Infertility resolved after proper thoracic assessment: A case of disseminated endometriosis

We present a case involving a 36-year-old woman with a 14-year history of secondary infertility who presented with dyspnea. Initial evaluation revealed right-sided pneumothorax, managed with chest tube insertion, and subsequent high-resolution CT scan demonstrated small pleural nodules, fat stranding and nodularity of the omentum. Two months later, she had recurrent hydropneumothorax, managed again by chest tube insertion, revealing bloody pleural fluid. CT abdomen showed a right iliac fossa soft tissue mass attached to the cecum with non-visualization of the appendix, multiple peritoneal deposits and nodules, and a bulky right ovary. A multidisciplinary team agreed on thoracoscopic decortication with biopsies and laparoscopic appendectomy, confirming the diagnosis of disseminated endometriosis. Surgical management included right VATS decortication with partial pleurectomy, chemical pleurodesis, and repair of right hemi-diaphragmatic fenestration were done for worsening hydropneumothorax. Post-surgery, CT chest showed right-sided pleural collections and reduced right lung volume. The patient underwent thoracoscopic evacuation of clotted loculated hemothorax. Gynecology started Leuprolide therapy. Over the next 2 years, she remined asymptomatic with repeated x-ray revealing residual small right pleural effusion. After 16 years of infertility, the patient became pregnant over the follow up period. This case underscores the challenges of diagnosing and managing extra-pelvic endometriosis, emphasizing the need for a multidisciplinary approach. The patient's eventual pregnancy highlights the importance of timely and comprehensive management for complex endometriosis cases.