Arizona Thoracic Society Notes
November 2014 Arizona Thoracic Society Notes
The November 2014 Arizona Thoracic Society meeting was held on Wednesday, November 19, 2014 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were about 30 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities. Jud Tillinghast was nominated as the Arizona Thoracic Society physician of the year.
Three cases were presented:
- George Parides presented a case of a 70-year-old woman with a 3 areas of ground glass picked up incidentally on CT scan. She had some wheezing. A needle biopsy revealed adenocarcinoma. The biopsy and radiologic pattern were consistent with adenocarcinoma in situ or minimally invasive adenocarcinoma. Discussion centered around treatment. Most felt that if the areas could be removed that surgical resection was indicated (1).
- Lewis Wesselius presented a 60-year-old man with Marfan's syndrome and a history of an aortic valve replacement on chronic anticoagulation with a thyroid papillary carcinoma. The patient underwent a total thyroidectomy. Post-operatively he developed a large mass-like area in the right lower lung. It was unclear whether this was in the lung parenchymal or in the pleural space. A preliminary differential diagnosis of abscess, parenchymal hemorrhage or pleural hemorrhage was made. His INR was in the appropriate therapeutic range. A chest tube was placed with minimal drainage and no change in the radiographic appearance. Video-assisted thorascopic surgery (VATS) was performed and a large intraparenchymal hematoma was found which was removed. A review of the literature revealed a small number of reports of spontaneous intraparenchymal hemorrhages but none associated with Marfan's (2,3).
- Jasminder Mand presented a case of an asymptomatic 66-year-old man with inspiratory crackles and a mildly reduced diffusing capacity on pulmonary function testing. He had a past minimal smoking history. His CT scan showed areas of ground glass and reticulation surrounding of septal emphysema. An open lung biopsy was performed which was consistent with usual interstitial pneumonia (UIP). The patient raised the question of whether he should be treated with nintedanib or pirfenidone. There was disagreement amongst the audience with some favoring treatment while others favored following the patient.
There being no further business the meeting was adjourned about 8:00 PM. There is no meeting in December. The next meeting will be Phoenix on Wednesday, January, 6:30 PM at Scottsdale Shea Hospital.
Richard A. Robbins, MD
References
- Tsushima Y, Suzuki K, Watanabe S, Kusumoto M, Tsuta K, Matsuno Y, Asamura H. Multiple lung adenocarcinomas showing ground-glass opacities on thoracic computed tomography. Ann Thorac Surg. 2006;82(4):1508-10. [CrossRef] [PubMed]
- Riachy M, Mal H, Taillé C, Dauriat G, Groussard O, Cazals-Hatem D, Biondi G, Fournier M. Non-traumatic pulmonary haematoma complicating oral anticoagulation therapy. Respirology. 2007;12(4):614-6. [CrossRef] [PubMed]
- Chakraborty AK, Dreisin RB. Pulmonary hematoma secondary to anticoagulant therapy. Ann Intern Med. 1982;96(1):67-9. [CrossRef] [PubMed]
Reference as: Robbins RA. November 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;9(5):289-90. doi: http://dx.doi.org/10.13175/swjpcc153-14 PDF
September 2014 Arizona Thoracic Society Notes
The September 2014 Arizona Thoracic Society meeting was held on Wednesday, 9/24/14 at the Kiewit Auditorium on the University of Arizona Medical Center campus in Tucson beginning at 5:30 PM. This was a dinner meeting with case presentations. There were about 21 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.
Four cases were presented:
- Mohammad Dalabih presented a 22 year old hypoxic man with a history of asthma and abdominal pain. A bubble echocardiogram showed bubbles in the left ventricle within 3 heartbeats. Thoracic CT scan showed a pulmonary arteriovenous malformation (AVMs). The patient underwent coil embolization and improved. Dr. Dalabih reviewed the diagnosis and management of pulmonary AVMs (1). Aarthi Ganesh presented a 70 year old woman complaining of dyspnea on exertion. A chest x-ray showed complete opacification of the right hemithorax and a thoracic CT scan showed a large right pleural effusion with right lung atelectasis. After thoracentesis was nondiagnostic, she underwent video-assisted thorascopic surgery (VATS). Although she clinically appeared to have mesothelioma, histology was consistent with a pseudomesotheliomatous adenocarcinoma. She is currently undergoing treatment with platinum based agents.
- Gordon Carr presented a 75 year old woman with dyspnea. Chest x-ray showed interstitial disease with a possible usual interstitial pneumonia (UIP) pattern on CT scan. Dr. Carr reviewed the initial evaluation and diagnosis of the interstitial lung disease (2). VATS showed a bronchocentric process with some fibrosis in the periphery most consistent with chronic hypersensitivity pneumonitis. The likely source was thought to be mold in her indoor pool area.
- James Knepler presented a 55 year old woman with breast cancer and bone metases receiving tamoxifen. She also had a history of multiple sclerosis and was receiving on interferon-beta 1a. A positron emission tomography (PET) scan showed increased uptake in several mediastinal lymph nodes. Endobronchial ultrasound (EBUS) guided aspiration biopsy was non-diagnostic. Endobronchial biopsy showed granulomas. It was felt the most likely diagnosis was interferon-induced sarcoidosis. Several case reports have recently been published.
There being no further business the meeting was adjourned about 7:00 PM. The next meeting will be Phoenix on Wednesday, October 22, 6:30 PM at Scottsdale Shea Hospital.
Richard A. Robbins, MD
References
- Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158(2):643-61. [CrossRef] [PubMed]
- Selman M, Pardo A. Update in diffuse parenchymal lung disease 2012. Am J Respir Crit Care Med. 2013;187(9):920-5. [CrossRef] [PubMed]
Reference as: Robbins RA. September 2014 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2014;9(3):191-2. doi: http://dx.doi.org/10.13175/swjpcc127-14 PDF
August 2014 Arizona Thoracic Society Notes
The August 2014 Arizona Thoracic Society meeting was held on Wednesday, 8/27/14 at Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were about 30 in attendance representing the pulmonary, critical care, sleep and radiology communities.
A presentation was given by Julie Reid of the American Lung Association in Arizona on their Lung Force initiative. This is an initiative to make women more aware that lung cancer is the number one cause of cancer deaths in women. There will be a fund raising Lung Force Walk on November 15, 2014 in Phoenix. More information can be found at http://www.lungforce.org/walk-events or http://www.lung.org/associations/states/arizona/local-offices/phoenix/ or contact Julie Reid at JReid@Lung Arizona.org or (602) 258-7505.
A discussion was instigated by Dr. Parides on whether there is an increased risk of clinical Valley Fever in patients previously treated who begin therapy with biological therapy for rheumatoid arthritis. The common practice has been to initiate azole antifungal therapy in patients who begin biologics for rheumatoid arthritis. Although all agreed there was an increased risk of Valley Fever in patients treated with biological therapy, none were aware of any patients who developed Valley Fever who had previously been treated with azole therapy. This was extended to similar discussions including whether patients who had previously been treated for a +PPD need anti-tuberculosis therapy. This has been common practice, but again, none were aware of any cases or literature.
Lewis Wesselius presented a 66 year old man with a history of multiple pneumonias and skin infections. The patient was short with a prominent forehead. Immunoglobulin evaluation revealed a normal IgG and IgM but a markedly elevated IgE of 7419 kIU/mL (normal <380 kIU/mL). The patient was diagnosed with hyperimmunogloublin E syndrome, also known as Job's syndrome. For a review of this case as well as a differential diagnosis of elevated IgE please see the "September 2014 Pulmonary Case of the Month: A Case for Biblical Scholars" which will be posted on 9/1/14.
There being no further business the meeting was adjourned about 7:45 PM. The next meeting will be Tucson on Wednesday, September 24. Time and location to be announced.
Richard A. Robbins, MD
Reference as: Robbins RA. August 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;9(2):145. doi: http://dx.doi.org/10.13175/swjpcc114-14 PDF
June 2014 Arizona Thoracic Society Notes
The June 2014 Arizona Thoracic Society meeting was held on Wednesday, 6/25/14 at the Bio5 building on the University of Arizona Medical Center campus in Tucson beginning at 5:30 PM. This was a dinner meeting with case presentations. There were about 33 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.
