November 2015 Arizona Thoracic Society Notes

The November 2015 Arizona Thoracic Society meeting was held on Wednesday, November 18, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities. 

There were 3 case presentations:

1. Dr. Gerald Schwartzberg presented a case of a 56-year-old man with a history of diabetes, alcoholism and tobacco abuse who has a history of Mycobacterium avium-intracellulare (MAI) with a residual thin-walled cavity in his right upper lobe (RUL). After quitting drinking and smoking and years of being asymptomatic, he presented with hemoptysis. Chest x-ray showed increasing density in the RUL. CT scan showed an intracavitary density in his previous cavity presumably a fungus ball. Sputum cultures are pending. Discussion followed on management of fungus balls. Bronchoscopy was recommended to view the bronchial anatomy to exclude other diagnosis as well as obtaining additional cultures. The consensus of the group was operative intervention if possible. If not, bronchial artery embolization was offered as an alternative.
2. Dr. Schwartzberg presented a second case of a middle-aged woman with a past history of Valley Fever who was treated and left with a negative serology and a pulmonary nodule. She has developed rheumatoid arthritis and is being considered for biological therapy. The question was whether she should received fluconazole during therapy. No one knew of any data but the group advised caution and suggested fluconazole during immunosuppressive therapy.
3. Dr. Lewis Wesselius presented a case of an 18-year-old with a prior diagnosis of Ehlers-Danlos syndrome. CT scan revealed multiple lung cysts. Dr. Wesselius reviewed Ehlers-Danlos syndrome and congenital pulmonary airway malformations (CPAM) (1,2). CPAM, previously known as congenital cystic adenomatoid malformation, is a developmental lesion of the lung comprising single or multiple cysts of uniform or varying sizes arising from anomalous growth of airways. Most of the cases are identified in infants and neonates with respiratory distress. Rarely, CPAM can present in adulthood with recurrent chest infections, pneumothorax, hemoptysis, or dyspnea. Dr. Michael Gotway showed CT scans of several additional patients.

There being no further business, the meeting was adjourned about 7:45 PM. The next meeting will be in Phoenix on Wednesday, January 27,2016 at 6:30 PM. A change of venue was discussed and will be announced prior to the meeting.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Dowton SB, Pincott S, Demmer L. Respiratory complications of Ehlers-Danlos syndrome type IV. Clin Genet. 1996;50(6):510-4. [CrossRef] [PubMed]
2. Baral D, Adhikari B, Zaccarini D, Dongol RM, Sah B. Congenital pulmonary airway malformation in an adult male: a case report with literature review. Case Rep Pulmonol. 2015;2015:743452. [CrossRef] [PubMed] 

Cite as: Robbins RA. November 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(5):233-4. doi: http://dx.doi.org/10.13175/swjpcc143-15 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

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:

1. 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.
2. 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.
3. 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.
4. 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

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:

1. 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.
2. 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. 
3. 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 24^th 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

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