December 2020 Arizona Thoracic Society Notes

For a recording of the December 3, 2020 Arizona Thoracic Society meeting click here.

September 2019 Arizona Thoracic Society Notes

The September 2019 Arizona Thoracic Society meeting was held on Wednesday, September 18, 2019 at the Banner University Medical Center Phoenix beginning at 6:00PM. There were 16 in attendance representing the pulmonary, critical care, sleep, radiology communities.

An announcement was made that cases of acute lung injury suspected of being secondary to vaping should be reported to Poison Control (1-800-222-1222) or to the State Department of Health (602-364-3587).

There were 3 case presentations:

1. Warren Carll DO, a second-year pulmonary fellow from the Mayo Clinic Arizona, presented a case of a 26-year-old man who complained of a 4-month history of hemoptysis. He had a past medical history of gastroesophageal reflux disease and frequent eye infections. His hemoptysis was up to ½ cup per day and he presented to the Mayo Clinic emergency room when he became frustrated that his outpatient work up was proceeding slowly. Physical examination showed erythematous and injected conjunctiva. His thoracic CT scan showed bilateral ground glass opacities with areas showing a reverse halo sign. Bronchoscopy showed only an increased number of neutrophils on the bronchoalveolar lavage. Laboratory evaluation showed positive cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) at 1:1024 and a proteinase 3 (PR3) of >8U (normal <1). A diagnosis of granulomatosis with polyangiitis (GPA, formerly called Wegener's granulomatosis) was made and the patient responded to corticosteroids and was discharged with a plan for rituximab as an outpatient. Dr. Kevin Leslie discussed the pathology of GPA and pointed out that it is a capillaritis and despite the name well-formed, sarcoid-like granulomas are rarely seen.
2. Kurt Olson MD, a third-year pulmonary fellow at the University of Arizona Phoenix presented a 52-year-old woman who complained of progressive dyspnea and a dry cough for 2 years. She had a past medical history of gastroesophageal reflux disease. Thoracic CT scan showed bronchiectasis with fibrosis most prominent in the lower lungs and an enlarged esophagus. Antinuclear antibodies (ANA) and anti-Scl-70 (also known as antitopoisomerase 1) were both positive. Discussion centered around a recent report in the New England Journal of Medicine showing that nintedanib slowed the rate of decline in the forced vital capacity in scleroderma (1)
3. Dr. Lewis Wesselius presented a 51-year-old immunocompromised host from a heart transplant who presented with a week long history of increasing shortness of breath. His chest X-ray was unremarkable but his SpO2 was found to be decreased.  However, a thoracic CT scan showed ground glass opacities with peripheral sparing. Bronchoscopy with bronchoalveolar lavage was negative for infection. His chest x-ray worsened over 3 days and he was treated with high dose corticosteroids, however, he continued to decline. At about this time it was discovered he had been vaping cannabinoid oil. He gradually improved and his chest x-ray cleared. However, on outpatient follow-up he still had a decreased exercise capacity and his DLco was decreased on pulmonary function testing.

Steve Tseng DO, a third-year fellow at University of Arizona Phoenix, presented a summary of the experience at Banner University Medical Center Phoenix of bronchoscopic lung volume reduction using endobronchial valves. To date they have treated over 50 patients with about 50% showing an improvement in FEV1 of >15% after 3-6 months.

The meeting was adjourned about 8:00PM. The next meeting will be in about 2 months with location and time to be announced.

Reference

1. Distler O, Highland KB, Gahlemann M, et al. Nintedanib for systemic sclerosis-associated interstitial lung disease. N Engl J Med. 2019 Jun 27;380(26):2518-28. [CrossRef] [PubMed]

Cite as: Arizona Thoracic Society. September 2019 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2019;19(3):99-100. doi: https://doi.org/10.13175/swjpcc059-19 PDF 

November 2018 Arizona Thoracic Society Notes

The November 2018 Arizona Thoracic Society meeting was held on Wednesday, November 28, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 10 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting  the Tobacco 21 bill was discussed. This bill has been twice held up in the Arizona House of Representatives Commerce Committee by the committee chairman. It was noted that one of the healthcare executives had financially supported the reelection campaign of the commerce committee chairman. A decision was made to send a letter to the healthcare executive pointing the pro-tobacco stance of the committee chairman. CME for the Arizona Thoracic Society meetings was also discussed. CME case presentations that had been previously approved will be presented and CME granted through the University of Arizona.

There were 3 case presentations:

1. Dr. Richard Robbins presented for Dr. Robert Raschke a case of a 54-year-old man with neck pain that eventually proved to be a paraspinous abscess.
2. Dr. Mike Gotway presented a 36-year-old woman who presented with respiratory failure. She eventually proved to have been self-injecting hydrocodone.
3. Dr. Lewis Wesselius presented a 28-year-old man from Tennessee with enlarging lung nodules who had been treated for presumed histoplasmosis, but was clinically worsening. Lung biopsy demonstrated metastatic angiosarcoma. 

The meeting was adjourned about 8:30 PM. The next meeting will be on January 23, 2019 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Cite as: Robbins RA. November 2018 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2018;17(6):149. doi: https://doi.org/10.13175/swjpcc119-18 PDF

September 2018 Arizona Thoracic Society Notes

The September 2018 Arizona Thoracic Society meeting was held on Wednesday, September 26, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were representatives in attendance from the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting attendance was again discussed.

There were 3 case presentations:

1. Dr. Gerry Schwartzberg presented a case of a woman in her 70’s with diffuse cystic lung disease. She had a monoclonal gammopathy of undetermined significance due to light chain disease and the possibility of amyloidosis causing cystic lung disease was discussed.  
2. Dr. Lewis Wesselius presented a 28-year-old man from Tennessee with enlarging lung nodules who had been treated for presumed histoplasmosis, but was having hemoptysis and clinically worsening. Lung biopsy demonstrated metastatic angiosarcoma.  
3. Dr. Wesselius also presented a 44-year-old woman with diabetes and cavitary pulmonary coccidioidomycosis which involved both left upper lobe and left lower lobe which had progressed despite 400 mg/day of fluconazole who had been referred in 2012 for possible thoracotomy. Surgery was deferred since it would have required a left pneumonectomy. The fluconazole dose was increased, and cavity resolved gradually over 6 years.  This led to discussion of indications for surgery in cavitary coccidioidomycosis. 

The meeting was adjourned about 8 PM. The next meeting will be on November 28 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Lewis J. Wesselius, MD
President, Arizona Thoracic Society

Cite as: Wesselius LJ. September 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;17:116. doi: https://doi.org/10.13175/swjpcc109-18 PDF 

July 2018 Arizona Thoracic Society Notes

The July 2018 Arizona Thoracic Society meeting was held on Wednesday, July 25, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 8 in attendance representing the pulmonary, critical care, sleep, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

• The dwindling attendance at these meetings. It was decided to again reach out to the pulmonary fellowship programs at Mayo, University of Arizona Phoenix and University of Arizona Tucson.
• The two recent cases of pharmacists refusing to dispense medications was discussed without coming to a consensus. One physician said he would refuse to submit prescriptions to the Peoria Walgreens.
• Discussion regarding the Tobacco 21 which had been killed in committee by Rep. Jeff Weninger was tabled until the next meeting.