Four cases were presented:
- Eric Chase presented a 68 year old incarcerated man shortness of breath, chest pain and productive cough. The patient was a poor historian. He was supposed to be receiving morphine for back pain but this had been held. He also had a 45 pound weight loss over the past year. His PMH was positive for COPD, hypertension, congestive heart failure, chronic back pain and hepatitis C. Past surgical history included a back operation and some sort of chest operation. On physical examination he was tachypneic, tachycardic and multiple scars over his neck, back and chest including a median sternotomy scan. Subcutaneous emphysema was present. Laboratory evaluation was most remarkable for a lactate of 4.6 mg/dL. Chest x-ray revealed subcutaneous and mediastinal air, LLL consolidation, and a left pleural effusion. Thoracentesis of the pleural effusion showed a high amylase and a low pH. A chest tube was placed. Esophagram showed contrast draining through the left chest and chest tube. CT scan was consistent with a colonic interposition graft with a graft to pleural fistula. The patient was deemed to be a poor surgical candidate and a jejunostomy tube was placed.
- Mohammad Dalabih presented a 72 year old woman with asthma who had no response to asthma medications. Spirometry was consistent with moderate restriction. A thoracic CT scan showed two small nodules along with mosaic attenuation. A lung wedge biopsy showed nonmalignant appearing cells with tumorlets and bronchitis. The cells were CD56 positive. A diagnosis of diffuse interstitial pulmonary neuroendocrine hyperplasia (DIPNECH). Dr. Dalabih reviewed DIPNECH which usually presents in middle aged women with symptoms of cough and dyspnea; obstructive abnormalities on pulmonary function testing; and radiographic imaging showing pulmonary nodules, ground-glass attenuation, and bronchiectasis. In general, the clinical course remains stable; however, progression to respiratory failure can occur. Long-term follow- up studies and the best treatment remains unknown. The April 2014 Pulmonary Case of the Month also presented a case of DIPNECH (1).
- Mohammad Alzoubaidi presented the case of a 61 year old woman with right upper quadrant pain who was found to have a large liver lesion on abdominal CT scan. She suffered a cardiac arrest shortly after the CT scan and her hemoglobin decreased to 5.6 g/dL. Angiography revealed multiple pseudoaneursyms with the largest apparently bleeding. Coil embolization was performed but a couple of days later her shock recurred. A repeat angiogram showed enlargement of the known pseudoaneursyms and several new ones. She was begun on corticosteroids for a presumed vasculitis. Unfortunately, she continued to bleed and died. Autopsy was consistent with fibromuscular dysplasia. Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory disease of the blood vessels resulting in constriction and dilatation (pseudoaneursyms) (2). The cause and best treatment are unknown.
- John Bloom presented a 22 year old Somali man that grew up in India who came to the US about 15 months before presentation. He was relatively asymptomatic but was found to have supraclavicular adenopathy on a "wellness" physical examination. Biopsy of the lymph nodes was recommended but he refused. He presented about a month later with neck and back pain. Physical examination revealed by adenopathy and a fever of 38.2º C. His white blood cell count was 12,600 cells/µL. Thoracic CT showed a miliary pattern with vertebral destruction. Laminectomy with cord stabilization was performed. Biopsy was negative for acid fast bacilli but positive for GMS+ organisms consistent with coccidioidomycosis. A large cervical paraspinal abscess just below the skull was drained and a large mediastinal abscess was also seen on CT scan. Discussion ensued about whether drainage was appropriate for the mediastinal mass, but most thought not. The case illustrates that Valley Fever is common and in most chest differential diagnosis in the Southwest.
There being no further business the meeting was adjourned about 6:45 PM. There will be no meeting in July. The next meeting in Phoenix will be a case presentation conference on August 27, 6:30 PM at Scottsdale Shea Hospital.
Richard A. Robbins, MD
References
- Wesselius LJ. April 2014 pulmonary case of the month: DIP-what? Southwest J Pulm Crit Care. 2014;8(4):195-203. [CrossRef]
- Slovut DP, Olin JW. Fibromuscular dysplasia. N Engl J Med. 2004;350(18):1862-71. [CrossRef] [PubMed]
Reference as: Robbins RA. June 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(6):356-7. doi: http://dx.doi.org/10.13175/swjpcc084-14 PDF
May 2014 Arizona Thoracic Society Notes
The May 2014 Arizona Thoracic Society meeting was held on Wednesday, 5/28/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep and radiology communities.
A discussion was held regarding the Arizona Thoracic Society relationship with the American Lung Association. Several members volunteered to talk to the lung association regarding common ground to strengthen the relationship.
The wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting was a big success. There were about 55 at the meeting. The tasting will probably be held again next year.
At the ATS meeting data was presented that pirfenidone was effective in reducing the progression of idiopathic pulmonary fibrosis (IPF). The data was published in the New England Journal of Medicine on 8/29/14 (1). Lewis Wesselius is one of the investigators enrolling patients in a phase 3 trial while InterMune reapplies to the FDA for approval of pirfenidone in IPF.
Two cases were presented:
- Lewis Wesselius from the Mayo Clinic Arizona presented a 53 year old woman with a chronic, nonproductive accompanied by malaise and a modest weight loss. She was treated for asthma without improvement. She was a nonsmoker and had a SpO2 of 98% on room air. Her lungs were clear to auscultation. Routine laboratory evaluation was unremarkable and exhaled nitric oxide was normal. Thoracic CT scan showed a subtle broncholitis. She was empirically treated for gastroesophageal reflux disease (GERD) without improvement. Bronchoalveolar lavage was performed and showed Nocardia asteroides. She had no evidence of immunocompromise. She was treated with sulfamethoxazole and trimethoprim which produced a rash and then minocycline for 4 months. Her cough resolved. However, when the minocycline was stopped her cough returned. She is currently receiving an additional course of minocycline planned for 6 months.
- Suresh Uppalapu presented a 58 year old fireman with a complaint of dyspnea on exertion. He has a history of obstructive sleep apnea and lives at an elevation of 7000 feet. The patient had significant desaturation with exercise. Chest x-ray showed borderline cardiomegaly but was otherwise normal. Thoracic CT scan showed pulmonary artery enlargement and borderline right ventricular (RV) enlargement. Ultrasound of the hear showed an enlarged RV but it was difficult to measure PA pressure. Right-sided heart catherization showed a mean pulmonary artery pressure of 35 cm H2O with a step up in the oxygen saturation at the right atrium. Transesophageal echocardiogram (TEE) showed a patent foramen ovale (PFO). Insertion of a balloon stopped the right to left shunting but resulted in a significant increase in the pulmonary artery pressure. He was referred for percutaneous closure of the PFO along with treatment of his pulmonary artery hypertension.
There being no further business the meeting was adjourned about 8:15 PM. The June meeting is scheduled for Tucson. There will be no meeting in July. The next meeting in Phoenix will be a case presentation conference on August 27, 6:30 PM at Scottsdale Shea Hospital.
Richard A. Robbins, MD
Reference
- King TE Jr, Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med 2014;370:2083-92. [CrossRef] [PubMed]
Reference as: Robbins RA. May 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(6): 297-8. doi: http://dx.doi.org/10.13175/swjpcc072-14 PDF
April 2014 Arizona Thoracic Society Notes
The April 2014 Arizona Thoracic Society meeting was held on Wednesday, 4/23/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 15 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.
It was announced that there will be a wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting. The tasting will be led by Peter Wagner and is scheduled for the Cobalt Room in the Hilton San Diego Bayfront on Tuesday, May 20, from 4-8 PM.
Guideline development was again discussed. The consensus was to await publication of the IDSA Cocci Guidelines and respond appropriately.
George Parides, Arizona Chapter Representative, gave a presentation on Hill Day. Representatives of the Arizona, New Mexico and Washington Thoracic Societies met with their Congressional delegations, including Rep. David Schweikert, to discuss the Cigar Bill, NIH funding, and the Medicare Sustainable Growth Rate Factor (SGR). Dr. Parides also spoke about the need for increased funding for Graduate Medical Education.
