Answer to the last #DiagnosticDilemma
Answer to the last D/D (A 41-year-old woman presented to the hospital complaining of breathlessness and pain in the right side of her chest. She said that the problem was not new and that it happened every time she had her period. she had begun menstruating 24 hours earlier. The following conditions are known to occur or be exacerbated around the time of menstruation except Rheumatoid arthritis)

In her medical history, it was noted that she had been diagnosed with catamenial pneumothorax 9 years earlier for which she was treated with the gonadotropin-releasing hormone agonist buserelin 1200 ?g/day; she stopped taking it after 6 months. A CT scan of her chest showed a moderately sized pneumothorax on the right side. A blood test showed a serum concentration of the tumour marker cancer antigen 125 of 2219 U/mL . Considering the history and the current presentation, its concluded that patient had again had a catamenial pneumothorax. Therefore its decided to do a thoracoscopy, during which a red lesion was seen in the pleura of the superior segment of the right lower lobe (figure) and two black lesions were seen in the pleura of the right middle lobe: the lesions were resected. Additionally, several small defects—known as blueberry spots—ranging between 2-3 mm in diameter, were seen on the right side of the diaphragm, through which the liver was visible. She was re-started on buserelin.

Catamenial pneumothorax is a rare condition and has a mean age of onset of 32–35 years. The pneumothorax usually occurs within 72 h before or after the start of menstruation. The lesions are classically on the right side and endometriosis might also be present. Menstruation has a clear association with the worsening of several other diseases including migraine, epilepsy, and some psychological disorders. Questions about the relationship of any symptoms to the menstrual cycle can sometimes provide an important clue to the precise diagnosis.

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Source: The Lancet

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