There were 2 case presentations:

1. Dr. Lewis Wesselius presented a 67-year-old woman who had increasing shortness of breath. She was started on prednisone by another physician and her dyspnea improved although it recurred when her prednisone was tapered. Unfortunately, she gained 30 lbs. while on the prednisone. The patient did not smoke. She had a few crackles at her right base but otherwise the physical examination was normal. She desaturated with exercise. Her CT scan showed ground glass opacities with multiple small cysts. PFTs were restrictive with a DLCO of 55% of predicted. She was further questioned about additional symptoms and stated she had dry mouth and eyes for years. Rheumatology consultation was ordered, her SSP and SSA were both positive, and she had a diagnosis of Sjogren’s syndrome made. Because she was symptomatic it was thought she needed to treatment but she did not want to take prednisone again. For this reason, she was begun on mycophenolate.
2. Dr. Gerald Schwartzberg presented a 62-year-old man who was seen in the office with shortness of breath. Physical examination was normal and he had normal PFTs. He was admitted to the hospital a couple of weeks later after a trip with a pulmonary embolus. Discussion centered on when a CT angiogram should be ordered. There was a consensus that a CT-angiogram did not need to be done in all patients complaining of dyspnea but no consensus on criteria for whom it should be ordered.

The meeting was adjourned about 8 PM. The next meeting will be on September 26 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins MD

Editor, SWJPCC

Cite as: Robbins RA. July 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;17(1):41. doi: https://doi.org/10.13175/swjpcc095-18 PDF

March 2018 Arizona Thoracic Society Notes

The March 2018 Arizona Thoracic Society meeting was held on Wednesday, March 28, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 12 in attendance representing the pulmonary, critical care, sleep, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

1. The Tobacco 21 which had been introduced into the Arizona House was killed in committee by Rep. Jeff Weninger, Chairman of the Commerce Committee.
2. Council of Chapter Representatives (CCR) Meeting and “Hill Day” was cancelled due to inclement weather. It will probably be rescheduled for the summer.

An update on pirfenidone in IPF was presented by Jessica Castle, PhD, Medical Science Liaison with Genentech. Dr. Castle discussed the antifibrotic, anti-inflammatory, and anti-oxidant effects of pirfenidone.

Data was also presented from post-hoc analysis from pirfenidone trials.

• Overall no difference in morality data
• Reduction in respiratory hospitalizations
• Reduction in deaths after respiratory hospitalizations
• Quantitative Image Analysis showed a decrease in fibrosis with pirfenidone

Lastly, Dr. Castle introduced several ongoing trials with combination therapy for IPF.

There were 3 case presentations:

1. Dr. Tim Kuberski, Chief of Infectious Disease at Maricopa, presented a 45-year-old Caucasian man who collapsed in the market and was brought to Maricopa Medical Center. He had evolving gangrene of his distal extremities which proved to be secondary to Yersinia pestis. He received continuous sympathetic blockade to treat his gangrene (1). The patient’s gangrene of his toes resolved but he did require amputation of his fingers and reconstruction of his ears and nose.
2. Dr. Richard Robbins presented a 54-year-old man with triad asthma, eosinophilia and coronary artery spasm. He was begun on montelukast and was doing well. He presented a series from New Zealand of 15 patients with eosinophilia and coronary artery spasm (2). Four of the patients were noted to have asthma. No one could recall a similar case.
3. Dr. Lewis Wesselius presented an 72-year-old woman who was a life-long nonsmoker with progressive dyspnea over 3-4 years. She had bibasilar crackles on physical examination and a low DLco on pulmonary function testing. Thoracic CT scan showed subtle changes of bibasilar reticulation. This did not appear to be UIP. Biopsy showed rather uniform changes with alveolar wall thickening but not areas characteristic for a definitive diagnosis. The consensus was that her case was most likely chronic hypersensitivity pneumonitis.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix on May 23 at 6:30 PM at HonorHealth Rehabilitation Hospital. This will be a planning meeting to structure Arizona Thoracic Society meetings and activities.

Richard A. Robbins MD

Editor, SWJPCC

References

1. Kuberski T, Robinson L, Schurgin A. A case of plague successfully treated with ciprofloxacin and sympathetic blockade for treatment of gangrene. Clin Infect Dis. 2003 Feb 15;36(4):521-3. [CrossRef] [PubMed]
2. Wong CW, Luis S, Zeng I, Stewart RA. Eosinophilia and coronary artery vasospasm. Heart Lung Circ. 2008 Dec;17(6):488-96. [CrossRef] [PubMed]

Cite as: Robbins RA. March 2018 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2018;16(3):170-1. doi: https://doi.org/10.13175/swjpcc051-18 PDF 

January 2018 Arizona Thoracic Society Notes

The January 2018 Arizona Thoracic Society meeting was held on Wednesday, January 24, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 11 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting several issues were discussed:

1. CME for Arizona Thoracic Society Meetings. Dr. Robbins will be going to Washington and will meet with the ATS concerning obtaining CME for the Arizona Thoracic Society meetings.
2. Tobacco 21. It was unclear if any action was occurring. Dr. Parides said he would check.
3. Council of Chapter Representatives (CCR) Meeting and “Hill Day”. Dr. Robbins will be attending the CCR meeting March 21-22 for Dr. Schwartzberg. This includes meeting with the Arizona Congressional representatives. Those that have issues they wish presented to either the ATS leadership or their legislators should contact Dr. Robbins at rickrobbins@cox.net. 

There were 4 case presentations:

1. Dr. Gerry Swartzberg presented a follow-up of a now 74-year-old who was presented in 2014 who was asymptomatic but with a CT scan showing cysts.  No diagnosis was made at that time. She has been followed for the last 3 years. She now has some shortness of breath with exertion. It was discovered that she had cockatiels. A complete “bird” hypersensitivity was recommended but the patient declined because of cost. A repeat CT in late 2017 showed that the cysts had enlarged. A pigeon serum serologic test was positive. Dr. Gotway pointed out that lung cysts can occur with hypersensitivity pneumonitis (1). A biopsy was performed which showed necrotizing granulomas without any organisms. Although she got rid of her cockatiels, further history reveals that the patient still feeds pigeons.  The consensus (although by no means unanimous) was this was likely hypersensitivity pneumonitis with an unusual presentation. It was thought that a trial of steroids might be beneficial.
2. Dr. Lewis Wesselius presented a 75-year-old woman with a thymic carcinoid tumor diagnosed in 2015. She was treated with resection and radiation therapy. CT scan showed changes consistent with radiation pneumonitis. Bronchoscopy with transbronchial biopsy showed “organizing pneumonitis”. She was treated with corticosteroids for 1 month. CT scan showed some improvement and the steroids were tapered. Her symptoms recurred and she was again started on corticosteroids with improvement but after tapering her steroids, her symptoms again recurred. CT scan showed marked worsening of the lung infiltrates. A bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy was performed. The BAL showed 12% eosinophils and the biopsy was consistent with chronic eosinophilic pneumonia.
3. Dr. Wesselius also presented a 79-year-old woman who had a right upper lobe resection for non-small cell lung cancer. A follow-up CT scan sometime later showed ground glass opacities (GGOs). A decision was made to follow the GGO’s but a year later CT scan showed worsening of the lesions. Navigational bronchoscopy was nondiagnostic. After a tumor board conference, she received radiation therapy for presumed carcinoma. She was followed but again had increasing shortness of breath. CT scan showed changes consistent with radiation pneumonitis. A long discussion ensued about empiric radiation therapy.
4. Dr. George Parides presented a woman with a clinical history consistent with idiopathic pulmonary fibrosis (IPF) and a CT scan which showed ground glass opacities. Most felt that this was IPF. Pirfenidone was started. A discussion about therapies, including experimental therapies for IPF ensued.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix on March 28 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins MD