Four cases were presented:
- Jud Tillinghast presented a case of a middle aged man who suffered a cervical cord injury 6-7 years ago resulting in paraplegia. The patient had just moved from California and was referred because of an abnormal chest x-ray. After his injury the patient had a great deal of pain and repeated episodes of aspiration. The patient was asymptomatic. The chest x-ray showed haziness surrounding the right hilum. A CT scan showed RLL, LLL, and RML consolidation which was essentially unchanged from a thoracic CT performed 6 months earlier. A biopsy was performed and consistent with lipoid pneumonia. On further questioning the patient recalled taking mineral oil for the first 2-3 years after his injury to relieve constipation induced by narcotics for pain.
- Gerald Schwartzberg presented a 79 year old man with very severe COPD who presented with hemoptysis. Chest x-ray showed bilateral lower lobe consolidation with an air-fluid level in the right chest. Bronchoalveolar lavage revealed only Aspergillus. A discussion ensued and many were unconvinced that the consolidations resulted from Aspergillus. Since the patient was relatively asymptomatic except from the dyspnea from his COPD, the consensus was to perform a repeat thoracic CT scan.
- Lewis Wesselius presented a 71 year old woman with dyspnea since late 2013. She had a cardiac pacemaker placed in 2008. Her physical exam was unremarkable. Her SpO2 was 96% on room air but decreased to 84% with exercise. Chest x-ray and pulmonary function testing were unremarkable (a DLco was unable to be performed. Echocardiogram revealed a large patent foramen ovale (PFO).
- Allen Thomas presented a 65 year old with dyspnea. The patient had a history of cardiomegaly with diastolic dysfunction and a bipolar disorder treated with lithium, lamotrigine, gabapentin. Chest x-ray showed bilateral interstitial infiltrates. CT scan showed sub-pleural patchy ground-glass opacities combined with irregular reticular opacities reminiscent of nonspecific interstitial pneumonia (NSIP). Collage vascular work up was negative. Review of the website Pneumotox (http://www.pneumotox.com) showed reports of interstitial disease with lamotrigine. The medication was stopped an follow-up CT scan showed near resolution of the abnormalities.
There being no further business the meeting was adjourned about 8:15 PM. The next meeting is scheduled to be a case presentation conference for May 28, 6:30 PM at Scottsdale Shea Hospital.
Richard A. Robbins, MD
Reference as: Robbins RA. April 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(4):236-7. doi: http://dx.doi.org/10.13175/swjpcc054-14 PDF
March 2014 Arizona Thoracic Society Notes
The March 2014 Arizona Thoracic Society meeting was a special meeting. In conjunction with the Valley Fever Center for Excellence and the Arizona Respiratory Center the Eighteenth Annual Farness Lecture was held in the Sonntag Pavilion at St. Joseph's Hospital at 6 PM on Friday, April 4, 2014. The guest speaker was Antonio "Tony" Catanzaro, MD from the University of California San Diego and current president of the Cocci Study Group. There were 57 in attendance representing the pulmonary, critical care, sleep, and infectious disease communities.
Dr. Antonio Catanzaro
After opening remarks by Arizona Thoracic Society president, Lewis Wesselius (a former fellow under Dr. Catanzaro at UCSD), John Galgiani, director of the Valley Fever Center for Excellence, gave a brief history of the Farness lecture before introducing Dr. Catanzaro. The lecture is named for Orin J. Farness, a Tucson physician, who was the first to report culture positive coccidioidomycosis (cocci or Valley Fever). The title of Dr. Catanzaro's talk was "Coccidioidomycosis, Why I Have Found It So Interesting". Dr. Catanzaro came to San Diego from Georgetown to study the immunology of sarcoidosis. Much to his surprise, he found little sarcoidosis in San Diego and was looking for a new direction. While attending the California Thoracic Society meeting, Tony met Dr. Hans Einstein from Bakersfield, California, the leading authority on Valley Fever. He persuaded Tony to attend the Cocci Study Group meeting, held in conjunction with the California Thoracic Society meeting. Dr. Catanzaro reviewed his investigations of Valley Fever including transfer factor, hypercalcemia associated with Valley Fever and treatment with ketoconoazole, fluconazole, itraconazole, and posaconazole (1-4). Prominently mentioned Hans Einstein from Bakersfield, John Galgiani from Tucson, Bernie Levine from Phoenix and J. Burr Ross also from Phoenix.
The Cocci Study Group meeting was held the following day, Saturday, April 5th at the University of Arizona College of Medicine, Phoenix. The next meeting of the Arizona Thoracic Society is on Wednesday, April 23, 2014, 6:30 PM at Shea Hospital.
Richard A. Robbins, M.D.
References
- Catanzaro A, Einstein H, Levine B, Ross JB, Schillaci R, Fierer J, Friedman PJ. Ketoconazole for treatment of disseminated coccidioidomycosis. Ann Intern Med. 1982 Apr;96(4):436-40. [CrossRef] [PubMed]
- Catanzaro A, Galgiani JN, Levine BE, Sharkey-Mathis PK, Fierer J, Stevens DA, Chapman SW, Cloud G. Fluconazole in the treatment of chronic pulmonary and nonmeningeal disseminated coccidioidomycosis. NIAID Mycoses Study Group. Am J Med. 1995;98(3):249-56. [CrossRef] [PubMed]
- Galgiani JN, Catanzaro A, Cloud GA, Johnson RH, Williams PL, Mirels LF, Nassar F, Lutz JE, Stevens DA, Sharkey PK, Singh VR, Larsen RA, Delgado KL, Flanigan C, Rinaldi MG. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med. 2000;133(9):676-86. [CrossRef] [PubMed]
- Catanzaro A, Cloud GA, Stevens DA, Levine BE, Williams PL, Johnson RH, Rendon A, Mirels LF, Lutz JE, Holloway M, Galgiani JN. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clin Infect Dis. 2007;45(5):562-8. [CrossRef] [PubMed]
Reference as: Robbins RA. March 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(4):223-4. doi: http://dx.doi.org/10.13175/swjpcc038-14 PDF
February 2014 Arizona Thoracic Society Notes
The February 2014 Arizona Thoracic Society was a dinner meeting sponsored by Select Specialty Hospital and held on Wednesday, 2/26/2014 at Shea Hospital beginning at 6:30 PM. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities.
Gerald Swartzberg was presented a plaque as the Arizona Thoracic Society clinician of the year by George Parides (Figure 1).
Figure 1. George Parides (left), Arizona Representative to the ATS Council of Chapter Representatives, presenting a plaque to Gerald Swartzberg (right), Arizona Thoracic Society Clinician of the Year.
A discussion was held about having a wine tasting in San Diego at the ATS International Conference. Peter Wagner (Slurping Around with PDW) has agreed to lead the conference. It was decided to extend invitations to the New Mexico, Colorado and California Thoracic Societies along with the Mayo Clinic.
A question was raised about guideline development. It was felt that we should review the Infectious Disease Society of America Valley Fever guidelines and determine if the Arizona Thoracic Society might have something to contribute.
Three cases were presented:
Lewis Wesselius from the Mayo Clinic Arizona presented a 19 year old man with shortness of breath and fever. He was seen in the Emergency Department and had a normal chest x-ray but returned 6 days later with a diffuse nodular pneumonia. Bronchoscopy with bronchoalveolar lavage revealed blood but all cultures with negative. He underwent video-assisted thorascopic lung (VATS) biopsy. Histologically the biopsy showed massive neutrophilic infiltration, hemorrhage, and small, angiocentric abscess formation. This was considered compatible with pyoderma gangrenosum of the lung (1). He had dramatic improvement with corticosteroids.
Elijah Poulos, a second year fellow at the Good Samaritan/VA program, presented a case of a non-resolving lung infiltrate in the left lower lobe after 6 weeks. CT scan showed a patchy, nodular consolidation with hazy borders. The patient was asymptomatic. Lung biopsy showed adenocarcinoma. He was referred to thoracic surgery for possible resection. A discussion ensued reminding everyone that carcinoma is a consideration in non-resolving lung lesions and that adenocarcinoma is becoming more common (2).
Dr. Poulos also presented a 66 year old who is retired but a semi-retired handyman/farmer who had a persistent nonproductive cough. CT scan showed a diffuse increase in interstitial markings. Pulmonary function testing revealed restrictive lung disease. Bronchoscopy with bronchoalveolar lavage was unremarkable. He was treated with fluticasone nasal spray and improved. Most advised a VATS biopsy to establish a diagnosis.
