. She had no history of trauma, surgery, infection, or other diagnosis.
ration. A left-sided 60 percent pneumothorax is appreciated that increases during expiration. Note the visceral pleural line confirming the diagnosis. What is your diagnosis? 1. Spontaneosly ruptured bulla 2. Pneumothorax secondary to sarcoidosis
3. Pneumomediastinum 4. "Catamenial" pneumothorax
Spontaneously Ruptured Bulla A bulla is an air-containing space within the lung, more than 1 cm in diameter in the distended state.1 The
Physical Examination The physical examination revealed: blood pressure, 140/100; pulse, 80; respiration, 20; and temperature, 98.8 F. An S4 gallop was appreciated on auscultation and an ECG showed occasional premature ventricular contractions.
Radiologic Findings Figures 1 and 2 show PA projections of the chest during inspiration and expiRequests for reprints should be addressed to Dr. Harry C. Press, Jr., Department of Radiology, Howard University Hospital, 2041 Georgia Avenue, NW, Washington, DC 20060.
Figure 1. PA view of the chest demonstrating the left-sided pneumothorax.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
Figure 2. PA view of chest during expiration showing an increase in the pneumothorax.
363
walls of bullae are formed by pleura, connective tissue septa, or compressed lung parenchyma. These walls are quite thin and sharply defined. A bleb connotes a collection of air within the layers of visceral pleura. Bullae and blebs have a predilection for upper lobes, especially the extreme apex. Ruptured bullae and blebs are the most common cause of spontaneous pneumothorax.I Bullae are usually associated with generalized obstructive emphysema or chronic bronchitis, neither of which affected this patient. Bullae frequently are found in otherwise normal lungs and asymptomatic patients and are frequently very difficult to detect roentgenologically especially if they are located within the lung parenchyma.I Ruptured bullae or blebs, therefore, should always be considered when determining the cause of a spontaneous pneumothorax.
Pneumothorax Sarcoidosis
Secondary
to
The diagnosis of sarcoidosis may be suspected from symmetrical hilar and paratracheal lymph nodal enlargement. Partial bronchial obstruction results with air trapping and overflation. Although sarcoidosis is an uncommon cause of spontaneous pneumothorax, it does occur,2 and should always be considered because of the relatively high incidence of sarcoidosis in blacks.
Pneumomediatinum Pneumomediastinum connotes the presence of gas in the mediastinal space. ' It is rare in adults. Bronchiolitis and rupture of marginally situated alveoli, trauma with rupture of the esophagus or tracheobronchial tree, or extension of gas from below the diaphragm following abdominal or pelvic procedures have been implicated as causes. Roentgenographic signs include a longitudinal shadow parallel to the heart border and separated from the heart by gas. A lateral projection usually demonstrates a layer of extrapulmonary gas in the retrosternal region. Displacement of air into the neck and thoracic wall is another common finding.
Catamenial Pneumothorax Catamenial pneumothorax is the term applied to the recurrent spontane364
ous pneumothorax temporally related to menstrual flow.2 The relationship between pneumothorax and menses has now been definitely established. With few exceptions, all reported cases have occurred on the right side.3'4 Two cases of bilateral catamenial pneumothorax have now been reported.25 Patients with catamenial pneumothorax fall into a consistent pattern. They are parous women with an age range of 24 to 44 years. They have repeated episodes, but pneumothorax may not occur at every menses. Why pneumothorax occurs at the onset of menstruation is still not fully understood nor adequately explained. Associated entities include endometriosis6-8 involving either the pleura or diaphragm, or the presence of bullae, blebs, or scars. Congenital diaphragmatic defects usually involving the right side7 have been considered. This could explain the high incidence of right-sided pneumothorax.
Hospital Course The patient was admitted and a water-seal type drainage was placed in the left chest to re-expand the lung. During this admission, a left-sided thoracotomy was performed with the excision of an emphysematous bleb. A partial pleurectomy was performed on the left apex. The pathologist reported bullous emphysematous changes, compatible with focal fibrosis and atelectasis. Since then the patient has experienced no recurrence of a left-sided pneumothorax. However, she was readmitted in each of the following three months with right-sided pneumothoraces concommitent with the onset of her menstrual flow.
