Endometriosis presenting as catamenial pneumothorax, pneumopericardium and pneumoperitoneum

A nulliparous woman in her late 30s with a history of pericardial patch repair for atrial septal defect and completed treatment for pulmonary tuberculosis 9 years ago presented with chest pain, breathlessness and abdominal pain. Radiological imaging revealed right-sided pneumothorax, pneumopericardium and pneumoperitoneum for which an intercostal drain (ICD) was placed. A contrast-enhanced CT of the abdomen showed a distal stomach perforation, which was managed conservatively. The ICD was removed after complete lung expansion. She returned twice with similar symptoms coinciding with her perimenstrual period. Imaging suggested a right hemidiaphragm defect, indicating a pleuroperitoneal fistula. Definitive treatment involved laparoscopic diaphragmatic repair and pleurodesis. Histopathology of tissue from a supra-umbilical nodule confirmed endometriosis. Postsurgery, she was initiated on hormonal therapy and has had no recurrence. This case underscores the need to consider endometriosis in women of childbearing age with recurrent pneumothorax.