A 31-year-old Nigerian woman with a history of endometriosis and primary infertility was referred to the hospital after an abnormal chest X-ray, which was performed for immigration purposes, showed a large right-sided pleural effusion. Despite having no respiratory or constitutional symptoms, an examination revealed dullness to percussion and absent breath sounds on the right lower and middle lung zones. The patient had a history of endometriosis four years prior, which was characterized by severe dysmenorrhea. Hormonal therapy was prescribed for three months, and an excisional biopsy was taken from an umbilical mass (Fig. 1) that occasionally bled during menses. The mass was later proven to be of endometrial origin.
Upon admission, a complete blood count was unremarkable except for mildly reduced hemoglobin and low albumin. C-reactive protein was normal, and initial work-up for Mycobacterium tuberculosis was negative. A chest X-ray (Fig. 2a) revealed pleural effusion, and pleural tapping yielded bloody fluid that was sent for analysis and microscopy. The analysis revealed glucose of 5.3 mmol/L, LDH 314 U/L, and protein of 47.7 gm/L. The total nucleated cells were 250/muL, and red blood cells (RBCs) were 104,062/muL (Table 1). Thoracoscopy showed extensively inflamed parietal pleura (Fig. 3), and a large bore chest tube was placed afterward. The tissue biopsy confirmed endometriosis.
An abdominal ultrasound revealed fluid in the right and left iliac fossae and a trace of fluid in the subcutaneous fat plane of the irregular umbilical mass. Chest computed tomography (CT) (Fig. 4) showed right pleural effusion with subtle pleural thickening and bilateral apical thickening, as well as mildly enlarged axillary lymph nodes mainly on the right.
During the patient's follow-up, re-accumulation of pleural fluid was discovered by an X-ray with her menstruation (Fig. 2d). A therapeutic thoracocentesis was done to prevent possible complications of the bloody effusion. After considering the patient's desire for using assisted reproductive technology, a multidisciplinary approach recommended right-side pleurodesis prior to any conception attempts and avoiding hormone suppressive therapy. Fig. 5 demonstrates the timeline order of events from the initial evaluation until the final treatment.