Editor, SWJPCC

Reference

1. Franquet T, Hansell DM, Senbanjo T, Remy-Jardin M, Müller NL. Lung cysts in subacute hypersensitivity pneumonitis. J Comput Assist Tomogr. 2003 Jul-Aug;27(4):475-8.[CrossRef] [PubMed]

Cite as: Robbins RA. January 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;16(1):51-2. doi: https://doi.org/10.13175/swjpcc018-18 PDF 

November 2017 Arizona Thoracic Society Notes

The November 2017 Arizona Thoracic Society meeting was held on Wednesday, November 15, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with a lecture followed by case presentations. There were 15 in attendance representing the pulmonary, critical care, sleep, allergy, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

1. CME offered by the Southwest Journal of Pulmonary and Critical Care Medicine (SWJPCC) is currently offered to only the Southwest state thoracic societies and the Mayo Clinic. After discussion it was felt that this restriction of access was no longer appropriate and CME credits should be available to all.
2. Efforts continue to obtain CME for the Arizona Thoracic Society meetings. Our Chapter Representative, Dr. Gerry Schwartzberg, is approaching this with the American Thoracic Society. Locally, HonorHealth sent out a survey on CME needs. Members were encouraged to fill out the survey suggesting HonorHealth offer CME for these meetings.
3. No one was able to attend the last Tobacco 21 meeting in late October. In order to keep the Arizona Thoracic Society in the loop, Dr. Rick Robbins will contact the American Lung Association to clarify if any legislation has been proposed for this year. 
4. Dr. Robbins also proposed conducting a survey of members through the SWJPCC rating various insurance plans.

“Eosinophils: A Potent Contributor to Disease in Severe Asthma” was presented by Kevin Murphy, MD from the University of Nebraska Medical Center in Omaha.

Dr. Murphy reviewed the pathophysiology of eosinophils in asthma making use of a figure from Nat Immunol 2015;16:45-56. He also described the clinical usage of benralizumab made by AstraZeneca, the sponsor of the talk. Benralizumab induces apoptosis of eosinophils. On Tuesday, the FDA approved benralizumab for the add-on maintenance treatment of patients age 12 years and over with severe asthma with an eosinophilic phenotype. Questions included how an eosinophilic phenotype was defined and if the monoclonal antibody might work in asthma with a neutrophilic phenotype. Although data was lacking it was thought by Dr. Murphy that benralizumab would probably not be beneficial in a neutrophilic phenotype.

There were 4 case presentations:

1. Dr. Paul Conomos presented a middle-aged woman with long-standing rheumatoid arthritis who has been multiple therapies but none with the success of biologic therapies. She has a history of an atypical Mycobacterium in the skin in 2007 and on chest x-ray she has progressive lung nodules. She was asymptomatic. Bronchoscopy was nondiagnostic and a needle biopsy of one of the nodules showed granuloma. Discussion on whether to proceed to video-assisted thorascopic surgery (VATS). The majority felt that continued observation was the most appropriate course at this time.
2. Dr. Lewis Wesselius presented a 52-year-old woman from Iowa with a previous diagnosis of possible sarcoidosis. She complained of a cough and heaviness in her chest. Thoracic CT showed a left hilar mass. Bronchoscopy with endobronchial ultrasound was done in Iowa but was nondiagnostic. A follow-up CT scan showed progression of the mass and that a left lung lesion had developed. Bronchoscopy was nondiagnostic. Histoplasmosis complement-fixing antibodies were positive at 1:16 (normal < 1:8). Needle biopsy of the mass showed chronic inflammation and VATS showed fibrosis with granulomatous inflammation. No cultures from any of the procedures were positive. She was placed on itraconazole and has clinically improved. Dr. Wesselius proposed that perhaps the patient has fibrosis with a variance of fibrosing mediastinitis (1).
3. Dr. Wesselius presented a 67-ear-old woman he had seen that afternoon with cough and sputum production who had nonpitting edema. Thoracic CT scan showed bronchiectasis but no pleural effusions. The patient’s fingernails were discolored yellow typical of yellow nail syndrome.
4. Dr. Rick Robbins presented a 69-year-old man from Bismarck, ND who presented with cough and a rash typical erythema nodosum on the right ankle which had been present for 6 months. Chest x-ray showed multiple nodules in the right lung.  Both coccidioidomycosis IgM and IgG were positive. The patient was begun on fluconazole and after a week felt better. In the context of Dr. Gerry Schwartzberg’s recent Medical Image of the Week: Erythema Nodosum, Uncle Jun was right, “They come in threes.” This case would be the third in addition to Dr. Schwartzberg’s two cases.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix in January (date TBA) at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins, MD

Reference

1. Koksal D, Bayiz H, Mutluay N, Koyuncu A, Demirag F, Dagli G, Berktas B, Berkoglu M. Fibrosing mediastinitis mimicking bronchogenic carcinoma. J Thorac Dis. 2013 Feb;5(1):E5-7. [CrossRef] [PubMed]

Cite as: Robbins RA. November 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(5):225-6. doi: https://doi.org/10.13105/swjpcc141-17 PDF

September 2017 Arizona Thoracic Society Notes

The September 2017 Arizona Thoracic Society meeting was held on Wednesday, September 27, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

There was a discussion of the Tobacco 21 bill which had been introduced the last session in the Arizona State Legislature. Since it seems likely that the bill will be reintroduced, the Arizona Thoracic Society will support the bill in the future. Dr. Rick Robbins announced that the SWJPCC has applied to be included in PubMed. In addition, Dr. Robbins was assigned the task of tracking down the campaign contributions to congressional members from the tobacco PAC before the next election.