Richard A. Robbins, M.D.
References
- Kanoh S, Kobayashi H, Sato K, Motoyoshi K, Aida S. Tracheobronchial pulmonary disease associated with pyoderma gangrenosum. Mayo Clin Proc. 2009;84(6):555-7. [CrossRef] [PubMed]
- Lortet-Tieulent J, Soerjomataram I, Ferlay J, Rutherford M, Weiderpass E, Bray F. International trends in lung cancer incidence by histological subtype: Adenocarcinoma stabilizing in men but still increasing in women. Lung Cancer. 2014 Jan 25. pii: S0169-5002(14)00044-0. [PubMed]
Reference as: Robbins RA. February 2014 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2014;8(2):138-9. doi: http://dx.doi.org/10.13175/swjpcc026-14 PDF
January 2014 Arizona Thoracic Society Notes
The January Arizona Thoracic Society meeting was held on Wednesday, 1/22/2014 at Shea Hospital beginning at 6:30 PM. There were 11 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.
A discussion was held how to encourage attendance of young physicians to the Arizona Thoracic Society. A short presentation was made by Rick Robbins on the SWJPCC reiterating the material published in the yearly report from the editor (1).
Three cases were presented:
Dr. Tom Colby from the Pathology at the Mayo Clinic Arizona presented the first case. The patient was a 62 year old with polycythemia vera and shortness of breath. CT scan showed diffuse ground glass densities. The right ventricle and the pulmonary artery were slightly enlarged. A VATS lung biopsy was performed. The biopsy showed an increase in megakarocytes, immature red blood cells and immature white cell precursors consistent with extramedullary hematopoiesis. There was no fibrosis. There was a marked increase in CD34 staining consistent with alveolar septal capillary proliferation. Review of three other similar cases revealed similar findings. Dr. Colby questioned whether the endothelial proliferation could contribute to the clinical and radiologic findings. Suggestions were made to obtain pulmonary function testing, echocardiography and arterial blood gases. Depending on results it was felt that pulmonary hypertension needed to be excluded and he might require a right heart catherization.
Lewis Wesselius also from the Mayo Clinic Arizona presented a 53 year old woman from Indiana with a history of chronic cough and progressive shortness of breath since May 2013. Echocardiography showed 16% left ventricular ejection fraction. She had a biventricular pacemaker placed. A clinical diagnosis of sarcoidosis with a dilated cardiomyopathy was made but the patient did no improve on corticosteroids and methotrexate. CT scan of the chest showed some mosaic attenuation. There were no perilymphatic abnormalities as often seen in sarcoidosis. A VATS biopsy was performed. Histology revealed a proliferation of neuroendocrine cells within the airways forming tumorlets. A diagnosis of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) or a diffuse carcinoid tumor was made. Previously, 24 cases of DIPNECH were reported in the American Journal of Respiratory and Critical Care by Nassar et al. (2) but none had cardiomyopathy. It was questioned whether her cardiomyopathy could be secondary to DIPNECH.
Jessica Hurley from Bethesda North Hospital presented a 27 year old man with asthma, recurrent pneumonia, dyspnea and progressive hypoxia. He had an elevated IgE but less than 1000. Thoracic CT scan showed diffuse consolidation. Cultures were negative. He was placed on high dose corticosteroids but his hypoxia progressively worsened. A lung biopsy was performed and revealed broncholitis. No definitive diagnosis was apparent and it was felt there was more going than asthma but there were differing opinions on how to proceed. The biopsy will be reviewed by the lung pathologists at Mayo Clinic Arizona.
There being no further business the meeting was adjourned at about 8:30 PM. The next meeting is scheduled for Wednesday, February 26, 6:30 PM at Scottsdale Shea hospital.
Richard A. Robbins, M.D.
References
- Robbins RA. The tremedous threes! annual report from the editor. Southwest J Pulm Crit Care. 2014:8(1):1-3. [CrossRef]
- Nassar AA, Jaroszewski DE, Helmers RA, Colby TV, Patel BM, Mookadam F. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: a systematic overview. Am J Respir Crit Care Med. 2011;184(1):8-16. [CrossRef] [PubMed]
Reference as: Robbins RA. January 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014:8(1):66-7. doi: http://dx.doi.org/10.13175/swjpcc006-14 PDF
December 2013 Arizona Thoracic Society Notes
A breakfast meeting of the Arizona Thoracic Society and the Tucson winter lung series was held on Saturday, 12/14/2013 at Kiewit Auditorium on the University of Arizona Medical Center Campus beginning at 8:30 AM. There were 31 in attendance.
A lecture was presented by Joe G. N. "Skip" Garcia, MD, the senior vice president for health sciences at the University of Arizona (Figure 1).
Figure 1. Joe G. N. “Skip” Garcia, MD
The title of Garcia’s talk was “Personalizing Medicine in Cardiopulmonary Disorders: The Post ACA Landscape”.
Garcia began with reiterating that the Affordable Care Act (ACA, Obamacare) is fact and could pose a threat to academic medical centers. However, he views the ACA as an opportunity to develop personalized medicine which grew from the human genome project. Examples cited included the genetic variability among patients in determining the dose of warfarin and bronchodilator response to beta agonists in asthma (1,2).
Garcia’s laboratory has studied predominately 6 diseases including the adult respiratory distress syndrome (ARDS), idiopathic pulmonary fibrosis (IPF), sarcoidosis, asthma, pulmonary artery hypertension and sickle cell disease. Each has in common that there has been minimal progress made in the past generation and each has been shown to have racial or ethnic disparities in outcomes. He cited examples of how molecular testing could improve care.
Black and Hispanic patients with ARDS have a significantly higher risk of death compared with white patients (3). Garcia noted that the ventilator is not necessarily a friend and use of higher tidal volumes has been associated with increased mortality (4). He reasoned that the variation in susceptibility to ventilator induced lung injury could potentially explain the racial differences in mortality. Beginning with a dog model of ARDS, highly significant regional differences in gene expression were observed between lung apex/base regions. One of these potential targets was pre-B-cell colony enhancing factor (PBEF), a gene not previously associated with lung pathophysiology (5). Further work showed PBEF could induce changes seen in ARDS including a neutrophil alveolitis and increases in nuclear factor-κβ (NFKB) expression (6).
Few would question that there is a need for validated biomarkers in idiopathic pulmonary fibrosis. Using a similar approach to the investigation of PBEF in ARDS, peripheral blood mononuclear cell (PBMC) gene expression profiles predictive of poor outcomes in idiopathic pulmonary fibrosis (IPF) were examined by microarray. Microarray analyses suggest that 4 genes (CD28, ICOS, LCK, and ITK) are potential outcome biomarkers in IPF and should be further evaluated for patient prioritization for lung transplantation and stratification in drug studies (7). PBMC gene expression profiles were also examined in sarcoidosis. There was a significant association of single nucleotide polymorphisms (SNPs) in signature genes with sarcoidosis susceptibility and severity (8). Further examples were presented on sickle cell disease.
Garcia concluded that molecular techniques represent powerful tools to investigate potential therapeutic approaches in respiratory diseases where little progress has been made.
Richard A. Robbins, MD
References
- International Warfarin Pharmacogenetics Consortium, Klein TE, Altman RB, Eriksson N, Gage BF, Kimmel SE, Lee MT, Limdi NA, Page D, Roden DM, Wagner MJ, Caldwell MD, Johnson JA. Estimation of the warfarin dose with clinical and pharmacogenetic data. N Engl J Med. 2009;360(8):753-64. [CrossRef] [PubMed]
- Duan QL, Lasky-Su J, Himes BE, Qiu W, Litonjua AA, Damask A, Lazarus R, Klanderman B, Irvin CG, Peters SP, Hanrahan JP, Lima JJ, Martinez FD, Mauger D, Chinchilli VM, Soto-Quiros M, Avila L, Celedón JC, Lange C, Weiss ST, Tantisira KG. A genome-wide association study of bronchodilator response in asthmatics. Pharmacogenomics J. 2013 Mar 19. [Epub ahead of print] [CrossRef] [PubMed]
- Erickson SE, Shlipak MG, Martin GS, Wheeler AP, Ancukiewicz M, Matthay MA, Eisner MD; National Institutes of Health National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. Racial and ethnic disparities in mortality from acute lung injury. Crit Care Med. 2009 Jan;37(1):1-6. [CrossRef] [PubMed]
- The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8. [CrossRef] [PubMed]
- Simon BA, Easley RB, Grigoryev DN, Ma SF, Ye SQ, Lavoie T, Tuder RM, Garcia JG. Microarray analysis of regional cellular responses to local mechanical stress in acute lung injury. Am J Physiol Lung Cell Mol Physiol. 2006;291(5):L851-61. Herazo-Maya JD, Noth I, Duncan SR, Kim S, Ma SF, Tseng GC, Feingold E, Juan-Guardela BM, Richards TJ, Lussier Y, Huang Y, Vij R, Lindell KO, Xue J, Gibson KF, Shapiro SD, Garcia JG, Kaminski N. Peripheral blood mononuclear cell gene expression profiles predict poor outcome in idiopathic pulmonary fibrosis. Sci Transl Med. 2013 Oct 2;5(205):205ra136.
