Respiratory Papillomatosis with Small Cell Carcinoma: Case Report and Brief Review

Priya Sharma

Anish Kumar

Bharath Janapati

Anil Kumar Jain

Department of Respiratory Medicine

National Institute of Tuberculosis and Respiratory Diseases

New Delhi 110030, India

Abstract

Respiratory Papillomatosis is a rare disease in which multiple exophytic squamous wart-like lesions occur within the respiratory tract. Recurrent Respiratory Papillomatosis (RRP) has the potential for malignant transformation to squamous lung cell carcinoma with a dismal prognosis. Most of the prior literature has shown malignant transformation of respiratory papillomatosis into squamous cell carcinoma. Here, we report a rare presentation of respiratory papillomatosis coexisting with small cell carcinoma and a review of relevant literature.

Introduction

RRP is a rare disease in which multiple exophytic squamous wart-like lesions occur within the respiratory tract. RRP has the potential for malignant transformation to squamous lung cell carcinoma with a dismal prognosis. The cases of squamous cell carcinomas developing within lung papillomas have been reported and these are usually associated with HPV 11 DNA (1,2). Here we present a rare case of respiratory papillomatosis coexisting with small cell carcinoma.  

Case Report

A 47-year-old woman presented with right sided chest pain and cough for 8 months. She had history of two episodes of blood streaked sputum four months ago. She also complained of loss of appetite and weight loss. She was a former smoker (1-2 cigarettes per day for 2-3 years quitting 5 years ago) and had a history of exposure to biomass fuel while working as a farmer. On examination pallor and clubbing was noted. Chest x-ray was suggestive of hilar enlargement (Figure 1).

Figure 1. Initial chest radiography.

Contrast-enhanced CT of the chest showed homogeneously enhancing soft tissue density central lung mass that is narrowing and circumferentially encasing right main bronchus. The mass was abutting arch of aorta and the ascending aorta and circumferentially encasing and narrowing the superior vena cava and right main pulmonary artery. Subsegmental collapse of superior segment of right lower lobe was also seen with right paratracheal and pretracheal lymph node enlargement (Figure 2).

Figure 2. Representative axial image from thoracic CT scan in soft tissue windows showing the right lung mass.

Flexible optic bronchoscopy showed an endoluminal irregular mass invading distal end of trachea along with carina and right main bronchus (Figure 3).

Figure 3. Photograph taken at bronchoscopy of the endobronchial mass in the distal trachea and right main bronchus.

Endobronchial biopsy showed papillary structures with fibro vascular cores lined with cell with moderate amount of cytoplasm with enlarged nuclei with granular chromatin and inconspicuous nuclei suggestive of RPR on histopathological examination. The patient was lost to follow up. Two months later she presented with increased breathlessness. Chest x-ray showed unilateral opaque right hemithorax with mediastinum slightly shifted to right (Figure 4).

Figure 4. Repeat chest radiography taken 2 months after initial presentation.

Hyponatremia was seen on routine blood investigation. CECT chest showed a well-defined heterogeneously enhancing soft tissue mass lesion with irregular margins involving the upper and middle lobe of right lung (Figure 5).

Figure 5. Coronal view of repeat thoracic CT in soft tissue windows.

The mass was encasing the right main bronchus and distal trachea, abutting large vessel, shifting trachea towards right side with moderate pleural effusion. Sputum analysis for acid-fast bacteria and malignant cells was negative. Ultrasound of abdomen showed no abnormality. Pleural fluid analysis showed paucicellular smear on cytology with ADA 20.5U/l, Protein 2.4 mg/dl and glucose 95.1 mg/dl. The patient refused bronchoscopy but consented to an ultrasound guided trans-thoracic biopsy. Histopathology showed pulmonary tissue with infiltrating tumor and the tumor was made up of sheets of small round cells with irregular contours suggestive of small cell carcinoma. Patient refused further management and left against medical advice. She passed away 11 days later.

