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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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Thursday
Jan242013

January 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 1/23/2013 at Scottsdale Shea beginning at 6:30 PM. There were 25 in attendance representing the pulmonary, critical care, sleep, infectious disease, thoracic surgery and radiology communities.

Dr. George Parides presented a plaque to Al Thomas for being voted Arizona’s Clinician of the Year (Figure 1).

Figure 1. George Parides, Arizona Thoracic Society President, presenting a plaque to Allen Thomas, Arizona Thoracic Society Clinician of the Year.

Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, gave a PowerPoint slide presentation updating the membership on the Arizona Thoracic Society’s official journal.

Five cases were presented:

  1. Tim Kuberski, chief of infectious disease at Maricopa Medical Center, presented a 29 year old diabetic who underwent a sinus operation for a sinus mass which proved to be a fungus ball. A biopsy was also done of the bone which showed osteomyelitis with cultures showing methicillin-sensitive Staphylococcus aureus. The patient received a 6 week course of daptomycin. Near the end of his daptomycin he began to complain of shortness of breath. Chest x-ray and thoracic CT scan showed peripheral lung consolidation with a “reverse batwing” appearance. The patient had 5% eosinophils in his blood. The symptoms and consolidation resolved with stopping the daptomycin. This was thought to be a drug reaction to the daptomycin.
  2. Andrew Goldstein, thoracic surgery, presented a case of a 71 year old man who developed an upper respiratory tract infection after a hunting trip. His complaints led to a chest x-ray which showed fullness in the right hilum and a question of oligemia in the right lung. Review of the patient’s old chest x-rays showed RLL collapse for at least a couple of years Thoracic CT showed the RLL collapsed with a question of a mass in the bronchus intermedius. PET scanning did not show increased metabolic activity. Bronchoscopy showed a mass in bronchus intermedius. Multiple biopsies were non-diagnostic. A rigid bronchoscopy was performed with multiple biopsies which showed an endobronchial hamartoma. The mass was endobronchially resected until both the RML and RLL bronchus were patent. Post-operatively the RLL was expanded.
  3. Heemesh Seth and John Roehrs, pulmonary at the Phoenix VA, presented a 34 year old man with progressive dyspnea since 2006 when was a Marine in Iraq injured by an IED. Chest x-ray and thoracic CT scan showed a mild left PA enlargement. Pulmonary function tests were normal. An echocardiogram showed pulmonic stenosis with a mild gradient and mild pulmonic regurgitation.  Referral to a pediatric cardiologist confirmed a diagnosis of pulmonic stenosis with pulmonic dilatation. Discussion regarding right heart catherization and optimal treatment ensued without a consensus being reached.
  4. Elijah Poulos and Allen Thomas, pulmonary at the Phoenix VA, presented a case of a 57 year old man who had been admitted with atrial fibrillation and a rapid ventricular response. He had a past medical history of COPD and optic neuritis of uncertain etiology. A chest x-ray revealed a right pleural effusion and scattered right central peribronchial lung consolidation with less on left. The patient was asymptomatic. Various diagnoses were discussed including sarcoidosis and lymphoma but most felt that diagnosis would require biopsy.
  5. Gerald Swartzberg presented three cases. All had been exposed to obnoxious fumes and developed vocal cord dysfunction. Most had diagnosed with asthma and all had extra thoracic obstruction on their flow-volume loops. Dr Schwartzberg reviewed irritant-associated vocal cord dysfunction and a discussion ensued regarding this poorly described disorder.

There being no further business, the meeting was adjourned at about 8 PM. The next meeting is Wednesday, February 27, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. January 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2013;6(1):38-40. PDF

Thursday
Nov292012

November 2012 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 11/28/2012 at Scottsdale Shea beginning at 6:30 PM. There were 20 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

Dr. George Parides stated he was unable to find further information on treating patients begun on biologicals for RA who developed a + QuantiFERON.