There were 7 case presentations:

1. Ashley L. Garrett, MD, pulmonary fellow at Mayo, presented an elderly man with insulin-dependent diabetes who felt he had inhaled a pill. He takes multiple medications and was unsure which pill he might have inhaled. Since the inhalation, he was bothered by coughing.  His chest x-ray was normal. Bronchoscopy revealed severe left lower lobe bronchitis. No pill fragments were seen. He was managed conservatively and his coughing has nearly resolved. A discussion of pill aspiration ensued with an article published in Chest forming the basis for discussion (1).
2. Paul Conomos, M.D. presented a case of a 57-year-old woman who is largely asymptomatic but has had worsening bronchiectasis on serial CT scans since 2006. She is a nonsmoker. The CT scans show typical tree-in-bud bronchiectasis most marked in the right upper lobe but present in scattered areas throughout both right and left lungs. Her pulmonary function tests showed mild-moderate obstruction. Bronchoscopy times three with bronchoalveolar lavage and cultures has been unrevealing. Alpha-1 antitrypsin levels and esophageal pH monitoring were normal. Sweat chloride was equivocal at 44 and 50 millimoles per liter. Gene sequencing was recommended but too expensive for the patient ($2500, her copay $900). Discussion focused on whether further work up should be done and whether treatment was necessary. Most felt the work up was fairly comprehensive and that treatment was probably not indicated since she was not symptomatic.
3. Dr. Conomos also presented a second case of an 18-year-old from the Congo who presented with a chronic cough and hemoptysis. PPD was reported by the patient as negative. Physical examination was unremarkable. Chest x-ray showed a right lower lobe mass and thoracic CT scan showed right lower lobe (RLL) bronchiectasis with a question of a foreign body. Bronchoscopy showed obstruction in the lateral subsegment of the RLL with a mass with what appeared to be a stone. The patient was referred to thoracic surgery but returned 6 days later with fever and pleuritic chest pain. Chest x-ray showed RLL pneumonia. The patient underwent a RLL lobectomy. A foreign body was present. In retrospect, his mother recalled him inhaling a super glue cap when he was 7 or 8 years old. He was doing well post-operatively.
4. Dr. Gerald Schwartzberg presented 3 cases. The first was 43-year-old woman who developed erythema nodosum after a month history of sharp pleuritic chest pain and multiple other systemic complaints. Her eosinophil count was 13% and cocci serologies were weakly positive. Discussion centered on treatment. Most favored treatment although it was agreed that data supporting treatment was lacking.
5. Dr. Schwartzberg presented a second case of 75-year-old woman with mild COPD on albuterol only. She was a smoker and complained of a cough productive of green sputum. Chest x-ray revealed a large left mass with mucoid impaction. Bronchoscopy revealed hyphae with 45º branches typical of Aspergillus on biopsy. Thoracic CT scan showed bronchiectasis. An IgE was suggested. Several were suspicious of lung cancer and suggested a needle biopsy of the mass.
6. The last of Dr. Schwartzberg’s cases was a 92-year-old man who was found to have a polyp on upper GI endoscopy and a chest x-ray which showed a mass. Biopsies of both stained positive for melanin and were consistent with malignant melanoma. He was referred to oncology. Discussion centered on whether he should receive treatment.
7. Dr. Lewis Wesselius presented a 67-year-old man with a right neck mass found in 2015. Biopsy revealed a high-grade sarcomatoid cancer. At that time a CT/PET of the chest was negative. About 6 months later a CT/PET revealed new areas of tracer accumulation within the liver. His chemotherapy was switched to ipilimumab and nivolumab. A repeat CT/PET showed symmetric bilateral mediastinal lymphadenopathy. An endobronchial bronchial ultrasound (EBUS) biopsy of the nodes showed noncaseating granuloma consistent with sarcoidosis. He was begun on corticosteroids and nodes and liver lesions resolved on CT/PET. Discussion centered on sarcoidosis induced by these newer checkpoint inhibitors. It was speculated that drug-induced sarcoidosis might be observed more commonly as these agents are more frequently used (2,3).

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, November 15, 2017 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins, MD

References

1. Kinsey CM, Folch E, Majid A, Channick CL. Evaluation and management of pill aspiration: case discussion and review of the literature. Chest. 2013 Jun;143(6):1791-5. [CrossRef] [PubMed]
2. Reuss JE, Kunk PR, Stowman AM, Gru AA, Slingluff CL Jr, Gaughan EM. Sarcoidosis in the setting of combination ipilimumab and nivolumab immunotherapy: a case report & review of the literature. J Immunother Cancer. 2016 Dec 20;4:94. [CrossRef] [PubMed]
3. Danlos FX, Pagès C, Baroudjian B, et al. Nivolumab-induced sarcoid-like granulomatous reaction in a patient with advanced melanoma. Chest. 2016 May;149(5):e133-6. [CrossRef] [PubMed]

Cite as: Robbins RA. September 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(3):122-4. doi: https://doi.org/10.13175/swjpcc118-17 PDF

March 2017 Arizona Thoracic Society Notes

The March 2017 Arizona Thoracic Society meeting was held on Wednesday, March 22, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There 11 attendance representing the pulmonary, critical care, sleep, thoracic surgery and radiology communities.

There was a discussion of supporting the Tobacco 21 bill which had been introduced into the Arizona State Legislature. The bill was assigned to the House Commerce Committee but was not scheduled for a hearing by the Chair-Representative, Jeff Weninger from Chandler. It seems likely that the bill will be reintroduced in the future and the Arizona Thoracic Society will support the bill in the future.

Three cases were presented:

1. Dr. Bridgett Ronan presented a 57-year-old man with cough and shortness of breath. His physical examination and spirometry were unremarkable. A thoracic CT scan showed large calcified and noncalcified pleural plaques and mediastinal lymphadenopathy. A bronchoscopy showed some mild thickening and a cobblestone appearance of the LUL bronchus. Bronchoalveolar lavage was unremarkable. Biopsy of the LUL bronchus showed noncaseating granuloma. Discussion ensued of whether this was sarcoidosis. Most agreed that calcified pleural plaque-like lesions would be unusual for sarcoidosis and that further investigation with complete pulmonary function testing and perhaps VATS was warranted. Most favored not treating the patient empirically with corticosteroids.
2. Dr. Lewis Wesselius presented a 41-year-old man was referred because of cough, hemoptysis and recurrent pneumothorax. His thoracic CT showed scattered nodules, some cavitated, with surrounding ground glass opacities. He eventually came to open lung biopsy. A tentative diagnosis of Ehlers-Danlos was made. This will be the April 2017 Pulmonary Case of the Month (click to be directed to the case which will be posted on 4/1/17). Please see the entire case presentation for details and discussion.
3. Dr. Rick Robbins presented a case from Dr. Michael Gotway of a 48-year-old non-smoking woman with a history of hysterectomy and right oophorectomy, and cholecystectomy, otherwise previously healthy, who presented with a spontaneous pneumothorax. Her thoracic CT scan showed multiple small cysts. She also had follicular lesions on her face. Biopsy of the facial lesions revealed fibrofolliculomas, or hamartomas of the hair disc. Fibrofolliculomas with lung cysts are relatively specific for Birt Hogg Dubé syndrome. This case was the November 2015 Imaging Case of the Month (click to be directed to the full presentation). Please see the entire case presentation for details and discussion.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, May 24, 2017 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins, MD

Cite as: Robbins RA. March 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;14(3):125-6. doi: https://doi.org/10.13175/swjpcc038-17 PDF

January 2017 Arizona Thoracic Society Notes

The January 2017 Arizona Thoracic Society meeting was held on Wednesday, January 25, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting (prime rib) with case presentations. There was a good attendance representing the pulmonary, critical care, sleep, and radiology communities.

There was a discussion of supporting the Tobacco 21 bill which has been introduced into the Arizona State Legislature. There was unanimous support for this bill. Another bill to allow school nurses to administer an albuterol inhaler without a doctor’s prescription was also discussed but the members wanted more information.

The new CDC Ventilator-Associated Events (VAE) criteria were also discussed. Before endorsing or opposing the this as a measure, the members wished more information.

It was decided that a decision on both would be postponed until discussed at the next meeting.