Discussion

The incidence of RRP is bimodal, with the juvenile-onset form typically first occurring in children aged 2 to 4 years and adult-onset RRP typically occurring in adults aged 20 to 40 years. Juvenile-onset RRP is thought to be caused from peripartum exposure through an infected birth canal (3). Risk factors for adult-onset RRP include multiple lifetime sexual partners as well as a high frequency of oral sex. There was no statistically significant difference in illicit drug use between patients with adult-onset RRP vs a control group in a study by Ruiz et al. (4). RRP affects, from the most common site to the least common site, the true vocal cord, oral cavity, trachea, bronchi, and esophagus. Only 5% of the patients had the distal involvement of the trachea, and the involvement of the lung parenchyma is very rare, which is seen in, 1% of all cases (5). Therefore, patients present most commonly with hoarseness followed by stridor, cough, and dyspnea. Risk factor for malignant conversion includes smoking, prior irradiation, HPV-6. A recent study showed the presence of E6 and E7 oncogenes and their transcripts in HPV-positive lung cancer cases that are prerequisite for cancer development, thus reinforcing further the hypothesis that HPV could be a co-factor in bronchial carcinogenesis (6).Our patient had history of smoking as the only risk factor for malignant conversion.

Progressively increased expression of p53 and pRb proteins along with a reduced expression of p21^WAF1 protein appears to be significant subsequent events in the progression to carcinoma (7). Talierco et al. (8) reported 100% of patients with adult onset RRP had concurrent HPV infection of the oral cavity; however, our patient had no evidence of oral cavity HPV infection on physical examination. Bronchoscopic pictures were suggestive of papillary lesion although association with HPV can’t be commented upon as patient refused for further testing. A literature review of RRP case reports revealed that patients usually have the diagnosis of RRP many years before evidence of malignant transformation (9-12). In contrast, our patient had evidence of malignant transformation about six months after diagnosis of respiratory papillomatosis.

DiMarco et al. (13) were the first to report the presence of the multiple RRP of the tracheobronchial tree with malignant degeneration, in 1978. One other case report showing coexistence of multiple squamous cell papilloma and carcinoma in the upper trachea with severe airway obstruction has been reported (14). A case study done in Taiwan suggests that HPV infection is an important risk factor for lung cancer among women (15).

Surgical excision of RRP is the current standard of care with objective of preserving adequate voice quality and airway patency (16). Lasers can also be employed for surgical excision of RRP. Either cutting/ablating lasers (CO2 and thallium lasers), or photoangiolytic lasers such as pulsatile (PDL) and potassium- titanil-phosphate lasers (KTP) can be used. Both KTP and PDL lasers are safe and effective for in office treatment of RRP (17). Microdebriders have distinct advantages over lasers and cold instruments because of their shorter operating time and absence of thermal injury (18). Adjuvant therapies for RRP include the usage of immunomodulators such as IFN, antivirals such as Cidofovir, Angiogenesis inhibitor (Bevacizumab) and PDL-1 inhibitor (19). The development of HPV- 1 vaccination is perhaps the most important modality in the management of RRP, by preventing infection with papilloma virus.

Conclusion

To the best of our knowledge, this is the first case report of coexisting respiratory papillomatosis with small cell carcinoma lung. Thus, coexistence of malignancy or malignant degeneration of respiratory papillomatosis is although unusual but can still occur without the associative factors. Patients with RRP should be radiographically monitored at regular intervals for pulmonary involvement and further evaluation actively pursued if any suspicion of malignancy arises.