- Hong SB, Huang Y, Moreno-Vinasco L, Sammani S, Moitra J, Barnard JW, Ma SF, Mirzapoiazova T, Evenoski C, Reeves RR, Chiang ET, Lang GD, Husain AN, Dudek SM, Jacobson JR, Ye SQ, Lussier YA, Garcia JG. Essential role of pre-B-cell colony enhancing factor in ventilator-induced lung injury. Am J Respir Crit Care Med. 2008;178(6):605-17. [CrossRef] [PubMed]
- Zhou T, Zhang W, Sweiss NJ, Chen ES, Moller DR, Knox KS, Ma SF, Wade MS, Noth I, Machado RF, Garcia JG. Peripheral blood gene expression as a novel genomic biomarker in complicated sarcoidosis. PLoS One. 2012;7(9):e44818. [CrossRef] [PubMed]
Reference as: Robbins RA. December 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(6):360-2. doi: http://dx.doi.org/10.13175/swjpcc175-13 PDF
November 2013 Arizona Thoracic Society Notes
The November Arizona Thoracic Society meeting was held on Wednesday, 11/20/2013 at Shea Hospital beginning at 6:30 PM. There were 26 in attendance representing the pulmonary, critical care, sleep, nursing, radiology, and infectious disease communities.
As per the last meeting a separate area for upcoming meetings has been created in the upper left hand corner of the home page on the SWJPCC website.
A short presentation was made by Timothy Kuberski MD, Chief of Infectious Disease at Maricopa Medical Center, entitled “Clinical Evidence for Coccidioidomycosis as an Etiology for Sarcoidosis”. Isaac Yourison, a medical student at the University of Arizona, will be working with Dr. Kuberski on his scholarly project. Mr. Yourison hypothesizes that certain patients diagnosed with sarcoidosis in Arizona really have coccidioidomycosis. It would be predicted that because of the immunosuppression, usually due to steroids, the sarcoidosis patients would eventually express the Coccidioides infection. The investigators will be collaborating with the University of Washington to perform polymerase chain reaction (PCR) on tissue samples diagnosed with sarcoidosis for Coccidioides.
There were 4 cases presented:
- The first case was presented by Lewis Wesselius from the Mayo Clinic Arizona. The patient was a 56 year old woman with rheumatoid arthritis and a prior history of bronchiectasis. In 2009 she was diagnosed with Mycobacterium avium-intracellulare (MAI) on bronchoscopy and started on azithromycin, ethambutol, and rifabutin. She had been on etanercept which was held after her diagnosis of MAI. She had a negative sputum culture for MAI in September 2012 and her MAI medications were stopped. However, in May 2013 she had increasing symptoms and bronchoscopy demonstrated Pseudomonas and nontuberculous mycobacterium (NTB). She subsequently moved to Phoenix and a CT scan showed the size of her lung nodules to be increased. Bronchoscopic cultures showed Pseudomonas and Mycobacterium abscessus only sensitive to amikacin. She was treated with tigecycline and inhaled amikacin. A repeat CT scan indicated some decrease in size of lung nodules. Dr. Wesselius gave a short presentation on bronchiectasis associated with rheumatoid arthritis and NTB infection in these patients.
- The second case was presented by Gerry Swartzberg. Dr. Schwartzberg showed a chest x-ray and asked the audience to guess the diagnosis. Jasminder Mand was the first to correctly guess allergic bronchopulmonary aspergillosis (ABPA) because of the finger in glove sign which best seen in the right upper lobe. The density forms from mucous impaction in a more central bronchus and has been referred to as a rabbit ear appearance, Mickey Mouse appearance, toothpaste shaped opacities, Y-shaped opacities, and V-shaped opacities. Dr. Mand also referred to this as the Churchill sign since it looks like the “V” gesture often associated with Churchill. The patient was begun on corticosteroids and a repeat chest x-ray taken about a month later showed near clearing of the opacities.
- Dr. Schwartzberg presented a second case of an elderly woman in her 80’s with a history of bronchiectasis. Chest x-ray and CT scan showed several rapidly expanding lung masses. The radiographic appearance was not particularly suggestive of a diagnosis. There was a concern for malignancy and the majority thought bronchoscopy would be appropriate.
- The last case was presented by Joshua Jewell, a third year pulmonary fellow in the Good Samaritan/VA program. The patient was a middle-aged man who had a history of diffusely metastatic hepatocellular cancer including to his lung and mediastinal lymph nodes. He was also diagnosed with sleep apnea and begun on continuous positive airway pressure (CPAP). He had increasing size of his neck and presented to the pulmonary clinic. Palpation revealed crepitus and a chest x-ray and CT scan confirmed the presence of subcutaneous air and a pneumomediastinum. Dr. Jewell hypothesized that the air was introduced or at least was exacerbated by the CPAP possibly from a ball valve mechanism. Most in the audience agreed this was a reasonable explanation but none had observed this phenomenon previously.
There being no further business the meeting was adjourned at about 8:30 PM. The next meeting is scheduled for Saturday, December 14, 8-12 AM in Tucson at the Kiewit Auditorium at the University of Arizona Medical Center. The next meeting in Phoenix will be held on Wednesday, January 22, 2014, 6:30 PM at Scottsdale Shea hospital.
Richard A. Robbins, M.D.
Reference as: Robbins RA. November 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013:7(5):311-2. doi: http://dx.doi.org/10.13175/swjpcc167-13 PDF
October 2013 Arizona Thoracic Society Notes
The October Arizona Thoracic Society meeting was held on Wednesday, 10/23/2013 at Shea Hospital beginning at 6:30 PM. There were 21 in attendance representing the pulmonary, critical care, sleep, and thoracic surgery communities.
A proposal was made to decrease the number of meetings from 10 to 8 per year. After a brief discussion, this was adopted. Dr. Parides will try and coordinate these changes with Tucson.
Meetings were announced for December in Tucson, January in Carmel, February in Albuquerque, and April in Phoenix. A suggestion was made to have a separate area for meetings on the SWJPCC website.
There were 2 cases presented-both by Nick Sparacino, a first year fellow at Good Samaritan/VA.
- The first case was a 48 year old man admitted to podiatry for chronic diabetic foot ulcers. His preoperative chest x-ray revealed multiple pulmonary nodules. Importantly, he had a history of working in a brake pad factory for about 15 years, a strong family history of lung cancer and was currently actively smoking. Review of the chest x-ray and the CT scan revealed that pleural nodules only on the left. Additional history was obtained of a gunshot wound through the spleen into the chest. A liver-spleen scan showed high uptake in the nodules. The nodules were thought to be secondary to thoracic splenosis which occurs when splenic tissue is autoimplantated to the thoracic cavity following splenic injury (1). No further work up or therapy was thought to be needed.
- The second case was a 66 year old man with 2-3 week history of shortness of breath, subjective fevers, sputum production, two falls without injury, and urinary incontinence. Chest x-ray showed right lower lobe pneumonia and CT scan of the chest showed narrowing of the bronchus intermedius. Bronchoscopy revealed a veruccous, obstructing mass in the bronchus intermedius that was suspicious for squamous cell carcinoma. However, on biopsy the mass separated from the bronchial wall and fractured. It was eventually removed piecemeal with the flexible fiberoptic bronchoscope (1). Pathology was consistent with a walnut.