Three cases were presented:

1. Dr. Lewis Wesselius from the Mayo Clinic presented a case of a 53-year-old woman who presented with hemoptysis. The hemoptysis was eventually shown to be secondary to mitral stenosis. There were some dramatic photographs from the bronchoscopy of hyperemic airways with dilated submucosal veins. This case was also presented as the January 2017 Pulmonary Case of the Month in the SWJPCC.
2. Dr. Kyle Henry from Banner University Phoenix/VA presented a case of combined emphysema and pulmonary fibrosis. The pros and cons of establishing a diagnosis were discussed. Although a biopsy would be considered ideal, the patient was severely hypoxemic.
3. Dr. Gerald Swartzberg presented several cases of cavitary coccidioidomycosis. A discussion followed regarding management of cavitary cocci ensued.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, March 22, 2017 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Lewis J. Wesselius, MD

President, Arizona Thoracic Society

Cite as: Wesselius LJ. January 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;14(1):42. doi: https://doi.org/10.13175/swjpcc010-17 PDF

November 2016 Arizona Thoracic Society Notes

The November 2016 Arizona Thoracic Society meeting was held on Wednesday, November 17, 2016 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Two cases were presented:

1. Dr. Lewis Wesselius presented a case of a 29-year-old man from India on a work visa who complained of right pleuritic pain. Chest x-ray showed a large right pleural effusion. CT scan confirmed the presence of effusion with minimal lung parenchyma changes or mediastinal adenopathy. Gold quantiferon was positive and coccidioidomycosis serology was negative. Thoracentesis showed a lymphocytic predominant effusion and adenosine deaminase was borderline high. No acid-fast bacilli (AFB) were seen in the fluid. PCR for M. tuberculosis was negative. The pleural biopsy did show AFB and eventually grew M. tuberculosis. The patient was started on a 4 drug regimen. Dr. Wesselius gave a short presentation on the sensitivity of the various diagnostic tests for M. tuberculosis.
2. Dr. Richard Robbins presented the case of a 45-year-old Iraqi war veteran who was referred for COPD based on abnormal blood gases. The arterial blood gases showed a PaO2 40 mm Hg, PaCO2 82 mm Hg, pH 7.12, HCO3 34 mEq/L, and SaO2 76. The patient was diagnosed with hypoventilation probably secondary to narcotic abuse which he took for chronic back pain. He was admitted to the ICU but unfortunately administered high flow oxygen and was intubated. He was subsequently given naloxone but became awake and combative. After sedation and small doses of morphine, he was quickly liberated from mechanical ventilation, transferred to the floor and discharged. He did complain to the patient advocate on discharge about the smaller doses of narcotics he was give. A discussion followed regarding narcotic abuse, patient satisfaction, and mortality.

Dr. Parides has been approached regarding having the Arizona Thoracic Society meetings at Select Hospital in Scottsdale. In addition, he has been in contact with Dr. Rajeev Saggar at Banner University Medical Center Phoenix regarding having Arizona Thoracic Society meetings with a video link to Tucson.

Dr. Parides presented a plaque to Dr. Lewis Wesselius who is the Arizona Thoracic Society clinician of the year (Figure 1).

Figure 1. Dr. George Parides (left) presented a plaque to Dr. Lewis Wesselius as Arizona Thoracic Society Clinician of the Year.

A discussion was held regarding the recent American College of Graduate Medical Education (ACGME) decision to allow first year house officers to work 28 hours while on call rather than 16 (1). This is based on a study published in the New England Journal of Medicine in February, 2016 (2). After much discussion, a motion was made by Dr. Parides and seconded by Dr. Alp Umar to draft a letter to the ACGME during this public comment period favoring that ACGME decisions on resident work hours being made on data rather than emotion or politics.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, January 25, 2016 at 6:30 PM location to be announced prior to the meeting.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Robbins RA. ACGME proposes dropping the 16 hour resident shift limit. Southwest J Pulm Crit Care. 2016;13(5):216-7. [CrossRef]
2. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016 Feb 25;374(8):713-27.  [CrossRef] [PubMed]

Cite as: Robbins RA. November 2016 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2016;13(5):246-7. doi: https://doi.org/10.13175/swjpcc119-16 PDF 

July 2016 Arizona Thoracic Society Notes

The July 2016 Arizona Thoracic Society meeting was held on Wednesday, July 27, 2016 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Prior to the case presentations, a discussion was held on 4 issues. First, Dr. Rick Robbins  gave a summary of ATS Hill Day. During Hill Day a presentation was given by a representative from the Campaign for Tobacco-Free Kids. Their web site lists tobacco company contributions to members of Congress on their web site. Dr. Gary Ewart from the ATS office in Washington gave a presentation on the Traditional Cigar Manufacturing and Small Business Jobs Preservation Act before Congress (aka the Cigar Bill) which the ATS opposes. He noted that cosponsors for the bill included several Congressmen from Southwestern states. Dr. Robbins combined the two sets of data to see if there was a correlation between the tobacco company contributions and cosponsorship of the Cigar Bill. There was a highly significant correlation and Dr. Robbins asked the group if they felt this data was worthy of publication in the SWJPCC. The consensus was that Dr. Robbins should write an article and send it out for review.

Second, the Arizona Hospital Executive Compensation Act 2016 was discussed. This is an Arizona state proposition to limit hospital executive pay to $450,000/year which was circulated by Service Employees International Union and submitted to the Arizona Secretary of State to include on the November ballot. Although the required number of signatures were present, the validity of those signatures is being challenged by Arizona Chamber of Commerce. The Arizona Hospital and Healthcare Association said a cap on executive pay would "harm healthcare and hurt patients.“ Dr. Robbins asked if a survey through the SWJPCC should be conducted to determine whether the act would harm patients. After discussion, the Arizona Thoracic Society asked Dr. Robbins to conduct the survey the report on the results.  

Third, a discussion was held on Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The ATS along with other groups has been asked for input for quality measures. However, Rep. Kevin Brady (R-Texas), chairman of the House Ways and Means Committee, was recently quoted by Medpage Today as saying “MACRA is a good law, but I'm frustrated with the implementation…The heart of this [was supposed to be] how do you measure quality? Should we measure it from Washington, or measure the best practice of what is occurring in that region or in those physician practices?” (1). After discussion and noting that many previous quality measures are not evidence based, the Arizona Thoracic Society thought that local input was important. Dr. Robbins is to ATS CCR representatives from the Southwest and to report to a committee consisting of Dr. Wesselius, Parides and Robbins to determine how best to voice the Arizona Thoracic Society's input into determining quality measures.

Lastly, Dr. Parides moved to name Dr. Lewis Wesselius as the Arizona Thoracic Society clinician of the year. This was unanimously approved.

Dr. Lewis Wesselius presented a 52-year-old woman with a past renal transplant for eclampsia and hypertension who presented with a low grade fever 38.2º C and a right upper lobe mass. Her coccidioidomycosis serology was negative. Bronchoscopy with bronchoalveolar lavage was performed but was initially non-diagnostic.

After bronchoscopy, the mass markedly enlarged but the patient refused further diagnostic studies since despite her worsening radiologic appearance, she felt somewhat better. Her Legionella serology subsequently returned positive as did her Legionella culture from her bronchoscopy. She was treated with levofloxacin and markedly improved.