Four cases were presented:

  1. Dr. Suresh Uppalapu, a pulmonary fellow at Good Samaritan/VA, presented a case of a 29 yo woman with a rash and a myriad of nonspecific complaints. She had recently been a contestant in a reality TV show. Just prior to admission she developed a neurologic complaints including incontinence. Her CXR was negative but CT of the chest showed scattered areas of ground glass opacities peripherally. A MRI of the brain revealed nonspecific abnormalities. CBC showed an elevated eosinophil count of 8%. Coccidioidomycosis antigen was negative. An LP was performed which showed a protein of 144 mg/dL, a glucose of 33 mg/dL, and 553 cells/mm3 with 79% eosinophils. Biopsy revealed angiostrongylus. She is being treated with albendazole and steroids and is improving.
  2. Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a case of a 61 yo man who presented with fever, chills and renal failure. He had diffuse patch ground glass opacities and a WBC scan localized to the lung. Open lung biopsy showed intravascular lymphocytes which stained positively for the B cell marker CD79a. The patient is receiving chemotherapy
  3. Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 56 yo homeless man with schizophrenia and alcoholism who was found to have Mycobacterium kansasii about a year ago. He was begun on INH, rifampin, ethambutol, and PZA. He was lost to follow up but returned with a LUL cavity and respiratory failure. He was intubated and placed on mechanical ventilation. Bronchoalveolar lavage was AFB+. He was again begun on INH, rifampin, ethambutol, and PZA. When he failed to improve after several weeks he was treated with moxifloxacin, azithromycin and amikacin. A repeat BAL was Coccidioidomycosis antigen positive although the serum Coccidioidomycosis antigen negative. He was treated with amphotericin and was improving.
  4. Dr. Jessica Hurley, a pulmonary fellow at St. Joseph, presented a 60 yo woman who underwent lung transplantation in May, 2012 for sarcoidosis. She developed progressive hypoxia and was intubated. CT scan showed multiple small nodules surrounded by ground glass opacities and mediastinal adenopathy. A VATS biopsy was performed which showed spindle shaped CD34+ positive cells consistent with Kaposi’s sarcoma. Her Mycophenolate was stopped and she was begun on doxorubicin.

There being no further business, the meeting was adjourned at about 8 PM. There being no meeting in December, the next meeting is Wednesday, January 23, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. November 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:270-1. PDF

Thursday
Oct252012

October 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 10/24/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

An announcement was made that the Colorado Thoracic Society has accepted an invitation to partner with the Arizona and New Mexico Thoracic Societies in the Southwest Journal of Pulmonary and Critical Care Medicine.

Discussions continue to be held regarding a combined Arizona Thoracic Society meeting with Tucson either in Casa Grande or electronically.

Six cases were presented:

Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 48 year old female who had been ill for 2 weeks. A CT of the chest revealed a left lower lobe nodule and a CT of the abdomen showed hydronephrosis and a pelvic mass. Carcinoembryonic antigen (CEA) was elevated. All turned out to be coccidioidomycosis on biopsy.  CEA decreased after the pelvic mass was resected.

Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a 60 year old man with a past medical history of a transbronchial biopsy showing nonspecific interstitial lung disease. CT scan showed bilateral hilar lymphadenopathy and multifocal ground glass opacities. Multiple serologies were all negative. Biopsy revealed both hypersensitivity pneumonitis and sarcoidosis. It was pointed out by Drs. Michael Gotway and David August that the usual presentation of sarcoidosis in the lung is bilateral lymphadenopathy with multiple small nodules in a peribronchovascular distribution along with irregular thickening of the interstitium. Although multifocal ground glass opacities have been reported with sarcoidosis, it is unusual.

Dr. George Parides presented two cases of patients with rheumatoid arthritis receiving biologic therapy. One presented with a positive QuantiFERON test for tuberculosis and the other with a positive PPD. Management was discussed. None were aware of any data but the majority thought that stopping the biologics, if possible, and treating with INH for 9 months was probably appropriate.