There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, November 20, 6:30 PM in Phoenix at Scottsdale Shea Hospital.
Richard A. Robbins, M.D.
References
- Khan AM, Manzoor K, Gordon D, Berman A. Thoracic splenosis: A diagnosis by history and imaging. Respirology. 2008;13(3):481-3. [CrossRef] [PubMed]
- Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchial foreign body aspiration in adults. South Med J. 2009;102(2):171-4. [CrossRef]
Reference as: Robbins RA. October 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(4):253-4. doi: http://dx.doi.org/10.13175/swjpcc144-13 PDF
September 2013 Arizona Thoracic Society Notes
The September Arizona Thoracic Society meeting was held on Wednesday, 9/25/2013 at Shea Hospital beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep, and pathology communities.
After a brief discussion, Gerry Swartzberg was selected as Arizona’s 2014 nominee for Clinician of the Year.
There was 1 case presented:
Dr. Thomas Colby, pulmonary pathologist from Mayo Clinic Arizona, presented the case of a 67 year old woman with multiple pulmonary nodules. The largest was 1.2 cm CT scan. She had a fine needle aspiration of one of the nodules. The pathology revealed spindle-shaped cells which were synaptophysin + (also known as the major synaptic vesicle protein p38). Synaptophysin marks neuroendocrine tissue and on this basis the patient was diagnosed with multiple carcinoid tumors. Aguayo et al. (1) described six patients with diffuse hyperplasia and dysplasia of pulmonary neuroendocrine cells, multiple carcinoid tumorlets, and peribronchiolar fibrosis obliterating small airways. Miller and Müller (2) described a series of 25 patients that were mostly women. Eight had obliterative bronchiolitis. Many questions arose including PET positivity (variable), endobronchial spread (unknown), use of somatostatin receptor scintigraphy (unknown).
There being no further business the meeting was adjourned at about 7:30 PM. The next meeting is scheduled for Wednesday, October 23, 6:30 PM in Phoenix at Scottsdale Shea Hospital.
Richard A. Robbins, M.D.
References
- Aguayo SM, Miller YE, Waldron JA Jr, Bogin RM, Sunday ME, Staton GW Jr, Beam WR, King TE Jr. Brief report: idiopathic diffuse hyperplasia of pulmonary neuroendocrine cells and airways disease. N Engl J Med. 1992;327(18):1285-8. [CrossRef] [PubMed]
- Miller RR, Müller NL. Neuroendocrine cell hyperplasia and obliterative bronchiolitis in patients with peripheral carcinoid tumors. Am J Surg Pathol. 1995;19(6):653-8. [CrossRef] [PubMed]
Reference as: Robbins RA. September 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(3):205. doi: http://dx.doi.org/10.13175/swjpcc132-13 PDF
August 2013 Arizona Thoracic Society Notes
The August Arizona Thoracic Society meeting was held on Wednesday, 8/28/2013 at Shea Hospital beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, and pathology communities.
A brief discussion was held about the audio-visual aids available. It was generally agreed that our current projector is inadequate. Judd Tillinghast will inquire about using a hospital overhead projector. If that is not possible, it was agreed to purchase a new projector.Plans for telecasting the meeting between Phoenix and Tucson continue. A trial of a link between Shea and the University in Tucson failed. Once the link is successfully established, it is hoped that the meeting can be telecasted.
There were 6 cases presented:
1. Dr. Thomas Colby, pulmonary pathologist from Mayo Clinic Arizona, presented the case of a 10 year old boy with chronic dyspnea for > 4 yrs. He had growth retardation since age 1, a skin rash since age 2 on the limbs, nail dystrophy since age 3 on hands and feet, lacrimal duct stenosis, erythematous lesions on the pinnae, phimosis, interstitial lung disease on radiography, weakly positive p-ANCA, elevated erythrocyte sedimentation rate, and hypergammaglobulinemia. He came to lung biopsy. The patient was diagnosed with dyskeratosis congenita which is a disorder of poor telomere maintenance (1). Specifically, the disease is related to one or more mutations which directly or indirectly affect the vertebrate telomerase RNA component (TERC). This patient’s manifestations are fairly typical of the disease. Short telomere length was confirmed.
2. Dr. Colby presented a second case of a 14 year old boy with a history of osteosarcoma. Pulmonary nodules developed and biopsy showed metastatic osteosarcoma. He was given systemic chemotherapy but now has residual nodules that were biopsied. One of the pulmonary nodule resembled bronchoalveolar cell carcinoma. This is an apparent complication following chemotherapy in adolescent patients (2).
3. Dr. Colby presented the pathology of a patient from the Phoenix VA who underwent lung biopsy for interstitial disease. The pathology was typical for IgG4-related disease with a plasma cell rich lymphohistiocytic infiltrate in the bronchovascular sheath and histopathology showing diffusely stained positive for IgG4 plasma cells (3).
4. Dr. Suresh Uppalapu, a second year pulmonary fellow from Good Samaritan/VA, presented a 59 year old Sudanese male who was transferred to the Good Samaritan ICU in shock. His presenting complaints to the transferring hospital were acute mental status changes, weakness, and chills. He was intubated for hypercarbic respiratory failure. His brother related that the patient had just returned from Sudan three weeks earlier. He had a prior history of a splenectomy. He was hypothermic with a temperature of 32.3°C and a SpO2 of 91% on 100% FiO2 and PEEP of 8. His Glasgow Coma Scale was 3 (lowest possible score). He had many abnormalities on laboratory evaluation, most notably a creatinine of 5.1 mg/dL and a lactic acid of 26.3 mg/dL. The peripheral smear showed malaria parasites typical of falciparum malaria (figure 1).
Figure 1. Peripheral smear showing a gametocyte (red arrow) and trophozoites in various stages from falciparum malaria.
He developed hemoptysis and eventually expired. A preliminary autopsy report has detected aspergillosis in the lung. Invasive aspergillosis has been reported in cases of severe falciparum malaria (4).
5. Dr. Heemesh Seth, also a second year pulmonary fellow from Good Samaritan/VA, presented a case of a 57 year old man with cirrhosis secondary to hepatitis C diagnosed in 1998. He presented with a large right hydrothorax. Multiple thoracentesis were performed (Table 1).
Table 1. Summary of multiple thoracentesis.
Blood cultures were positive for acinetobacter as was the initial culture from the thoracentesis. He was treated with cephepime. It was felt that his effusion and empyema were most likely secondary to translocation of bacteria to the pleural space from spontaneous bacterial peritonitis. A discussion ensued regarding whether to perform tube thoracostomy. Data is sparse with most literature not favoring a chest tube (5). However, in this patient’s case a chest tube was eventually inserted when he failed to improve. It drained about 2 liters of fluid but the drainage then became minimal and the tube was removed. The patient developed hepato-renal syndrome but was felt not to be a liver transplant candidate. He was transferred to hospice.
6. Dr. Seth also presented a second case of a 66 year old Hispanic man who presented with a large left pleural effusion. He had a past medical history of systemic lupus erythematosis (SLE) with possible rheumatoid arthritis and was being treated with adalimumab, methotrexate, and prednisone. A thoracentesis was done and 2 liters of clear amber fluid was removed. Although be developed fever to 102°F he felt much better the next morning and was discharged. However, his coccidioidomycosis serologies were positive for both IgG and IgM and his complement fixation test were positive at 1:4. Pleural fluid cytology was positive for LE cells. He was continued on prednisone and treated with fluconazole. A discussion developed of whether the effusion was secondary to SLE, coccidioidomycosis, or both. No one knew data but it was felt that it was most prudent to continue the present course while following the patient and awaiting cultures.
There being no further business the meeting was adjourned at about 8:15 PM. The next meeting is scheduled for Wednesday, September 25, 6:30 PM in Phoenix at Scottsdale Shea Hospital.
Richard A. Robbins, M.D.
