A 34-year-old Nigerian woman presented to the ED with a chief complaint of dyspnea, cough, and fever for two days. The patient also complained of epigastric pain and intermittent emesis. She denied any significant prior medical or surgical history.
Physical exam revealed a toxic-appearing female in respiratory distress. Vital signs were temperature 100.5 F; blood pressure 103/76mmHg; heart rate 126bpm; respiratory rate 32bpm; and 99% oxygen saturation on room air. She had decreased breath sounds on the right side, and exhibited right upper quadrant tenderness on palpation. The cardiovascular exam was remarkable only for the tachycardia.
A portable chest radiograph (CXR) revealed complete atelectasis of the right lung with adjacent large right pleural effusion, causing mediastinal shift to the left, consistent with tension hydrothorax (Figure 1). A computed tomography (CT) angiogram of the chest confirmed the above findings; there was no evidence of pulmonary embolism or aortic dissection (Figure 2). An ultrasound-guided thoracentesis removed 1.5L of serosanguinous fluid. The patient reported relief of chest pain and dyspnea after the thoracentesis.
The patient was admitted to the hospital and treated for presumed pneumonia and sepsis with broad spectrum antibiotics. A purified protein derivative for tuberculosis was negative. She had a chest tube placed on hospital day 2 for recurrent right pleural effusion, with return of two liters of serosanguinous fluid. Pleural fluid cultures, acid fast bacteria (AFB) and cytology were all negative.
Because of worsening abdominal pain and distention, on hospital day 4 a CT of the abdomen/pelvis was ordered and revealed a pelvic mass of unclear uterine or adnexal etiology, with abdominal implants and ascites, suspicious for malignancy. A follow-up pelvic ultrasound was less suggestive of malignancy, and revealed two solid uterine lesions and an enlarged right ovary with cyst. Magnetic resonance imaging of the abdomen and pelvis revealed bilateral complex cystic adnexal structures with hemorrhage; a tubo-ovarian abscess was suspected.
On hospital day 14, the patient underwent laparoscopy with biopsy. Laparoscopy revealed blue-tinged lesions on the central omentum, a nodular omental lesion, and pelvic wall nodule. The peritoneum was described as having a fibrinous exudate with mucinous appearance along the surface. Biopsies of the omental and pelvic nodules confirmed the lesions to be consistent with endometriosis and a pelvic wall abscess. The final diagnosis was disseminated endometriosis resulting in tension hydrothorax and pelvic inflammatory disease. The patient was discharged on hospital day 22 to complete an outpatient course of antibiotics.