A Rare Case of Endometriosis Presenting With Massive Ascites and Pleural Effusion

A 25-year-old nulliparous woman presented with ascites and pleural effusion for 2 months detected by multiple imaging tests (Fig. 1). She reported progressive dysmenorrhea in the past 10 years and denied other obvious symptoms. Her medical history included a thoracoscopic bullae resection performed six years ago due to spontaneous recurrent pneumothorax, pathology of which demonstrated chronic inflammatory and fibrotic changes and no signs of malignancy. One month after this surgery, the patient suffered another pneumothorax and achieved remission with conservative treatment. Since then, the patient has not experienced any severe chest symptoms and has not undergone any further reviews. Through meticulous inquiry into the patient's menstrual cycle during each pneumothorax episode, our gynecologist ascertained that every attack coincided with the patient's menstrual period and diagnosed the patient with catamenial pneumothorax. For further diagnosis and treatment, a multi-team surgery involving the gynecologist and the thoracic surgeon was performed. On the day of the operation, right-sided thoracoscopic surgery revealed extensive pleural adhesions, a large amount of hemorrhagic pleural effusion, and numerous dark brown nodules densely distributed on the parietal pleura (Fig. 2). 800 mL pleural effusion was drained and nodules were biopsied. Subsequently, laparoscopy revealed a massive pool of bloody ascitic fluid in the pelvic cavity. After suction of about 400ml ascites, pelvic endometriosis lesions were more clearly observed, including blisters approximately 0.5-2 cm in size on the surface of the uterus and chocolate cysts in bilateral ovaries. The patient then underwent bilateral ovarian cystectomy and electrocautery of peritoneal endometriosis. Figure. 2Operative findings during thoracoscopy (A-D). Massive hemorrhagic pleural fluid (Panel A, asterisk); minimal red endometriotic lesions on the thoracic wall (Panel B, arrows); dark brown nodules scattered on the parietal pleura (Panel C, asterisk); extensive pleural adhesions (Panel D, asterisk). View Large Image Figure Viewer Download Hi-res image