References
- Dokal I. Dyskeratosis congenita in all its forms. Br J Haematol. 2000;110(4):768-79. [CrossRef] [PubMed]
- Travis WD, Linnoila RI, Horowitz M, Becker RL Jr, Pass H, Ozols R, Gazdar A. Pulmonary nodules resembling bronchioloalveolar carcinoma in adolescent cancer patients. Mod Pathol. 1988;1(5):372-7. [PubMed]
- Hurley JR, Leslie KO. IgG4-Related systemic disease of the pancreas with involvement of the lung: a case report and literature review. Southwest J Pulm Crit Care. 2013;7(2):117-130. [CrossRef]
- Hocqueloux L, Bruneel F, Pages CL, Vachon F. Fatal invasive aspergillosis complicating severe Plasmodium falciparum malaria. Clin Infect Dis. 2000;30(6):940-2. [CrossRef] [PubMed]
- Alonso JC. Pleural effusion in liver disease. Semin Respir Crit Care Med. 2010;31(6):698-705. [CrossRef] [PubMed]
Reference as: Robbins RA. August 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2013;7(2):114-6. doi: http://dx.doi.org/10.13175/swjpcc117-13 PDF
July 2013 Arizona Thoracic Society Notes
The first Arizona Thoracic Society meeting in Tucson was held on Wednesday, 7/24/2013 at Kiewit Auditorium on the University of Arizona Medical Center campus beginning at 6:30 PM. There were 36 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities. Dinner was sponsored by Accredo Health Group.
A brief discussion was held of plans to have the December 2013 meeting in Tucson on a weekend as part of the University of Arizona winter pulmonary meeting.
There were 4 cases presented:
- Mohammad Dalabih presented a case of a 48 yo woman with respiratory failure cared for by Gordon Carr, Linda Snyder, and himself. Radiology findings were discussed by Isabel Oliva. Lung biopsy showed acute fibrinous and organizing pneumonia rather than ARDS and was presented by Richard Sobonya.
- Franz Rischard presented a case of a 61 year old with progressive dyspnea and moderate COPD with evidence of pulmonary hypertension. Radiologic work up was presented by Dr. Oliva. It was determined the patient had primary hypertension and Dr. Rischard discussed how to separate pulmonary hypertension from COPD from primary pulmonary hypertension.
- Nathaniel Reyes presented a 50 year old woman with a history of granulomatous polyangiitis (GPA, formerly known as Wegener’s granulomatosis) who was pANCA+ but cANCA-. She developed diffuse alveolar hemorrhage. Dr. Soboyna reviewed pathology of GPA. Dr. Reyes discussed the ANCA+ vasculities. Some rheumatologists no longer consider GPA and microscopic polyangitis separate diseases but part of the same spectrum.
- Gordon Carr presented a case of a 65 year old man who died of an exacerbation of idiopathic pulmonary fibrosis (IPF). Dr. Sobonya reviewed the autopsy and pathology findings of IPF.
There being no further business the meeting was adjourned at about 8:15 PM. The next meeting is scheduled for Wednesday, August 28, 6:30 PM in Phoenix at Scottsdale Shea Hospital.
Richard A. Robbins, M.D.
Reference as: Robbins RA. July 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(1):50. doi: http://dx.doi.org/10.13175/swjpcc095-13. PDF
June 2013 Arizona Thoracic Society Notes
A dinner meeting was held on Wednesday, 6/26/2013 at Scottsdale Shea beginning at 6:30 PM. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.
Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, announced that the journal had begun using digital object identifiers (DOI) through the CrossRef service. In addition, the content of the journal will be stored in the CLOCKSS Archive.
The Mayo Clinic in Rochester has asked to partner with the Southwest Journal of Pulmonary and Critical Care. The Arizona Thoracic Society endorsed this association.
Rick Robbins is stepping down as the Arizona representative to the Council of Chapter (CCR) Representatives. Dr. George Parides was unanimously elected CCR representative.
Dr. Lewis Wesselius presented the case of an 80 year old Asian man with a history of the recent onset of cough, weight loss, headache and an abnormal chest x-ray. He was a nonsmoker. Physical exam revealed a thin man but was otherwise unremarkable. Laboratory showed only an elevated erythrocyte sedimentation rate. CBC was normal. Chest x-ray showed increased right perihilar densities and a small right pleural effusion. CT scan showed areas of dense consolidation in the right upper and middle lobes. Bronchoscopy was performed. No bronchial abnormality was noted. However, the cultures grew Crytococcus. Lumbar puncture showed elevated protein, slightly low glucose and slightly increased lymphocytes. A CD4 count was performed and was low at 150 cells/mm3. HIV was negative.
It was felt he had idiopathic CD4 lymphocytopenia which is a severe CD4 T-cell depletion resulting in a predisposition to opportunistic infections (1). The epidemiologic data do not suggest that the condition is caused by a transmissible agent. Unlike HIV infection, the decrease in the CD4 cell counts is often slow. The clinical spectrum ranges from an asymptomatic laboratory abnormality to life-threatening opportunistic infections. There cause is unknown and there is no proven treatment.
There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, July 24, 6:30 PM in Tucson at the Kiewit Auditorium on the University of Arizona campus.
Richard A. Robbins, M.D.
Reference
- Luo L, Li T. Idiopathic CD4 lymphocytopenia and opportunistic infection--an update. FEMS Immunol Med Microbiol. 2008;54(3):283-9. [CrossRef] [PubMed]
Reference as: Robbins RA. June 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;6(6):306-7. doi: http://dx.doi.org/10.13175/swjpcc085-13 PDF
May 2013 Council of Chapter Representatives Notes
The Council of Chapter Representatives met in conjunction with the ATS meeting in Philadelphia on May 18, 2012.
Roll Call. The meeting was called to order at 11 AM. Representatives from Arizona, California, DC Metro, Louisiana, Michigan, New Mexico, New York, Oregon, and Rhode Island were in attendance, and by telephone from Washington.
Chapter Updates. Information on chapter activities and a chapter brochure. There are currently 19 active chapters. Most are having annual meetings.
Advocacy. Gary Ewart from ATS Government Relations gave a presentation on Washington activities. Highlights included activities on the SGR, a number of air pollution regulations and a letter campaign advocating regulation of cigars.
ATS President 2013-14-vision for the coming year. Patrician Finn gave a summary of what she hopes to accomplish over the next year. The theme of her presidency will be health equality.
ATS Executive Director-update. Steve Crane gave a positive presentation on the financial status. Although not as well attended as last year’s ATS in San Francisco, this year’s Philadelphia meeting has better attendance than expected. The reserve has increased to nearly 75% of the yearly budget. The ATS is offering free maintenance of certification modules.
2013 Outstanding Clinician Award. The finalists for the ATS 2013 Outstanding Clinician Award; Allen Thomas (Arizona), Amine Temmar (New Mexico) and Steve Kirtland (Washington) will be recognized at the Clinician’s Center, Monday, 3:30-4:30 PM, Pennsylvania Convention Center, Hall C, 200 level.
Presentation of CCR Officers 2013-4
- Linda Nici-Immediate Past Chair
- Samya Nasr-Chair
- Robin Gross-Chair-elect
- Steve Kirtland-Secretary
ATS Foundation. Jim Donahue, Foundation president, gave a presentation of the activities of the ATS Foundation. Currently, all monies designated for research are used to support research. The ATS is also holding a meeting with the ALA to discuss joint grants.
Great Cases Symposium. The Great Cases Symposium organized by CCR will be held on Sunday, May 19, 2:00-4:30 PM.
A Look at the Coming Year. Samya Nasr, incoming CCR Chair, reviewed plans for the upcoming year.
Important Dates
- May 16-21, 2014-ATS International Conference, San Diego
- July 1, 2013-Call for input for 2014 International Conference
- November 6, 2013-Abstract deadline for the 2014 International Conference
CCR Committee Representatives 2013-4
- Clinicians Advisory: Robin Gross
- Education: Carol Welsh
- Ethics and Conflicts of Interest: Samya Nasr
- Health Policy: Dona Upson
- Planning and Evaluation: Linda Nici
- Quality Improvement: Rick Robbins
- Research Advocacy: Linda Nici
- Training: Samya Nasr
Adjournment. The meeting was adjourned at 1:00 PM.
Richard A. Robbins
Arizona Chapter Representative
Reference as: Robbins RA. May 2013 council of chapter representatives notes. Southwest J Pulm Crit Care. 2013:6(5):239-40. PDF
May 2013 Arizona Thoracic Society Notes
A dinner meeting was held on Wednesday, 5/15/2013 at Scottsdale Shea beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep, thoracic surgery, and radiology communities.