References

1. Magid MS, Chen YT, Soslow RA, Boulad F, Kernan NA, Szabolcs P. Juvenile-onset recurrent respiratory papillomatosis involving the lung: A case report and review of the literature. Pediatr Dev Pathol. 1998 Mar-Apr;1(2):157-63. [CrossRef] [PubMed]
2. Kramer SS, Wehunt WD, Stocker JT, Kashima H. Pulmonary manifestations of juvenile laryngotracheal papillomatosis. AJR Am J Roentgenol. 1985 Apr;144(4):687-94. [CrossRef] [PubMed]
3. Kashima HK, Shah F, Lyles A, Glackin R, Muhammad N, Turner L, Van Zandt S, Whitt S, Shah K. A comparison of risk factors in juvenile-onset and adult-onset recurrent respiratory papillomatosis. Laryngoscope. 1992 Jan;102(1):9-13. [CrossRef] [PubMed]
4. Ruiz R, Achlatis S, Verma A, Born H, Kapadia F, Fang Y, Pitman M, Sulica L, Branski RC, Amin MR. Risk factors for adult-onset recurrent respiratory papillomatosis. Laryngoscope. 2014 Oct;124(10):2338-44. Epub 2014 Jun 10. [CrossRef] [PubMed].
5. Cook JR, Hill DA, Humphrey PA, Pfeifer JD, El-Mofty SK. Squamous cell carcinoma arising in recurrent respiratory papillomatosis with pulmonary involvement: emerging common pattern of clinical features and human papillomavirus serotype association. Mod Pathol. 2000 Aug;13(8):914-8. [CrossRef] [PubMed]
6. Giuliani L, Favalli C, Syrjanen K, Ciotti M. Human papillomavirus infections in lung cancer. Detection of E6 and E7 transcripts and review of the literature. Anticancer Res. 2007 Jul-Aug;27(4C):2697-704. [PubMed]
7. Lele SM, Pou AM, Ventura K, Gatalica Z, Payne D. Molecular events in the progression of recurrent respiratory papillomatosis to carcinoma. Arch Pathol Lab Med. 2002 Oct;126(10):1184-8. [CrossRef] [PubMed]
8. Taliercio S, Cespedes M, Born H, Ruiz R, Roof S, Amin MR, Branski RC. Adult-onset recurrent respiratory papillomatosis: a review of disease pathogenesis and implications for patient counseling. JAMA Otolaryngol Head Neck Surg. 2015 Jan;141(1):78-83. [CrossRef] [PubMed]
9. Martina D, Kurniawan A, Pitoyo CW. Pulmonary papillomatosis: a rare case of recurrent respiratory papillomatosis presenting with multiple nodular and cavitary lesions. Acta Med Indones. 2014 Jul;46(3):238-43. [PubMed]
10. Azadarmaki R, Lango MN. Malignant transformation of respiratory papillomatosis in a solid-organ transplant patient: case report and literature review. Ann Otol Rhinol Laryngol. 2013 Jul;122(7):457-60. [CrossRef] [PubMed]
11. Hasegawa Y, Sato N, Niikawa H, Kamata S, Sannohe S, Kurotaki H, Sasaki T, Ebina A. Lung squamous cell carcinoma arising in a patient with adult-onset recurrent respiratory papillomatosis. Jpn J Clin Oncol. 2013 Jan;43(1):78-82. Epub 2012 Oct 30. [CrossRef] [PubMed]
12. Lin HW, Richmon JD, Emerick KS, de Venecia RK, Zeitels SM, Faquin WC, Lin DT. Malignant transformation of a highly aggressive human papillomavirus type 11-associated recurrent respiratory papillomatosis. Am J Otolaryngol. 2010 Jul-Aug;31(4):291-6. Epub 2009 Jul 10.  [CrossRef] [PubMed].
13. DiMarco AF, Montenegro H, Payne CB Jr, Kwon KH. Papillomas of the tracheobronchial tree with malignant degeneration. Chest. 1978 Oct;74(4):464-5. [CrossRef] [PubMed].
14. Paliouras D, Gogakos A, Rallis T, Chatzinikolaou F, Asteriou C, Tagarakis G, Organtzis J, Tsakiridis K, Tsavlis D, Zissimopoulos A, Kioumis I, Hohenforst-Schmidt W, Zarogoulidis K, Zarogoulidis P, Barbetakis N. Coexistence of squamous cell tracheal papilloma and carcinoma treated with chemotherapy and radiotherapy: a case report. Ther Clin Risk Manag. 2015 Dec 21;12:1-4. [CrossRef] [PubMed]
15. Lin FC, Huang JY, Tsai SC, Nfor ON, Chou MC, Wu MF, Lee CT, Jan CF, Liaw YP. The association between human papillomavirus infection and female lung cancer: A population-based cohort study. Medicine (Baltimore). 2016 Jun;95(23):e3856. Erratum in: Medicine (Baltimore). 2016 Jul 18;95(28):e0916. [CrossRef] [PubMed]
16. Kim HT, Baizhumanova AS. Is recurrent respiratory papillomatosis a manageable or curable disease? Laryngoscope. 2016 Jun;126(6):1359-64. [CrossRef] [PubMed] Epub 2015 Nov 26.
17. Yan Y, Olszewski AE, Hoffman MR, Zhuang P, Ford CN, Dailey SH, Jiang JJ. Use of lasers in laryngeal surgery. J Voice. 2010 Jan;24(1):102-9. Epub 2009 May 31.  [CrossRef] [PubMed]
18. Holler T, Allegro J, Chadha NK, Hawkes M, Harrison RV, Forte V, Campisi P. Voice outcomes following repeated surgical resection of laryngeal papillomata in children. Otolaryngol Head Neck Surg. 2009 Oct;141(4):522-6. [CrossRef] [PubMed]
19. Ivancic R, Iqbal H, deSilva B, Pan Q, Matrka L. Current and future management of recurrent respiratory papillomatosis. Laryngoscope Investig Otolaryngol. 2018 Jan 14;3(1):22-34. [CrossRef] [PubMed]

