# An Atypical Case of Thoracic Endometriosis Syndrome Mimicking Pulmonary Tuberculosis

## TL;DR

A woman's recurring chest and pelvic symptoms were initially mistaken for tuberculosis but were later diagnosed as thoracic endometriosis, a rare condition linked to the menstrual cycle.

## Contribution

Highlights an atypical case of thoracic endometriosis syndrome mimicking pulmonary tuberculosis in a clinical setting with limited diagnostic awareness.

## Key findings

- The patient's symptoms correlated with her menstrual cycle, suggesting thoracic endometriosis syndrome.
- Diagnostic challenges persist in Tanzania due to nonspecific symptoms and lack of awareness.
- Histological confirmation revealed hemorrhagic ovarian cysts and salpingitis.

## Abstract

Background: Thoracic endometriosis syndrome (TES) is a rare form of endometriosis characterized by the presence of functioning endometrial tissue in the thoracic cavity. Patients are women of reproductive age, with a genetic link as a significant risk factor. Patients present with long-standing chest symptoms and signs that mimic pulmonary tuberculosis (PTB). The crucial issue for establishing the diagnosis is the cyclicity of signs and symptoms which occur along with the menstrual cycle.

Clinical Case: A 34-year-old businesswoman had recurrent pelvic pain and heavy menses for 6 years, recurrent chest pain for 5 years, and recently coughing blood for 3 days. Symptoms peaked during menstruation. She reported a maternal grandmother with similar symptomatology. For the past 6 years, she was treated for recurrent pneumonia and PTB without improvement. Examination revealed right-sided pleural effusion and generalized pelvic tenderness. The catamenial nature of her symptoms led to a suspicion of TES, with PTB. Pleural fluid analysis showed exudative effusion, and Gene X-pert for MTB was negative. CA-125 was elevated, a nonspecific endometriosis marker. Pelvic ultrasound revealed features of pelvic endometriomas. Serial chest X-ray and CT scan showed right hydropneumothorax, lung mass, lung collapse, and pulmonary fibrosis. Multiple chest tubes were placed for the recurrent hydropneumothorax management. Exploratory laparotomy with bilateral ovarian cystectomy was done, and histology revealed ovarian hemorrhagic cysts and salpingitis. Hormonal suppression initiated as mainstay of treatment. She is monitored monthly as an outpatient to assess treatment efficacy and condition progression.

Conclusion/Learning Points: TES is a form of endometriosis involving the thoracic cavity, affecting women of reproductive age. TES may mimic PTB but symptoms correlate with the menstrual cycle (catamenial in nature). In Tanzania, diagnostic challenges persist due to its nonspecific symptoms, inadequate clinicians' awareness, and lack of treatment guideline national wide.