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Arizona Thoracic Society Notes

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September 2018 Arizona Thoracic Society Notes 
July 2018 Arizona Thoracic Society Notes
March 2018 Arizona Thoracic Society Notes
January 2018 Arizona Thoracic Society Notes
November 2017 Arizona Thoracic Society Notes
September 2017 Arizona Thoracic Society Notes
March 2017 Arizona Thoracic Society Notes
January 2017 Arizona Thoracic Society Notes
November 2016 Arizona Thoracic Society Notes
July 2016 Arizona Thoracic Society Notes
March 2016 Arizona Thoracic Society Notes
November 2015 Arizona Thoracic Society Notes
September 2015 Arizona Thoracic Society Notes
July 2015 Arizona Thoracic Society Notes
May 2015 Arizona Thoracic Society Notes
March 2015 Arizona Thoracic Society Notes
January 2015 Arizona Thoracic Society Notes
November 2014 Arizona Thoracic Society Notes
September 2014 Arizona Thoracic Society Notes
August 2014 Arizona Thoracic Society Notes
June 2014 Arizona Thoracic Society Notes
May 2014 Arizona Thoracic Society Notes
April 2014 Arizona Thoracic Society Notes
March 2014 Arizona Thoracic Society Notes
February 2014 Arizona Thoracic Society Notes
January 2014 Arizona Thoracic Society Notes
December 2013 Arizona Thoracic Society Notes
November 2013 Arizona Thoracic Society Notes
October 2013 Arizona Thoracic Society Notes
September 2013 Arizona Thoracic Society Notes
August 2013 Arizona Thoracic Society Notes
July 2013 Arizona Thoracic Society Notes
June 2013 Arizona Thoracic Society Notes
May 2013 Council of Chapter Representatives Notes
May 2013 Arizona Thoracic Society Notes
April 2013 Arizona Thoracic Society Notes 
March 2013 Arizona Thoracic Society Notes
March 2013 Council of Chapter Representatives Meeting 
   and “Hill Day” Notes
February 2013 Arizona Thoracic Society Notes
January 2013 Arizona Thoracic Society Notes
November 2012 Arizona Thoracic Society Notes
October 2012 Arizona Thoracic Society Notes
September 2012 Arizona Thoracic Society Notes
August 2012 Arizona Thoracic Society Notes
August 2012 Special Meeting Arizona Thoracic Society Notes
June 2012 Arizona Thoracic Society Notes
May 2012 Council of Chapter Representatives Meeting
May 2012 Arizona Thoracic Society Notes
April 2012 Arizona Thoracic Society Notes

 

For a complete list of the Arizona Thoracic Society notes click here.

The Arizona Thoracic Society meets every other month in Phoenix, usually on the fourth Wednesday of odd numbered months, from 6:30-8:00  PM at Scottsdale Healthcare Shea Hospital located at Shea and 90th Street in Phoenix. During these meetings dinner and case presentations occur.

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Wednesday
Oct032018

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 

Thursday
Jul262018

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

Wednesday
Mar282018

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 

Sunday
Jan282018

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 

Thursday
Nov162017

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