Cite as: Sharma P, Kumar A, Janapati B, Jain AK. Respiratory papillomatosis with small cell carcinoma: case report and brief review. Southwest J Pulm Crit Care. 2020;21:141-6. doi: https://doi.org/10.13175/swjpcc064-20 PDF

December 2020 Pulmonary Case of the Month: Resurrection or Medical Last Rites?

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

An 88-year-old man who has been short of breath and febrile up to 101.5° F for the past day presented on October 20, 2020. He has no known sick contacts or exposure to COVID-19.

PMH, SH, and FH

• No reported pulmonary history although he had a Xopenex MDI which he rarely used.
• Coronary artery disease with prior coronary artery bypass grafting (1978); multiple subsequent stents; chronic atrial fibrillation; pacemaker (Micra)
• Stage 3-4 CKD (creatinine 1.95)
• Chronically on warfarin

Physical Examination

• Temp 37.3, Sat 92% on RA, 95% on 2 lpm,
• Lungs: Few crackles in right upper chest
• CV: regular, no murmur
• Ext: 1 to 2+ edema (chronic, uses TED hose)

Which of the following is/are the most likely diagnosis? (Click on the correct answer to be directed to the second of seven pages)

1. Community-acquired pneumonia
2. Congestive heart failure
3. COVID-19
4. 1 and 3
5. Any of the above

Cite as: Wesselius LJ. December 2020 Pulmonary Case of the Month: Resurrection or Medical Last Rites? Southwest J Pulm Crit Care. 2020;21(6):128-37. doi: https://doi.org/10.13175/swjpcc065-20 PDF

Results of the SWJPCC Telemedicine Questionnaire

Richard A. Robbins, MD

Julene R. Robbins, PhD, NCSP

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

As the COVID-19 crisis puts pressure on outpatient providers to facilitate remote care, some have set aside their skepticism and opened telemedicine clinics as an alternative to the traditional office visit. In these visits, the provider and patient usually are able to visually and verbally interact. However, interactions that require contact such as a physical examination are not possible. We conducted a voluntary, anonymous, on-line survey of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership to determine their experience and attitudes toward telemedicine. Of the 84 respondents we surveyed, most were favorable towards telemedicine visits with two-thirds of respondents being very or mostly satisfied with telemedicine. However, some (30%) estimated that over 50% of their time was spent with documentation and a significant portion (55%) noted reduced reimbursement. These data support the Center for Medicare and Medicaid’s (CMS) decision to expand telemedicine beyond the present COVID-19 pandemic.

Introduction

The COVID-19 pandemic has created new challenges for patient care. The risk for severe illness from COVID-19 increases with age (1). Many patients and some providers are elderly and at risk for more severe disease. According to the Centers for Disease Control and Prevention (CDC), the best protection is to limit interactions with other people as much as possible (1).