Discussion Analysis of the causes of spontaneous pneumothorax begins with a careful clinical history. A recent history of trauma or surgery to the chest or abdomen must be elicited. Other disease entities that may be associated with pneumothorax must be considered.
thorax, ie, spontaneous and traumatic. Clinical manifestation includes acute onset of retrosternal pain aggravated by respiration. Dyspnea may be severe. A pneumomediastinum is less likely because it occurs more frequently in males. It is of greater significance that the roentgenographic signs are those of a pneumothorax rather than a pneumomediastinum. Sarcoidosis was considered because of its relatively high incidence in the black population. It was quickly ruled out because hilar lymph-nodal enlargement was not present, nor was there any evidence of diffuse pulmonary disease. A spontaneously ruptured bulla must always be considered as a cause for pneumothorax. Even though a causal relationship has not been established, in one study demonstrable bullae, blebs, or scars were found in 13 of 32 patients with pneumothorax concurrent with menses.4 The possibility of ruptured blebs as the cause of pneumothoraces in this patient is increased in view of the fact that there has been no recurrence on the left side since the left pleurectomy. There is a definite relationship with this patient's recurrent episodes of pneumothoraces and the onset of her menses. It is, therefore, very important that a careful menstrual history is taken when a woman of child-bearing age is of having recurrent episodes pneumothorax. In this case, a diagnosis beyond pneumothorax is impossible from the radiographs. This presentation is made to emphasize the importance of the history and physical in the interpretation of all radiography. Referring physicians should always give the reason for the examination and radiologists should not perform studies without this information.
Some of these diseases (not discussed)
Literature Cited 1. Fraser RG, Pare JAP: Diagnosis of Disease of the Chest. WB Saunders, 1970, p 1174 2. Littington GA, Mitchell SP, Wood GA: Catamenial pneumothorax. JAMA 219:13281332, 1972 3. Wilhelm JL: Catamenial pneumothorax-bilateral occurrence while on suppressive therapy. Obstet Gynecol 50(2):227-231, 1977
are: spasmodic asthma, staphylococcal septicemia, pulmonary alveolar proteinosis, and primary or metastatic carcinoma of the lungs. A pneumomediastinum was considered in this patient because of its etiologic similarities to a pneumo-
4. Shearin RPN, Hepper NGG, Payne WP: Recurrent spontaneous pneumothorax concurrent with menses. Mayo Clin Proc 49:98-101, 1974 5. Laws HL: Catamenial pneumothorax. Arch Surg 112(5):627-628, 1977 6. Assor D: Endometriosis of the lung. Am J dlim Pathol 57:311-315, 1972 7. Davies R: BrJ Dis Chest 65:222-224, 1971 8. Granber Gl: Endometriosis by aspiration biopsy. Acta dytol 21(2):295-297, 1977
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
.....
Recurrent Pneumothorax Dennis Scurry, Jr., MD, Harry C. Press, Jr., MD, and Oswald G. Warner, MD Washington, D.C.
Clinical History A 36-year-old gravida 3, para 3, black female was awakened from sleep by a sharp pain located anteriorly in her lower chest wall and radiating to her back. She had a three-year history of such frequent chest pains, often at monthly intervals and always concurrent with onset of her menses. She had no history of trauma, surgery, infection, or other diagnosis.
ration. A left-sided 60 percent pneumothorax is appreciated that increases during expiration. Note the visceral pleural line confirming the diagnosis. What is your diagnosis? 1. Spontaneosly ruptured bulla 2. Pneumothorax secondary to sarcoidosis
3. Pneumomediastinum 4. "Catamenial" pneumothorax
Spontaneously Ruptured Bulla A bulla is an air-containing space within the lung, more than 1 cm in diameter in the distended state.1 The
Physical Examination The physical examination revealed: blood pressure, 140/100; pulse, 80; respiration, 20; and temperature, 98.8 F. An S4 gallop was appreciated on auscultation and an ECG showed occasional premature ventricular contractions.
Radiologic Findings Figures 1 and 2 show PA projections of the chest during inspiration and expiRequests for reprints should be addressed to Dr. Harry C. Press, Jr., Department of Radiology, Howard University Hospital, 2041 Georgia Avenue, NW, Washington, DC 20060.
Figure 1. PA view of the chest demonstrating the left-sided pneumothorax.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
Figure 2. PA view of chest during expiration showing an increase in the pneumothorax.
363
walls of bullae are formed by pleura, connective tissue septa, or compressed lung parenchyma. These walls are quite thin and sharply defined. A bleb connotes a collection of air within the layers of visceral pleura. Bullae and blebs have a predilection for upper lobes, especially the extreme apex. Ruptured bullae and blebs are the most common cause of spontaneous pneumothorax.I Bullae are usually associated with generalized obstructive emphysema or chronic bronchitis, neither of which affected this patient. Bullae frequently are found in otherwise normal lungs and asymptomatic patients and are frequently very difficult to detect roentgenologically especially if they are located within the lung parenchyma.I Ruptured bullae or blebs, therefore, should always be considered when determining the cause of a spontaneous pneumothorax.
Pneumothorax Sarcoidosis
Secondary
to
The diagnosis of sarcoidosis may be suspected from symmetrical hilar and paratracheal lymph nodal enlargement. Partial bronchial obstruction results with air trapping and overflation. Although sarcoidosis is an uncommon cause of spontaneous pneumothorax, it does occur,2 and should always be considered because of the relatively high incidence of sarcoidosis in blacks.
