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Recurrent Pneumothorax
Dennis Scurry, Jr., MO, Harry C. Press, Jr., MD, and Oswald G. Warner, MD
Washington, D.C.

Clinical History ration. A left-sided 60 percent 3. Pneumomediastinum

A 36-year-old gravida 3, para 3,
black female was awakened from slecp
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 concur-
rent with onset of her menses. She
had no histoy of trauma, surgery,
infec-tion, or other diagnosis.
pneumothorax is appreciated that in-
creases during expiration. Note the
visceral pleural line confirming the
diagnosis.
What is your diagnosis?
1. Spontaneosly ruptured bulla
2. Pneumothorax secondary to sar
coidosis
4. "Catamenial" pneumothorax
Spontaneously Ruptured Bulla
A bulla is an air-containing space
within the lung, more than 1 cm in di-
ameter in the distended state. The

Physical Examination
The physical examination revealed:
blood pressure, 140/100; pulse, 80; res
piration, 20; and temperature, 98.8 F.
An S gallop was appreciated on aus-
cultation and an ECG showed occa-
sional premature ventricular
contrac-tions.
Radiologic Findings
Figures
1 and 2 show PA projections
of the chest during inspiration and expi

Requests for reprints should be addressed to Figure 1. PA view of the chest Figure 2. PA view of chest during
Dr. Harry C. Press, Jr., Department of Radiol demonstrating the left-sided pneu- expiration showing an increase in
ogy, Howard University Hospital, 2041 Georgia mothorax. the pneumothorax.
Avenue, NW, Washington, DC 20060.
JOURNAL OF THE NATIONAL MEDICAL ASsOCIATION, VOL. 70, NO. 5, 1978 363
walls of bullae are formed by pleura, ous pneumothorax temporally related esophagus or
connective tissue septa, or compressed to menstrual flow. The relationship be- tracheobronchia
l
lung parenchyma. These walls are quite tween pneumothorax and menses has t
thin and sharply defined. A bleb con- r
now been definitely established. With e
notes a collection of air within the e
few exceptions, all reported cases have ,
o
layers of visceral pleura. Bullae and
r
blebs have a predilection for upper occurred on the right side.34Two cases extension of gas Discussi
lobes, especially the extreme apex. of bilateral catamenial pneumothorax from below the dia on
Ruptured bullae and blebs are the most have now been reported.2.3 Analysis of the
common Patients with catamenial pneumo- phragm following causes of
cause thorax fall into a consistent patten. abdominal or pelvic spontane-
procedures have ous pneumothorax
of
been implicated as begins with a care-
They are parous women with an age causes. i
spontaneous Roentgenograp n ful clinical history.
range of 24 to 44 years. They have re- hic signs - A recent history of
clude a longitudinal
pneumothorax.' Bullae are usually as- shadow parallel to
trauma or
peated episodes, but pneumothorax the heart border and separated from the
surgery to the chest or ab-
sociated with generalized obstructive
domen must be
emphysema or chronic bronchitis, may not occur at every mensees. heart by gas. A elicited. Other
disease
neither of which affected this patient. Why pneumothorax occurs at the lateral projection
usu- entities that may
Bullae frequently are found in other- onset of menstruation is still not fully
be associated with
wise nomal lungs and asymptomatic understood nor adequately explained. ally demonstrates a
layer of extrapul- consi
patients and are frequently very dif Associated entities include endometrio-
monary gas in the pneumotho dered
ficult to detect roentgenologically retrosternal region. rax must be .
especially if they are located within the sis involving either the pleura or dia Some of these
phragm, or the presence of bullae, Displacement of air diseases (not
lung parenchyma.' Ruptured bullae or into the neck and discussed)
thoracic wall is are: spasmodic
blebs, therefore, should always be blebs, or scars. Congenital diaphrag-
another common asthma,
considered when determining the cause matic defects usually involving the find. staphylococcal
of a spontaneous pneumothorax. right side have been considered. This septicemia,