Dr. Gerry Swartzberg presented two cases of positive Gold Quantiferons in an asymptomatic 76 year old woman whose father had tuberculosis and a 35 year drug addict. After discussion, the consensus was not to treat the elderly woman but treat the younger drug addict.

Dr. George Parides again asked for input on bringing more young people into the Arizona Thoracic Society. Several suggestions were given and several members said they would contact the local fellowship directors.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, September 28, 2016 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. July 2016 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2016;13(1):38-9. doi: http://dx.doi.org/10.13175/swjpcc071-16 PDF

March 2016 Arizona Thoracic Society Notes

The March 2016 Arizona Thoracic Society meeting was held on Wednesday, March 23, 2016 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 17 in attendance representing the pulmonary, critical care, sleep, and radiology communities. Of note, Dr. Elijah Poulos drove from Flagstaff to attend the meeting.

Dr. Rick Robbins gave a summary of ATS Hill Day and the possibility of collecting dues for the Arizona Thoracic Society along with American Thoracic Society dues. Dr. Robbins also presented the results of emailing the Table of Contents of the Southwest Journal of Pulmonary and Critical Care to the ATS members in Arizona, New Mexico, Colorado, and Nevada along with listing the contents in Inspirations the California Thoracic Society newsletter. The number of page views doubled over usual the following day.

Dr. George Parides presented a short presentation on whether coccidioidomycosis nodules in the setting of biologics for rheumatoid arthritis should receive fluconazole and the new coccidioidomycosis skin test under development.

Dr. Lewis Wesselius presented a plaque to Dr. Robbins who was voted 2016 Arizona Thoracic Society clinician of the year (Figure 1).

Figure 1. Dr. Lewis Wesselius (left) presenting a plaque to Dr. Rick Robbins.

There were 5 case presentations:

1. Dr. George Parides presented a 67-year-old man with a thin walled cavity and positive coccidioidomycosis serology who was unable to tolerate fluconazole and voriconazole. There were several possible therapies suggested including posaconazole or resection of the cavity.
2. Dr. Elijah Poulos presented a case of 44-year-old woman who had occupational exposure to mineral spirits and presented with a chronic dry cough. Chest x-ray showed bilateral apical infiltrates. Thoracic CT scan confirmed the presence of the infiltrates which appeared lobular. Physical examination and laboratory evaluation including induced sputum specimens were unrevealing. A bronchoscopy with bronchoalveolar lavage and transbronchial biopsy were performed. The biopsy was consistent with acute eosinophilic pneumonia. Because her cough and CT scan were improving no therapy was given. A follow-up CT scan showed resolution of the apical consolidations but a new rounded 4 cm area of consolidation but her cough has resolved and she is now asymptomatic. The group suggested several possibilities including possible lipoid pneumonia or possible cryptogenic organizing pneumonia. The majority felt that following the patient was the most appropriate course of action.
3. Dr. Paul Conomos presented a case of a 43-year-old man who had an incidental finding of a vessel in the left lower lung originating from the abdominal aorta.  The abdominal CT scan was performed for abdominal pain which quickly resolved. He had no respiratory symptoms. It was that this was likely a pulmonary sequestration and discussions with invasive radiology to better define the vascular supply and thoracic surgery for possible resection  might be useful.
4. Dr. Lewis Wesselius presented a case of an 65-year-old woman who presented to her gastroenterologist with anemia and some weight loss. A thoracic CT scan was performed which suggested a tracheal abnormality, possibly a tracheal wall lesion. Bronchoscopy showed a smooth indentation in the trachea with a yellowish discoloration. A similar yellowish area was seen near the main carina. Biopsies were performed. Congo red stain was positive consistent with amyloidosis.
5. Dr. Allen Thomas presented a 62-year-old man with symptoms of an upper respiratory infection beginning in January who improved sufficiently that he rode his motorcycle near Bagdad, AZ this month. He rode through a dust storm and subsequently developed dyspnea, cough and gray sputum production. Laboratory evaluation in an emergency department showed a pO2 of 60 on room air but was otherwise unremarkable. He was seen in pulmonary consolidation a few days later. Thoracic CT scan showed subpleural areas of ground glass and consolidation. The patient was asymptomatic by this time and declined biopsy. The group suggested following the patient with a repeat thoracic CT scan. It was suggested that this could possibly be a case of acute eosinophilic pneumonia.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, May 25,2016 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. March 2016 Arizona thoracic society ntoes. Southwest J Pulm Crit Care. 2016 Mar;12(3):112-3. doi: http://dx.doi.org/10.13175/swjpcc029-16 PDF

November 2015 Arizona Thoracic Society Notes

The November 2015 Arizona Thoracic Society meeting was held on Wednesday, November 18, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities. 

There were 3 case presentations:

1. Dr. Gerald Schwartzberg presented a case of a 56-year-old man with a history of diabetes, alcoholism and tobacco abuse who has a history of Mycobacterium avium-intracellulare (MAI) with a residual thin-walled cavity in his right upper lobe (RUL). After quitting drinking and smoking and years of being asymptomatic, he presented with hemoptysis. Chest x-ray showed increasing density in the RUL. CT scan showed an intracavitary density in his previous cavity presumably a fungus ball. Sputum cultures are pending. Discussion followed on management of fungus balls. Bronchoscopy was recommended to view the bronchial anatomy to exclude other diagnosis as well as obtaining additional cultures. The consensus of the group was operative intervention if possible. If not, bronchial artery embolization was offered as an alternative.
2. Dr. Schwartzberg presented a second case of a middle-aged woman with a past history of Valley Fever who was treated and left with a negative serology and a pulmonary nodule. She has developed rheumatoid arthritis and is being considered for biological therapy. The question was whether she should received fluconazole during therapy. No one knew of any data but the group advised caution and suggested fluconazole during immunosuppressive therapy.
3. Dr. Lewis Wesselius presented a case of an 18-year-old with a prior diagnosis of Ehlers-Danlos syndrome. CT scan revealed multiple lung cysts. Dr. Wesselius reviewed Ehlers-Danlos syndrome and congenital pulmonary airway malformations (CPAM) (1,2). CPAM, previously known as congenital cystic adenomatoid malformation, is a developmental lesion of the lung comprising single or multiple cysts of uniform or varying sizes arising from anomalous growth of airways. Most of the cases are identified in infants and neonates with respiratory distress. Rarely, CPAM can present in adulthood with recurrent chest infections, pneumothorax, hemoptysis, or dyspnea. Dr. Michael Gotway showed CT scans of several additional patients.

