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:

1. 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 38^th 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.
2. 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).  
3. 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.
4. 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

February 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 2/27/2013 at Scottsdale Shea beginning at 6:30 PM. There were 27 in attendance representing the pulmonary, critical care, sleep, infectious disease, nursing, pathology and radiology communities.

Dr. George Parides, Arizona Thoracic Society President, congratulated Allen Thomas on being named ATS 2013 Clinician of the Year.

Lewis Wesselius announced the ALA 2013 Fight for Air Walk. This will be at the Scottsdale Civic Center on April 27, 2013. To participate or sponsor a walker contact Lonie Padilla at lpadilla@lungarizona.org or 602-429-0007.

Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, announced Tim Kuberski has been named an associate editor.

A discussion was held regarding other states in the Southwest to partner with the Southwest Journal of Pulmonary and Critical Care.  

Seven cases were presented:

1. Elijah Poulos, pulmonary fellow from the VA, presented a follow-up to a patient previously presented with optic neuritis, a positive ANCA at 1:40, a positive PR3 antibody at 1:8, and bilateral peribronchial consolidations right greater than left. The patient underwent a core needle biopsy of the lung with a final diagnosis of organizing pneumonia. The patient apparently declined rapidly and is now being given high dose methylprednisolone with the plan to begin cyclophosphamide shortly for a presumptive diagnosis of Wegner’s granulomatosis.
2. George Parides, pulmonologist, presented a case of a 17 year old woman when first seen in 2006 in the Emergency Department with chest pain. A CT was done which showed probably bronchial atresia on the left. She also had a positive coccidiomycosis serology. A bronchoscopy was negative. She was treated with fluconazole for about 9 months and then lost to follow up. She next presented in 2009 without change in her CT scan and again had a negative bronchoscopy. Rick Helmers saw her later that year. An open lung biopsy was performed but the results are unknown. She again presented in January of 2013 with increasing consolidation at the bases. Coccidiomycosis was seen on smear and she was begun on amphotericin. She has had minimal improvement. Most felt that continuing her amphotericin was appropriate.
3. Thomas Colby, pulmonary pathologist, presented a 68 year old woman who had a nonsmall cell carcinoma in 2011. She was treated with radiation therapy because her lung function was considered too compromised for pneumonectomy. She presented with increasing bilateral small nodules. A wedge biopsy showed many +CD1A cells and a diagnosis of histiocytosis X was made.
4. Thomas Colby and Maria L. Cabanas, pulmonary pathologists from the Mayo Clinic, presented a case of a 67 year old that had pulmonary fibrosis on CT scan but was asymptomatic. The fibrosis progressed and biopsy showed adenocarcinoma.
5. Tim Kuberski, infectious diseases from Maricopa, presented a 51 year old man who presented with cough. Chest x-ray revealed two large masses, one in the RUL and one in LUL, against a background of smaller nodules. The patient was a miner and a diagnosis of silicosis was made. He was followed and CT showed cavitation of one of the nodules. Quantiferon was negative as was PCR for Mycobacterium tuberculosis; however, his acid-fast smear was positive. He eventually grew Mycobacterium kansasii and is now on treatment.
6. Al Thomas, pulmonologist at the VA, presented a 65 year old who had a large osteophyte with surrounding fibrosis.
7. Gerald Swartzberg, pulmonologist, presented a 74 year old who had a squamous cell carcinoma resected who now has a fungus ball in a residual cough and has hemoptysis. Some suggested intracavitary amphotericin as a possibility for treatment.  

There being no further business, the meeting was adjourned at about 8 PM. The next meeting is Wednesday, March 20, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. Southwest J Pulm Crit Care. 2013;6(2):91-92. PDF

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