31 year old nulliparous lady presented with 2 months history of gradual worsening shortness of breath which was worse during periods of menstruation and was associated with dry cough and difficulty breathing on lying flat. Her shortness of breath was relieved by keeping an extra pillow while sleeping at night. Also had a history of mild abdominal distention noted during menstruation whereby she had with heavy and painful menses lasting 5 to 7 days with a concurrent history of failure to conceive despite seeking assistance from a fertility clinic. There was no history of fever, night sweat, weight loss, lower limb swelling, awareness of her heartbeat or easy fatigability. She otherwise had no significant family history of disease, no drug allergies and did not smoke or drink alcohol. During the course of the illness she reported use of different antibiotics and herbal medication without improvement. On examination she was alert, not pale, no lower limb edema and had stable vital signs. Respiratory system examination revealed normal chest appearance, bilateral chest expansion, trachea slightly deviated to the left side, reduced tactile vocal fremitus on the right side chest, stony dullness percussion note on right inframammary and intermammary region and absent breath on corresponding side. The left side of chest was normal. Per abdomen revealed mild distension, so scars, no obvious mass palpable nor tenderness with positive shifting dullness and rest of systemic examinations were normal. Was initially worked up in the family medicine outpatient department and referred to the gynecology department due to suspicion of Meigs syndrome due to findings of right sided pleural effusion on X-ray and abdominal ascites with ovarian enlargement on ultrasound. Baseline laboratory investigation results are as in. In the gynecology department was reviewed by a consultant gynecologist and discussion with consultant radiologist recommended computed topography (CT) scan of the chest and abdominopelvic which suggested right moderate pneumohemothorax with partial collapse of the right lower lobe (), bilateral enlarged complex ovarian masses with moderate left hydroureteronephrosis due abrupt tapering of the distal ureter (). General surgery team was involved and due to worsening respiratory distress chest tube for drainage was inserted on right side of chest which relieved the distress and samples of pleural fluid were taken. Results of the sample analysis revealed an acute inflammatory exudate containing abundant red blood cells and neutrophils. The patient was consented for diagnostic laparoscopy to be carried out by consultant general surgeon and gynecologist for tissue biopsy and possible resection of ovarian mass however was converted to explorative laparatomy due to extensive adhesions, endometriotic vesicles and poor visualization. Prior to conversion to laparotomy the urologist was involved and endoscopic double J stent was inserted into the left ureter to relive left ureteric narrowing as well as to ease visualization of ureter during laparotomy so as to minimize risk of iatrogenic ureteric injury. Abdomen was opened via sub umbilical midline incision with findings of hemorrhagic ascites, distorted pelvis with extensive adhesions and visible endometriotic vesicles suspicious of endometriosis. The pouch of Douglas was obliterated with endometriotic vesicles and fallopian tubes were distorted bilaterally with fimbria attached to the small bowels. Only the anterior portion of uterus was visualized. Bilateral multiple ovarian masses were seen largest measuring about 2 cm. Liver, kidney, urinary bladder and spleen appeared normal. Tissue biopsy from adhesions around fallopian tube was taken and adhesiolysis was done with histology revealing endometriosis (). Post-operative patient was kept on antibiotic, intravenous () Ceftriaxone 1 g every 12 h for 3 days and analgesia IV Paracetamol 1 g every 8 h for 3 days and intramuscular Pethidine 100 mg every 12 h for 1 day. In view of findings of extensive abdominal endometriosis, thoracic endometriosis was suspected as the cause of initial respiratory distress however due financial constraints and lack of expertise patient could not undergo bronchoscopy nor video assisted thoracoscopy. Hence decision to carry out chemical pleurodesis for symptomatic relief with bleomycin was done successfully (). Patient was discharged on 4th day post admission with minimal pain at incision site, no difficulty in breathing, no cough and scheduled to be followed up in the outpatient clinic with initiation of symptomatic treatment to reduce pain and heavy bleeding during menses due to endometriosis. At subsequent follow up visits at day 7, day 21, 6 weeks and 3 months patient had returned to daily activity with no episodes of difficulty in breathing and reduction in amount of volume of bleeding during menses. However she still complained of painful menses more so at the lower abdominal region. Of note ureteric stent were removed on day 21 post-surgery with subsequent imaging revealing resolution of hydronephrosis with no obvious ureteric obstruction.