There being no further business, the meeting was adjourned about 7:45 PM. The next meeting will be in Phoenix on Wednesday, January 27,2016 at 6:30 PM. A change of venue was discussed and will be announced prior to the meeting.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Dowton SB, Pincott S, Demmer L. Respiratory complications of Ehlers-Danlos syndrome type IV. Clin Genet. 1996;50(6):510-4. [CrossRef] [PubMed]
2. Baral D, Adhikari B, Zaccarini D, Dongol RM, Sah B. Congenital pulmonary airway malformation in an adult male: a case report with literature review. Case Rep Pulmonol. 2015;2015:743452. [CrossRef] [PubMed] 

Cite as: Robbins RA. November 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(5):233-4. doi: http://dx.doi.org/10.13175/swjpcc143-15 PDF

September 2015 Arizona Thoracic Society Notes

The September 2015 Arizona Thoracic Society meeting was held on Wednesday, September 23, 2015 at the Scottsdale Shea Hospital beginning at 6:00 PM. This was a dinner meeting with case presentations. There were 13 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

There were 6 case presentations:

1. Dr. Gerald Schwartzberg presented a case of a 58-year-old woman with a history of Mycobacterium avium presented with cough and malaise. CT revealed a history of lower love centrilobular nodules and scattered ground glass opacities and some bronchiectasis. Sputum revealed Aspergillus fumigatus. IgE was normal but IgA was deficient at 20 mg/dl (normal 80-350 mg/dl). She was started on itraconazole and clinically improved. Many questioned whether the Aspergillus was the cause of her pneumonia and some questioned the association of the IgA deficiency with her overall clinical picture.
2. Dr. Schwartzberg presented a second case of a 92-year-old former opera singer who had a past diagnosis of asthma but without airflow obstruction, gastroesophageal reflux disease, and myelodysplastic syndrome. CT scan revealed mosaic areas most consistent with hypoperfusion secondary to air trapping. Complete pulmonary function testing revealed only a markedly decreased DLco. She had oxygen desaturation with exercise. Clinically she did not respond to a bronchodilator. Most were perplexed as the cause of her overall clinical picture.
3. Dr. Schwartzberg presented a third case of a morbidly obese 61-year-old woman who presented with shortness of breath. CT scan showed some scattered lung nodules in her lower lobes. Laboratory evaluation including cocci serologies were negative. A needle biopsy of one of the lung nodules was nondiagnostic and she was empirically begun on fluconazole. She clinically improved. Many thought this could be possibly Valley fever and she should be followed.
4. Dr. Alan Thomas presented a 66-year-old man with a history of lymphoma about 10 years earlier who presented with some enlarging lymph nodes. Thoracic CT scan was performed as part of his evaluation and showed some areas of emphysema with scattered ground glass opacities. It was felt the radiologic pattern was most consistent with respiratory bronchiolitis with fibrosis (2).
5. Dr. Thomas also presented a case of an 82-year-old former smoker who quit about a year ago who presented with weight loss and minimal cough. Thoracic CT scan showed a large pleural mass with pleural effusion surrounding the right lung as well as pleural plaques. He did have a history of asbestos exposure in the Navy. Thoracentesis showed a nondiagnostic exudative effusion. A biopsy was performed which was consistent with a large cell neuroendocrine tumor.
6. Dr. Lewis Wesselius presented a 65-year-old man with exertional dyspnea and possible interstitial lung disease. He has a history of a Ross procedure (replacement of a bicuspid aortic valve with the pulmonic valve) and obstructive sleep apnea. Chest x-ray was unremarkable. Complete pulmonary function testing was normal. Thoracic CT scan showed peripheral reticulations especially in the lower lobes. A video-assisted thorascopic biopsy (VATS) was performed. Histology showed scattered fibroblast foci with scattered fibrosis with airway centricity. It was unclear whether this was usual interstitial fibrosis or chronic hypersensitivity pneumonitis. He was started on prednisone because his picture was felt to be most consistent with chronic hypersensitivity pneumonitis (1). Unfortunately, chronic hypersensitivity pneumonitis with features of UIP appears to carry a worse prognosis.

There being no further business, the meeting was adjourned about 7:30 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, November 18 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Reddy TL, Mayo J, Churg A. Respiratory bronchiolitis with fibrosis. High-resolution computed tomography findings and correlation with pathology. Ann Am Thorac Soc. 2013;10(6):590-601. [CrossRef] [PubMed]
2. Myers JL. Hypersensitivity pneumonia: the role of lung biopsy in diagnosis and management. Mod Pathol. 2012;25 Suppl 1:S58-67. [CrossRef] [PubMed]

Cite as: Robbins RA. September 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(3):117-8. doi: http://dx.doi.org/10.13175/swjpcc124-15 PDF

July 2015 Arizona Thoracic Society Notes

The July 2015 Arizona Thoracic Society meeting was held on Wednesday, July 23, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

It was decided to continue holding the meeting on the fourth Wednesday of the odd numbered months.

Lewis Wesselius relayed a request from the Mayo Clinic regarding a survey on how physicians in Arizona treat Valley Fever. There were no objections to using our mailing list to send out the survey.

Dr. Parides formed a committee to encourage younger clinicians to attend the Arizona Thoracic Society meetings.

Richard A. Robbins was chose as the Arizona Thoracic Society's nominee for clinician of the year.

There were 3 case presentations:

1. George Parides presented a 58-year-old woman with a past medical history of cavitating coccidioidomycosis in both upper lobes from which she had recovered. However, on thoracic CT scan she had traction bronchiectasis as well as narrowing of the inferior vena cava. It had been recommended that a vena cava filter be placed to prevent pulmonary embolism. She had no history of deep venous thrombosis. None in the audience knew of any data suggesting placement of a filter was indicated.
2. Lewis Wesselius presented a case of a 19-year-old man who presented with dyspnea and bilateral large pulmonary nodules. He had a history of smoking about 5 cigarettes per day and use of medical marijuana for sinusitis. Laboratory workup showed an elevated white blood cell count but a cANCA and cultures was negative. Bronchoscopy with bronchoalveolar lavage demonstrated alveolar hemorrhage. Open biopsy was consistent with pulmonary pyoderma gangrenosum. The patient was begun on corticosteroids and had resolution of both his symptoms and nodules.
3. Rick Robbins presented Drs. Ling and Boivin's case of a 40 year old man with a history of opioid abuse who was mechanically ventilated but failed an extubation trial (1). The videos of the diaphragm were presented along with a discussion of the diaphragm thickening fraction (DTF) assessed by ultrasound as a predictor for the success of extubation. DTF is calculated using the following formula: Thickness at end inspiration - Thickness at end expiration / Thickness at end expiration. Based on the study published by Ferarri and associates (2), they found that a DTF > 36% would provide a sensitivity of 0.82, a specificity of 0.88, a positive predictive value (PPV) of 0.92 and a negative predictive value (NPV) of 0.75.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, September 28 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Ling D, Boivin M. Ultrasound for critical care physicians: take a deep breath. Southwest J Pulm Crit Care. 2015;11(1):38-41. [CrossRef]
2. Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli G, Aprà F. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J. 2014;6(1):8. [CrossRef] [PubMed]

Reference as: Robbins RA. July 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(1):49-50. doi: http://dx.doi.org/10.13175/swjpcc098-15 PDF

May 2015 Arizona Thoracic Society Notes

The May 2015 Arizona Thoracic Society meeting was held on Wednesday, May 27, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Ms. Georgann VanderJagt, RN, MSN gave an update on clinical trials at Dignity Health including idiopathic pulmonary fibrosis and alpha-1 antitrypsin deficiency. To contact Ms. VanderJagt call her office at 602-406-3825, her cell at 602-615-2377 or by email at georgann.vaderjagt@digniftyhealth.org.  

Dr. Michael Smith, the surgical director for the lung transplant program at Dignity Health, gave an overview of their lung transplant program. They are currently the fifth busiest transplant program in the US.  They have done 46 lung transplants so far this year. They are on a par with UCLA in number of transplants and survival has been at the National average. Average wait time is only abut 2 weeks. He also discussed recent and ongoing transplant protocols. To contact Dr. Smith call 602-406-7564.