One potential solution which avoids contraction of COVID-19 by face-to-face exposure is telemedicine. Telemedicine is the remote diagnosis and treatment of patients by means of telecommunications technology usually employing both visual and audio interaction. Telemedicine has been around for some time and its use has increasing (2). However, telemedicine is not without limitations including the obvious concerns of reimbursement, regulatory issues, privacy, the need for access to telemedicine devices (e.g., smartphone, tablet, computer), comfort levels with the technology by both healthcare providers and patients, and cultural acceptance of conducting virtual visits in lieu of in-person visits (3). Furthermore, other fundamental issues such as selection of patients and outcomes are largely unknown.

To discover the experiences with and the attitudes toward telemedicine, we posted an on-line questionnaire and solicited the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership to fill out the questionnaire The results suggest that telemedicine usage has increased with the COVID-19 pandemic, and despite the short time of implementation, is generally acceptable to providers.

Methods

Questionnaire

A questionnaire was constructed with the goals of determining healthcare providers experience and attitudes towards telemedicine.  An additional goal was to keep the survey brief, since previous experience was that long surveys usually have a poor response. A series of 11 questions was developed (Appendix 1).

Data Collection and Statistical Analysis

Data was collected August 9, 2020 through August 31, 2020. The data was collected on the Southwest Journal of Pulmonary and Critical Care website using Excel.

Results

Demographics

There were 84 respondents. Eighty-one answered yes to offering telemedicine but 3 no’s appeared to have prior experience with telemedicine (Appendix 2). Although we did not question which were physicians, nurse practitioners, physician assistants, etc., the vast majority of respondents to previous SWJPCC surveys have been pulmonary and critical care physicians (4).

Sixty-eight of the eighty-four respondents (81%) did not offer telemedicine before the COVID-19 pandemic. The majority of these 64/84 (76%) offered telemedicine to both new and established patients. Only 20/84 (24%) offered telemedicine to established patients only.

Telemedicine platform

There were 90 responses from the 84 respondents to which telemedicine platform was being used. Some respondents apparently used more than one platform.

Table 1. Telemedicine platforms used.

The most common reason cited for using a platform was that the telemedicine platform was offered with the electronic healthcare record currently in use (30 of 84, 36%). An almost an equal number (29/84, 35%) did not know the basis of choosing the platform and presumably had not been involved in the selection process. Only 4 said the platform was chosen on the basis of reviews.

Connectivity

A major concern of telemedicine has been the ability of some patients and providers to use the technology (3). This would likely be reflected in a low number of patients and providers to establish a connection. The results of the questionnaire suggest connectivity is not a major problem (Figure 1).

Figure 1. Connectivity of telemedicine visits. Number of respondents is on the vertical axis and their responses are on the horizontal axis.

There was no consistent pattern in those who had problems with connections (Appendix 2).

Satisfaction

Two-thirds of the respondents were either very or mostly satisfied with their current telemedicine platform (Figure 2).

Figure 2. Satisfaction with current telemedicine system.

There was no consistent pattern to telemedicine satisfaction although other than only one of the seven respondents who used eVisit (Banner Healthcare system) or the VA system was satisfied (Appendix 3).

Disadvantages of Telemedicine

The five most common disadvantages of telemedicine as viewed by the respondents are listed in Table 2.

Table 2. Most common disadvantages of telemedicine.

No other pattern of responses was discerned other than four noting the obvious lack of vitals and physical exams possible with telemedicine.  The questionnaire also asked specifically about time for documentation and reimbursement because one of the authors (RAR) noted high documentation time and low reimbursement in his practice. Documentation time did tend to be high (Appendix 2). Twenty-five respondents (30%) noted that over half the time of a telemedicine visits was spent in documentation and/or billing. Many respondents (35 out of 84, 42%) did not know the reimbursement for the telemedicine visits compared to a face-to-face office visit. One respondent claimed a higher reimbursement with telemedicine; 21 (25%) claimed reimbursement was about the same; and the remainder (74%) claimed lower reimbursement (Appendix 2).