Dr. Colby presented a second case of a 52 year old heavy smoker with shortness of breath while playing basketball. Chest CT showed ground glass opacities with minimal fibrosis. A lung biopsy showed various areas consistent with desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease or nonspecific interstitial pneumonitis with scarring.  Dr. Colby stated that smokers with interstitial disease can have different patterns on biopsy. Drs. Gotway and August pointed out that the lung CT pattern is also often heterogenous.

Dr. Lewis Wesselius presented a 49 year old female admitted for hypoxia, lethargy, and an abnormal chest x-ray. She had a prior diagnosis of systemic lupus erythematosis (SLE) with a reported diagnosis of lupus pneumonitis made 3-4 years ago. There was a history of multiple episodes of pneumonia (25 in 5 years), a prior stroke and mitral valve disease with valve replacement. Chest CT showed multiple areas of ground glass opacities and bronchoscopy with bronchoalveolar lavage resulted in a bloody return. Serologies were inconsistent with SLE but anti-phospolipid antibodies were present. Dr. Wesselius reviewed antiphospholipid antibody syndrome (APS) which can occur as a primary condition or in the setting of an underlying systemic autoimmune disease such as SLE. Manifestations include deep venous thrombosis (32%), thrombocytopenia (22%), livedo reticularis (20%), stroke (13%), pulmonary embolus (9%), fetal loss (8%), transient ischemic attack (7%), hemolytic anemia (7%), and rarely alveolar hemorrhage. Treatment includes high dose corticosteroids, cyclophosphamide, mycophenolate, IVIG, and plasmapharesis. A recent report (Lupus 2012, 21:438-40) advocated Rituximab, a chimeric monoclonal antibody against the protein CD20, which is primarily found on the surface of B cells, for recurrent diffuse alveolar hemorrhage in primary APS.

There being no further business, the meeting was adjourned. The next meeting is November 28 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. October 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:218-9. PDF

Thursday
Sep272012

September 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 9/26//2012 at Scottsdale Shea beginning at 6:30 PM. There were 18 in attendance representing the pulmonary, critical care, sleep, pathology, and radiology communities.

A discussion was held on Pending Premium Cigar Legislation HR. 1639 and S.1461, the "Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2011”. This bill would exempt "premium cigars" from FDA oversight.  The definition of premium cigars is so broad that candy flavored cigars, cigarillos and blunts would be exempted from FDA regulation.  Teenage cigar smoking is increasing and this legislation may result in a further increase. The Arizona Thoracic Society is opposed to this bill. Dr. Robbins is to put a link on the Southwest Journal of Pulmonary and Critical Care website linking to the ATS website. This will enable members to contact their Congressmen opposing this legislation.

A discussion was also held on a proposed combined Tucson/Phoenix meeting. George Parides and Ken Knox have been discussing a combined meeting between the Arizona Thoracic members in Tucson and Phoenix in Casa Grande. Dr. William Peppo, chairman of medicine at Midwestern University, made the suggestion that perhaps the University of Arizona video link between the Tucson and Phoenix campus could be used to hold combined meetings. It was decided to pursue this possibility.

Two cases were presented:

  1. Rick Robbins presented a case of a 56 yo man with chronic cough and exertional dyspnea. He had mild restrictive disease and scattered areas of a reticular pattern and ground glass opacities on chest x-ray and CT scan of the chest. Bronchoscopy with bronchoalveolar lavage revealed 60% lymphocytes which were predominately CD8+. VATS was consistent with hypersensitivity pneumonitis. A careful history and hypersensitivity serology did not reveal an etiology of the hypersensitivity pneumonitis. It was pointed out that a pervious series revealed that 25% of chronic hypersensitivity cases had no identifiable etiology. A discussion ensued about how far to investigate the patient’s environment for an etiology. The consensus was that an aggressive, thorough investigation was probably warranted.
  2. Tom Colby presented a case of a 26 year old man with recurrent hemoptysis and pneumothoracies. An open lung biopsy revealed holes in the lung and areas with abnormal scarring. The patient eventually proved to have Ehlers Danlos syndrome characterized by joint hypermobility. None had seen a similar patient but Dr. Colby related he had seen this pattern on lung biopsy previously and since the disease occurs once in every 5000 births, he wondered if the disease was more common than reported.