There were 4 case presentations:

1. Jud Tillinghast presented a case of a large man who was short of breath. His CT scan showed multiple calcifications in the lower lobes. It was felt that clinically he was most likely aspirating as a cause of the calcifications.
2. Gerald Swartzberg presented a case of a large man who had some minimal dyspnea and an elevated right hemidiaphragm. His chest x-ray showed consolidation in this right lower lung. He had been seen at the Mayo Clinic and Dr. Lewis Wesselius reviewed his pathology from a needle biopsy of a right lower lobe nodule which was nonspecific. Reviewing his case he also had a biopsy from Sloan Kettering in 2006 which was also nonspecific. Further history was obtained and the patient admitted he was using Vick's Vaporub in his nose since he was 7 years old. It was unclear if this was the cause of his right lower lobe consolidation.
3. Dr. Swartzberg presented a second case of a 70-year-old woman with multiple medical problems. She has a cockatiel but is remarkably asymptomatic. A chest x-ray was taken showed nonspecific lower lobe changes. Pulmonary function tests showed a reduced vital capacity but a normal to high total lung capacity. A DLCO was not able to be obtained. CT scan showed small nodules with ground glass in her lower lobes. It was felt that most likely this was a hypersensitivity pneumonitis secondary to her bird. She got rid of the bird but did not improve.  The cause of her abnormal pulmonary radiology remains unclear.
4. Dr. Wesselius presented a case of a patient with a chronic cough which had been treated with antibiotics and corticosteroids. When he as on oral corticosteroids he was perhaps somewhat better. He was seen at the University of Massachusetts without a diagnosis being made. He subsequently moved to the Phoenix area and was evaluated at the Mayo Clinic. Chest x-ray showed consolidation in his right upper lobe. On bronchoscopy he had some whitish plaques along his trachea and main bronchi. Bronchoalveolar lavage showed 89% eosinophils and his transbronchial biopsy was consistent with chronic eosinophilic pneumonia. Apparently, this association has previously been sporadically reported. He was started on prednisone and improved.

Dr. Jud Tillinghast was acknowledged as the Arizona Thoracic Society Clinician of the Year and one of the four finalists as ATS Clinician of the Year.

After a brief discussion, the membership agreed to encourage and help Nevada form a state thoracic society.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, July 22 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. May 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(5):304-5. doi: http://dx.doi.org/10.13175/swjpcc075-15 PDF

March 2015 Arizona Thoracic Society Notes

The March 2015 Arizona Thoracic Society meeting was held on Wednesday, March 25, 2014 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, radiology and oncology communities.

Dr. Richard Robbins made a presentation entitled "The History of Exhaled Nitric Oxide Measurement" focusing on the development of exhaled nitric oxide in the early 1990's.

There were 3 case presentations:

1. Sandra Till, a third year pulmonary fellow at the Good Samaritan/VA program, presented an elderly man admitted to the Phoenix VA with an exacerbation of chronic obstructive pulmonary disease (COPD). His CT findings showed with centrilobular emphysema, bronchial edema, and scattered ground glass opacities. It was felt that the CT findings most likely represented a bronchiolitis from his exacerbation of COPD.
2. Richard Robbins presented a 49 year old man with a positive PPD and Gold QuantiFERON who has extensive psoriasis and had biological therapy with etanercept recommended. He had an extensive past medical history of diabetes and sleep apnea secondary to obesity which resolved with gastric bypass. His liver was palpable at his right costal margin and his liver enzymes were mildly elevated. Chest x-ray was normal. Most felt that therapy for latent tuberculosis was indicated with some recommending isoniazid, others recommending rifampin and others recommending both drugs. He was treated for one month with isoniazid and his liver enzymes all declined into the normal range. He has begun etanercept and 6-9 months of isoniazid therapy are planned.
3. Stephanie Fountain, a second year internal medicine resident from the Good Samaritan/VA program presented an elderly man with a history of adenocarcinoma of the pancreas treated with chemotherapy and radiation in Chicago just prior to moving to Phoenix. He presented with abdominal pain secondary to an ileus which spontaneously improved. A CT scan performed during the abdominal evaluation showed multiple small nodules and some scattered ground glass opacities which was reminiscent of idiopathic interstitial pneumonia with cystic changes. Biopsy showed adenocarcinoma which special stains were most consistent with a pancreas primary. Discussion ensued about this unusual presentation CT presentation of metastatic pancreatic cancer.

The next meeting in Phoenix will be at Scottsdale Shea on Wednesday, May 27 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. March 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(3):149. doi: http://dx.doi.org/10.13175/swjpcc041-15 PDF

January 2015 Arizona Thoracic Society Notes

Dr. Judd Tillinghast was presented a plaque in recognition of being chosen by his colleagues as the Arizona Thoracic Society Physician of the Year In 2014.  

Dr. Rajeev Saggar made a presentation entitled "Pulmonary fibrosis-associated pulmonary hypertension: a unique phenotype".  This presentation focused on new echocardiographic methods of assessing right ventricular (RV) function and the pathophysiology of RV dysfunction. Dr. Saggar presented data from a paper he authored on parenteral treprostinil in patients with idiopathic pulmonary fibrosis and pulmonary artery hypertension which was published in Thorax (1).

There were 2 case presentations, both from the Phoenix VA by Dr. Elijah Poulos:

1. A 65 year-old man presented with cough and chills.  His past medical history included multiple myeloma treated with chemotherapy, radiation therapy to spine and bone marrow transplant.  He had a prior vertebroplasty. His symptoms did not improve with doxycycline.  Computerized tomography angiography was done and showed areas of unusual abnormalities in lung that were very high density.  This was determined to be cement emboli from the prior vertebroplasty (pulmonary cement emboli, PCE) which has been previously reported as a complication of this procedure.  The appropriate treatment options in this case were discussed.
2. A 69 year-old man presented with dyspnea on exertion over past couple of years.  Chest radiography showed abnormal areas of central fibrosis with sparing of the lung periphery.  A thoracic CT scan also demonstrated central fibrotic/cystic changes.  The patient subsequently admitted to use of crack cocaine which started at age 59.  There are reports of similar pulmonary fibrosis associated with use of crack cocaine (2).  The possible pathophysiologic mechanisms were discussed.

The next meeting in Phoenix will be at Scottsdale Shea on Wednesday, March 25 at 6:30 PM.

Lewis J. Wesselius, MD

President, Arizona Thoracic Society

References

1. Saggar R, Khanna D, Vaidya A, et al. Changes in right heart haemodynamics and echocardiographic function in an advanced phenotype of pulmonary hypertension and right heart dysfunction associated with pulmonary fibrosis. Thorax. 2014;69(2):123-9. [CrossRef] [PubMed]
2. O'Donnell AE, Mappin FG, Sebo TJ, Tazelaar H. Interstitial pneumonitis associated with "crack" cocaine abuse. Chest. 1991;100(4):1155-7. [CrossRef] [PubMed] 

Reference as: Wesselius LJ. January 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(1):56. doi: http://dx.doi.org/10.13175/swjpcc012-15 PDF