Advantages of Telemedicine

Some advantages of telemedicine are obvious such as decreased exposure to COVID-19. This was noted by a majority of our respondents (80 out of 84 (95%), Table 3).

Table 3. Advantages of telemedicine. 

Other advantages cited included patient preference (42 respondents, 50%); more efficient time utilization (29 respondents, 35%); provider time savings (25 respondents, 30%); and reduced documentation (22 respondents, 26%). There were 11 other responses but none listed by more than 2 respondents.

Discussion

To our knowledge this is the first survey of healthcare providers providing telemedicine since the beginning of the COVID-19 pandemic. Although the sample-size of respondents is not large, it is adequate when compared to relatively smaller number of pulmonary and critical care providers in the Southwest United States. Most (67%) were satisfied with telemedicine. However, 30% noted high documentation times and 55% decreased reimbursement.

Our study is consistent with previous observations that patients are mostly satisfied with telemedicine[HD1] . Gustke et al. (5) reported an extraordinarily high patient satisfaction rate of 98.3% from a telemedicine center. Review articles and meta-analysis suggest that telemedicine is acceptable to most patients in a variety of circumstances (6,7). However, many studies have methodological deficiencies such as low sample sizes, context, and study designs which limit generalizability (6,7). Studies clearly defining “when” and “for what” telemedicine should be utilized are needed. Data demonstrating outcomes will be necessary but at the present time such data is lacking.

Telemedicine has been around for some time but has never been fully utilized. In 2019, only 12% of pulmonologists were using telemedicine although its use has slowly been increasing over the past 20 years (7). Telemedicine usage appears to have been markedly accelerated by the COVID-19 pandemic (8). According to The Physicians Foundation’s 2018 Survey of America’s Physicians conducted by Merritt Hawkins, approximately 18% of physicians indicated they were using telemedicine to treat patients in 2018 (9). That number had increased to 48% by April, 2020 according to a new survey (10). In this rush to establish telemedicine if and how much training the providers receive is unclear.

In a survey conducted by American Well physicians several reasons were listed for choosing telemedicine including: 1. Improved patient access to care (93%); 2. More efficient use of time (77%); 3. Reduced healthcare costs (71%); 4. High-quality communications with patients (71%); and  5. Enhanced doctor-patient relationship (60%) (7). Almost certainly contributing to the increase in telemedicine usage has been the relaxation of the Centers for Medicare & Medicaid Services (CMS) rules regarding reimbursement for telemedicine (11). CMS is now proposing changes to expand telemedicine permanently (12).

Telemedicine visits may require less efforts on the part of the support staff. For example, no vitals are needed. No show rates might also improve. Once telemedicine established and up and running, it can also reduce the size of office space required per provider in the clinic. This could help compensate for lower reimbursement by reducing overhead expenses.

It seems likely that telemedicine will persist in some form after the COVID-19 pandemic. What is unclear is which patients should be seen and what reimbursement should be provided. For example, doing an office visit to check on CPAP compliance for a patient with sleep-apnea is probably appropriate and can probably be done efficiently by telemedicine. However, a more complex patient and especially one where a physical examination is important, might require a face-to-face office visit. Further investigation is needed to determine both appropriateness and optimal reimbursement for telemedicine rather than a one telemedicine fits all approach.