Pneumomediatinum Pneumomediastinum connotes the presence of gas in the mediastinal space. ' It is rare in adults. Bronchiolitis and rupture of marginally situated alveoli, trauma with rupture of the esophagus or tracheobronchial tree, or extension of gas from below the diaphragm following abdominal or pelvic procedures have been implicated as causes. Roentgenographic signs include a longitudinal shadow parallel to the heart border and separated from the heart by gas. A lateral projection usually demonstrates a layer of extrapulmonary gas in the retrosternal region. Displacement of air into the neck and thoracic wall is another common finding.
Catamenial Pneumothorax Catamenial pneumothorax is the term applied to the recurrent spontane364
ous pneumothorax temporally related to menstrual flow.2 The relationship between pneumothorax and menses has now been definitely established. With few exceptions, all reported cases have occurred on the right side.3'4 Two cases of bilateral catamenial pneumothorax have now been reported.25 Patients with catamenial pneumothorax fall into a consistent pattern. They are parous women with an age range of 24 to 44 years. They have repeated episodes, but pneumothorax may not occur at every menses. Why pneumothorax occurs at the onset of menstruation is still not fully understood nor adequately explained. Associated entities include endometriosis6-8 involving either the pleura or diaphragm, or the presence of bullae, blebs, or scars. Congenital diaphragmatic defects usually involving the right side7 have been considered. This could explain the high incidence of right-sided pneumothorax.
Hospital Course The patient was admitted and a water-seal type drainage was placed in the left chest to re-expand the lung. During this admission, a left-sided thoracotomy was performed with the excision of an emphysematous bleb. A partial pleurectomy was performed on the left apex. The pathologist reported bullous emphysematous changes, compatible with focal fibrosis and atelectasis. Since then the patient has experienced no recurrence of a left-sided pneumothorax. However, she was readmitted in each of the following three months with right-sided pneumothoraces concommitent with the onset of her menstrual flow.
Discussion Analysis of the causes of spontaneous pneumothorax begins with a careful clinical history. A recent history of trauma or surgery to the chest or abdomen must be elicited. Other disease entities that may be associated with pneumothorax must be considered.
thorax, ie, spontaneous and traumatic. Clinical manifestation includes acute onset of retrosternal pain aggravated by respiration. Dyspnea may be severe. A pneumomediastinum is less likely because it occurs more frequently in males. It is of greater significance that the roentgenographic signs are those of a pneumothorax rather than a pneumomediastinum. Sarcoidosis was considered because of its relatively high incidence in the black population. It was quickly ruled out because hilar lymph-nodal enlargement was not present, nor was there any evidence of diffuse pulmonary disease. A spontaneously ruptured bulla must always be considered as a cause for pneumothorax. Even though a causal relationship has not been established, in one study demonstrable bullae, blebs, or scars were found in 13 of 32 patients with pneumothorax concurrent with menses.4 The possibility of ruptured blebs as the cause of pneumothoraces in this patient is increased in view of the fact that there has been no recurrence on the left side since the left pleurectomy. There is a definite relationship with this patient's recurrent episodes of pneumothoraces and the onset of her menses. It is, therefore, very important that a careful menstrual history is taken when a woman of child-bearing age is of having recurrent episodes pneumothorax. In this case, a diagnosis beyond pneumothorax is impossible from the radiographs. This presentation is made to emphasize the importance of the history and physical in the interpretation of all radiography. Referring physicians should always give the reason for the examination and radiologists should not perform studies without this information.
Some of these diseases (not discussed)
Literature Cited 1. Fraser RG, Pare JAP: Diagnosis of Disease of the Chest. WB Saunders, 1970, p 1174 2. Littington GA, Mitchell SP, Wood GA: Catamenial pneumothorax. JAMA 219:13281332, 1972 3. Wilhelm JL: Catamenial pneumothorax-bilateral occurrence while on suppressive therapy. Obstet Gynecol 50(2):227-231, 1977
are: spasmodic asthma, staphylococcal septicemia, pulmonary alveolar proteinosis, and primary or metastatic carcinoma of the lungs. A pneumomediastinum was considered in this patient because of its etiologic similarities to a pneumo-
4. Shearin RPN, Hepper NGG, Payne WP: Recurrent spontaneous pneumothorax concurrent with menses. Mayo Clin Proc 49:98-101, 1974 5. Laws HL: Catamenial pneumothorax. Arch Surg 112(5):627-628, 1977 6. Assor D: Endometriosis of the lung. Am J dlim Pathol 57:311-315, 1972 7. Davies R: BrJ Dis Chest 65:222-224, 1971 8. Granber Gl: Endometriosis by aspiration biopsy. Acta dytol 21(2):295-297, 1977
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