There being no further business, the meeting was adjourned at 7:45 PM. The next meeting is scheduled for October 24 at Scottsdale Shea 6:30 PM.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. September 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:149-50. (Click here for a PDF version of the notes)

Thursday
Aug302012

August 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 8/29/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, pathology, radiology, and thoracic surgery communities.

Four cases were presented:

  1. Lewis Wesselius and Thomas Colby presented a 39 yo female with cough and small amounts of hemoptysis for over a year.  Chest x-ray was interpreted as perhaps showing some small nodules in the lower lobes which were more easily seen with CT scan. The scattered nodules were lower lobe predominant, non-calcified and surrounded by ground glass haloes. Coccidioidomycosis serology was negative and rheumatologic serologies were negative. Bronchoscopy showed blood in the airway but other than blood, bronchoalveolar lavage was negative. A video-assisted thorascopic (VATS) biopsy showed a hemangioendothelioma, a malignant neoplasm that falls between a hemangioma and angiosarcoma. These vascular tumors can originate in the heart and often metastasize to the lung and pleura amongst other sites. Treatment is varied and depends on the site and extent of tumor involvement, site(s) of metastasis, and specific individual factors.
  2. Allen Thomas presented a 78 year old with a history of squamous cell carcinoma and right pneumonectomy done in Florida in 2002. He complained of right-sided chest pain and CT scan revealed a mass in the pneumonectomy space near the stump. Needle biopsy showed only fibrous tissue and hemorrhage. This was followed by a long discussion of what could be done but the patient chose to wait and obtain a follow up CT scan in about 3 months.
  3. Dr. Thomas presented a second case of a 62 yo former smoker with cough and blood-streaked sputum, weight loss, and night sweats. Chest x-ray revealed a large cavity in right middle lobe. Bronchoscopic transbronchial biopsy showed a question of necrotizing granulomas. Two weeks later the lesion had nearly doubled in diameter and he felt worse. This was felt to be most consistent with an infectious process based on doubling times and he was empirically treated with fluconazole pending the results of the cultures obtained at bronchoscopy. Two weeks later the lesion had again nearly doubled in size and he felt worse. Resection of the lesion revealed a poorly differentiated carcinoma. It was felt that the lesion enlarged rapidly because of bleeding into the cavity rather than enlargement of the tumor mass.
  4. Bridgett Ronan presented a 69 year old referred for recurrent hemoptysis. The hemoptysis was severe and the patient had been endotracheal intubated X 3, bronchoscoped X 2 and had bronchial artery embolization X 2 over the past year. The first episode occurred in July 2011 He was treated for presumed sepsis syndrome and improved. However, this sequence of fevers, rigors and hemoptysis recurred twice in Oct 2011 and again in November. In all instances chest x-ray and CT showed dense consolidation in the right upper lobe lung and he improved on antibioitics. After the November episode the patient was empirically treated with corticosteroids. He did well until January when his symptoms recurred while the corticosteroids were being tapered.  A repeat bronchoscopy in March was negative for infection and VATS showed nonspecific pathology with a question of capillaritiis. His rheumatology serologies including anti-nuclear cytoplasmic antibody (ANCA) were negative. He was begun on cyclophosphamide in addition to the corticosteroids. At his last follow up he had done well and the corticosteroids were slowly being tapered. This was felt to possibly be a case of small vessel, ANCA negative, pulmonary vasculitis but questions were raised about the adequacy of the biopsy.

There being no further business, the meeting was adjourned at 8 PM. The next meeting is scheduled for September 26 at Scottsdale Shea 6:30 PM.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. August 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:104-5. (Click here for a PDF version)

August 2012 Arizona Thoracic Society Notes