Dr. George Parides will have served his 2 year tenure as Arizona Thoracic Society President by July, 2013. However, he will be unable to attend the June meeting and for this reason Presidential elections were held. Dr. Lewis Wesselius was nominated and unanimously elected as President.
Three cases were presented:
- Dr. Gerald Schwartzberg presented the case of a 49 year old woman with a history of Valley Fever in 2009. She was a nonsmoker and had no other known medical diseases. However, she developed shortness of breath beginning earlier this year along with a cough productive of clear, jelly-like sputum. Her physical was normal. Pulmonary function testing revealed restrictive disease with significant improvements in the FEV1 and FVC after bronchodilators. Eosinophils were increased in her CBC at 12%. IgE was moderately increased at 286 IU/ml. Chest x-ray was normal. A high resolution thoracic CT scan revealed scattered bronchiectasis and mucoid impaction. Some speculated that this could be a case of allergic bronchopulmonary aspergillosis (ABPA) although all agreed that the level of IgE was lower than commonly occurs with ABPA. It was felt that an Aspergillus specific IgE might be useful. It was also suggested that the coccidiomycosis might have caused the bronchiectasis, noting that mycosis other than Aspergillus sp. may cause the syndrome similar to ABPA which has been termed allergic bronchopulmonary mycosis.
- Dr. Jud Tillinghast presented a case of 45 year old woman who worked as a nurse practioner. She had developed rheumatoid arthritis a few years earlier and was being treated with plaquenil and steroids. Recently she had developed shortness of breath. A few squeaks were normal on auscultation of the lungs. Pulmonary function testing was normal. However, a thoracic CT scan revealed a mosaic pattern consistent with air trapping. An open lung biopsy was performed and was consistent with constrictive bronchiolitis. The biopsy did not show inflammation but obliteration of the small bronchioles. Considerable discussion centered on treatment with most agreeing that there were no known efficacious treatments.
- Dr. Allen Thomas presented a case of a 72 year old man with 2 small pulmonary nodules discovered incidentally in Northern California. However, at the time of discovery he was in the process of moving to Arizona and presented a year later. Follow up thoracic CT scan revealed multiple small nodules and mediastinal nodes. Mediastinoscopy revealed noncaseating granulomas. A repeat CT showed that the mediastinal nodes have resolved but the nodules persisted. A PET scan showed markedly enhanced uptake by the nodules and in the mediastinum raising a question of carcinoma. Most felt that this was likely a manifestation of sarcoidosis and not necessarily an indication of cancer.
There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, June 26. The July meeting will be in Tucson on July 24th at 6:30 PM. Location to be determined.
Rick Robbins
Arizona CCR Representative
Reference as: Robbins RA. May 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2013;6(5):237-8. PDF
April 2013 Arizona Thoracic Society Notes
A dinner meeting was held on Wednesday, 4/24/2013 at Scottsdale Shea beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep, infectious disease, and radiology communities. Drs. Gotway and August, thoracic radiologists, were both unable to attend. Dr. Tilman Kolesch from Maricopa more than capably filled in as our radiologist.
The meeting was preceded by a discussion on Pharma and the availability of physicians who accept money, including dinners, from pharmaceutical companies. The Arizona Thoracic Society is sponsored by pharmaceutical companies.
Ken Knox asked if Arizona Thoracic Society meetings could be held in Tucson during July and December, the two months meetings have not been scheduled. The attendees enthusiastically endorsed this expansion of the Arizona Thoracic Society meetings.
In addition, Dr. Knox wishes to sponsor a winter symposium in Tucson in collaboration with the Arizona Thoracic Society. The attendees also enthusiastically endorsed this meeting.
Four cases were presented:
- Tim Kuberski, infectious disease from Maricopa, presented a case of a 27 year old woman who was in her 38th week of pregnancy who was referred for an abnormal chest x-ray. She has a positive history of tuberculosis which was treated with only 2 weeks of isoniazid, rifampin and ethambutol. Her chest x-ray showed volume loss and left upper lobe cavitary disease. This had progressed from an old chest x-ray taken several years previously. Sputum was positive for acid-fast bacilli. Previously the patient had grown Mycobacterium kansasii. Given that she was in her 38th week of pregnancy, the patient was asymptomatic and the tempo of her disease appeared slow, most suggested waiting until after her delivery to start therapy.
- Tom Colby, pulmonary pathologist from the Mayo Clinic presented a case of a 5 year old with enlarging nodules in both lungs. The child had a history of cystic pulmonary adenomatoid malformation or congenital cystic adenomatoid malformation (CPAM/CCAM) at 8 days. Biopsy of the lesions revealed histology consistent with mucinous adenocarcinoma. This has been previously reported (Am J Surg Pathol. 2003;27:1139-46).
- Dr. Colby also presented a case of a 38 year old with a history of sarcoidosis that had developed cystic changes in the left upper lobe. Biopsy was consistent with mucinous adenocarcinoma. Dr. Colby discussed the potential association of these lymphocytic predominant lesions with mucinous adenocarcinoma.
- Lewis Wesselius, pulmonologist from the Mayo Clinic, presented a 65 year old from Colorado with lung masses. The patient had a history of dermatomyositis and was being with intravenous immunoglobulin (IVIG), prednisone and methotrexate for his dermatomyositis and warfarin for his pulmonary embolism. A thoracic CT scan showed multiple nodules which were new compared to an old chest x-ray. A PET scan was positive. A CT guided biopsy was nondiagnostic. Video-assisted thorascopic surgery (VATS) biopsy showed an Epstein Barr Virus-positive immunodeficiency-associated lymphoproliferative disorder with Hodgkin lymphoma-like features. Dr Wesselius reviewed immunodeficiency-associated lymphoproliferative diseases. If was thought that the patient’s case was most consistent with a methotrexate-induced lymphoma which have been reported to spontaneously improve with discontinuation of methotrexate. Methotrexate was discontinued and the lesions are shrinking.
There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, May 15 prior to the American Thoracic Society meeting in Philadelphia.
Rick Robbins
Arizona CCR Representative
Reference as: Robbins RA. April 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;6(4):189-190. PDF
March 2013 Arizona Thoracic Society Notes
A dinner meeting was held on Wednesday, 3/20/2013 at Scottsdale Shea beginning at 6:30 PM. There were 14 in attendance representing the pulmonary, critical care, sleep, infectious disease, nursing, and radiology communities.
Copies of the book “Breathing in America: Diseases, Progress, and Hope” were distributed.
Three cases were presented:
- Tim Kuberski, infectious diseases from Maricopa, presented a 49 year old woman with a history of alcoholism who presented with RML pneumonia. Despite azithromycin and cephtriaxone she developed progressive respiratory failure and a right pleural effusion. A right chest tube was placed. Cultures of blood and the pleural fluid were negative. She was suspected of having an anaerobic infection. Follow-up CT scan showed abscess formation in her RML with areas of dense consolidation on the left and a left pleural effusion. Discussion focused on whether RML resection should be performed. Most favored a surgical approach.
- Andrew Goldstein, thoracic surgery, presented a 48 year old man with a large extrathoracic chest mass who presented with hematuria. The hematuria eventually proved to be secondary to bladder cancer. On CT the approximate 7 cm mass appears to be growing from the manubrium. Biopsy of the mass revealed transitional cell carcinoma. There are clinically no other metastasis. The sternal tumor was resected and the patient has done well and has returned to work.
- Tom Ardiles, pulmonary from Maricopa, presented 21 yo woman who presented with pneumonia after a cardiac arrest. She has a history of alcohol and dextroamphetamine abuse. Her procalcitonin levels were elevated. She developed right lower lung consolidation and a right pneumothorax. Sputum grew Pseudomonas. CT shows diffuse grown glass opacities and pneumomediastinum and intertidal emphysema. She has had progressive consolidation on chest x-ray and persistent respiratory failure. A right pleural effusion developed and was drained which also cultured Pseudomonas. She is gradually improving on oscillatory ventilation and antibiotics.
There being no further business, the meeting was adjourned at about 8 PM. The next meeting is Wednesday, April 24, 2013 at 6:30 PM at Scottsdale Shea.
Richard A. Robbins, MD
CCR Representative
Arizona Thoracic Society
Reference as: Robbins RA. March 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;6(3):148. PDF