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Arizona Thoracic Society Notes

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November 2018 Arizona Thoracic Society Notes
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

 

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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Saturday
Aug302014

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

Thursday
Jun262014

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:

  1. 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.
  2. 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).
  3. 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.
  4. 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

  1. Wesselius LJ. April 2014 pulmonary case of the month: DIP-what? Southwest J Pulm Crit Care. 2014;8(4):195-203. [CrossRef]
  2. 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

Sunday
Jun012014

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:

  1. 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.
  2. 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

  1. 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

Thursday
Apr242014

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:

  1. 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.
  2. 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.
  3. 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).
  4. 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

Saturday
Apr052014

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

  1. 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]
  2. 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]
  3. 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]
  4. 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