could explain the high incidence of ing pulmonary alveolar
mght-sided pneumothorax. . pro-
Pneumothorax to teinosis, and
primary or
Secondary
metastatic
Sarcoidosis carcinoma
Hospital Course of the
The diagnosis of sarcoidosis may be lungs.
The patient was admitted and a A
Catamenial pneumomediast
suspected from symmetrical hilar and water-seal type drainage was placed in Pneumothora
inum was
paratracheal lymph nodal enlargement. the left chest to re-expand the lung. x consid-
Partial bronchial obstruction results During this admission, a left-sided Cat er this patient
with air trapping and overflation. Al thoracotomy was performed with the ame pneumo e i because of
though sarcoidosis is an uncommon excision of an emphysematous bleb. A nial thorax isthe d n its
cause of spontaneous pneumothorax, it partial pleurectomy was performed on etio pne
term applied to the logi similar umo
the left apex. The pathologist reported
recurrent spontane c ities to a -
does occur bullous emphysematous changes, com-
and should always be patible with focal fibrosis and atelec-
considered because of the relatively tasis. Since then the patient has experi
high incidence of sarcoidosis in blacks. enced no recurrence of a
left-sided
pneumothorax. However, she was
Pneumomediastinum
Pneumomediastinum connotes the readmitted in each of the following
presence of gas in the mediastinal three
space.' It is rare in adults. Bronchiolitis months
with
and rupture of marginally situated al right-sided
veoli, trauma with nupture pneumothoraces concommitent with
of the the onset of her menstrual flow.
thorax, ie, spontaneous and traumatic. Clinical manifestation includes acute his-tory and physical in the
onset of retrosternal pain aggravated by respiration. Dyspnea may be severe. A interpretation of all radiography.
pneumomediastinum is iess likely be-cause it occurs more frequently in males. Referring physicians should always
It is of greater significance that the roentgenographic signs are those of a give the reason for the examination
pneumothorax rather than a pneumo-mediastinum. and radiologists should not perform
studies without this infor-mation.
Sarcoidosis was considered cause of its relatively high incidence in the
black population. It was quickly uled out because hilar lymph-nodal en-
largement was not present, nor was there any evidence of diffuse pulmo-nary Lterature Cited
disease. 1. Fraser RG, Pare JAP: Diagnosis of Dis-
ease of the Chest. W3 Saunders. 1970. p 1174
2. Littington GA, Mitchell SP, Wood
A spontaneously nuptured bulla GA: Catamenial pneumothorax. JAMA
219:1328 1332, 1972
must always be considered as acause for pneumothorax. Even though a 3. Wilhelm JL: Catamenial pneumotho rax-
bilateral occurrence whiie on suppressive
causal relationship has not been estab-lished, in one study demonstrable bul- therapy. Obstet Gynecol 50{2):227-231, 1977
lae, blebs, or scars were found in 13 of 32 patients with pneumothorax concur 4. Sheerin RPN, Hepper NGG, Payne WP:
rent with menses.' The possibility of ruptured
Hecurrent menses. Mayo Clin Proc 49:98-101,
blebs as the cause of pneumothoraces in this patient is in- ront with spontaneous pneumothorax concur-
creased in view of the fact that there has been no recurrence on the left side
1974
since the left pleurectomy.
There is a definite relationship with this patient's recurrent episodes of 5 Laws HL: Catamenial pneumothorax.
pneumothoraces and the onset of her menses. It is, therefore, very important Arch Surg 112(5):627-628, 1977
that a careful menstrual history is taken when a woman of child-bearing age is 6. Assor D: Endometriosis of the lung. Am
having
recurent JClin Pathol 57:311-315. 1972.
episodes 7. Davies R: Br J Dis Chest 65:222-224, 1971
of 8. Granber G: Endometriosis by aspira
pneumothorax. tion biopsy. Acta Cytol 21(2):295-297, 1977
In this case, a diagnosis beyond pneumothorax is impossible from the
radiographs. This presentation is made to emphasize the importance of the
364 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978