Thoracic and Umbilical Endometriosis Concurrently Presenting During Secondary Subfertility Evaluation

Thoracic endometriosis is a rare manifestation of extra pelvic endometriosis and it is often missed because of its variable clinical presentation. A 33-year-old woman undergoing evaluation for secondary subfertility presented with a three-year history of cyclical periumbilical pain, swelling and occasional catamenial bleeding. Contrast-enhanced CT (CECT) abdomen and pelvis demonstrated an umbilical soft tissue nodule consistent with umbilical endometriosis which was histologically confirmed. Incidentally this CECT also revealed a right-sided pleural effusion with a pleural-based nodule despite absence of respiratory symptoms. Thoracentesis yielded haemorrhagic exudative fluid, while thoracoscopy showed multiple nodules and haemorrhagic cysts on parietal and visceral pleura. Histopathology and immunohistochemistry confirmed pleural endometriosis. The patient subsequently developed a pneumothorax requiring chest tube repositioning and was treated with gonadotropin-releasing hormone (GnRH) analogue therapy, resulting in complete symptomatic and radiological resolution at follow-up. Hormonal therapy was later discontinued to pursue conception; however, recurrence of pleural effusion occurred, necessitating continuation of the medication. This case highlights the silent and multifocal nature of extra-pelvic endometriosis.