References

1. Centers for Disease Control and Prevention. Older adults and COVID-19. August 16, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html#:~:text=As%20you%20get%20older%2C%20your,than%20people%20in%20their%2050s. (accessed 9/14/20).
2. Health and Human Services. HHS Issues New Report Highlighting Dramatic Trends in Medicare Beneficiary Telehealth Utilization amid COVID-19.  July 28. 2020. Available at: https://www.hhs.gov/about/news/2020/07/28/hhs-issues-new-report-highlighting-dramatic-trends-in-medicare-beneficiary-telehealth-utilization-amid-covid-19.html (accessed 9/14/20).
3. Centers for Disease Control and Prevention. Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. June 10, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html (accessed 9/14/20).
4. Robbins RA, Gotway MB, Robbins JR, Wesselius LJ. Results of the SWJPCC healthcare survey. Southwest J Pulm Crit Care. 2020;20(1):9-15. [CrossRef]
5. Gustke SS, Balch DC, West VL, Rogers LO. Patient Satisfaction with Telemedicine. Telemedicine Journal. 2004;6(1):5-13. [CrossRef]
6. Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ. 2000;320(7248):1517-1520. [CrossRef] [PubMed]
7. Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. 2017;7(8):e016242. Published 2017 Aug 3. [CrossRef] [PubMed]
8. Zarefsky M. 5 huge ways the pandemic has changed telemedicine. AMA Practice Management. August 26, 2020. Available at: https://www.ama-assn.org/practice-management/digital/5-huge-ways-pandemic-has-changed-telemedicine?gclid=Cj0KCQjwqfz6BRD8ARIsAIXQCf0iteUTWx7lZpFS_uqgkRYc9c4Sjm6iRq9mflmInb-L1H_jvWMszW4aAnsAEALw_wcB (accessed 9/14/20).
9. The Physicians Foundation. 2018 Survey of America’s Physicians. Available at: https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf (accessed 9/14/20).
10. Miliard M. CMS relaxes more rules around telehealth, allowing care across state lines. Healthcare IT News. April 10, 2020. Available at: https://www.healthcareitnews.com/news/cms-relaxes-more-rules-around-telehealth-allowing-care-across-state-lines (accessed 9/14/20).
11. Centers for Medicare & Medicaid Services. Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural Areas. August 3, 2020. Available at: https://www.cms.gov/newsroom/press-releases/trump-administration-proposes-expand-telehealth-benefits-permanently-medicare-beneficiaries-beyond.

Cite as: Robbins RA, Robbins JR. Results of the SWJPCC Telemedicine Questionnaire. Southwest J Pulm Crit Care. 2020;21:66-72. doi: https://doi.org/10.13175/swjpcc049-20 PDF 

September 2020 Pulmonary Case of the Month: An Apeeling Example

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 67-year-old woman who developed a chronic nonproductive cough beginning in October 2019. After 4 weeks, she consulted her primary care physician.

PMH, SH, and FH

• She had a history of several prior pneumonias, including respiratory syncytial virus in 2018
• Irritable bowel syndrome
• Hypertension
• Prior smoker: 28 pack years, none since 1999
• FH negative

Physical Examination

Her physical examination is recorded as unremarkable other than decreased nasal flow.

Which of the following is/are common cause(s) of a chronic cough? (Click on the correct answer to be directed to the second of seven pages)

1. Cough-variant asthma
2. Gastroesophageal reflux disease
3. Upper airway cough syndrome (UACS) secondary to rhinosinus diseases
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. September 2020 pulmonary case of the month: an apeeling example. Southwest J Pulm Crit Care. 2020;21(3):56-63. doi: https://doi.org/10.13175/swjpcc048-20 PDF

June 2020 Pulmonary Case of the Month: Twist and Shout

Lewis J. Wesselius, MD¹

Staci E. Beamer, MD² 

¹Departments of Pulmonary Medicine and ²Thoracic Surgery

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

An 83-year-old man presented with a left upper lobe lung nodule. The nodule was noted on a routine follow-up chest radiograph obtained after a radical cystectomy and left nephro-ureterectomy done 9 months earlier for invasive bladder cancer as well clear cell carcinoma of left kidney. He had symptoms of a mild chronic cough but denied shortness of breath with activities of daily living.

PMH, SH, FH

• Prostate cancer, post prostatectomy in 2009. 
• Bladder cancer and left renal cell cancer resected in Jan 2019
• Post-op chemotherapy after bladder and left kidney resections
• Non-ischemic cardiomyopathy, possibly due to            chemotherapy, EF 45%
• Chronic atrial fibrillation
• Smoking history: 60 pack years, no occupational exposures

Physical Examination

Other than an irregular pulse, his physical examination was unremarkable.

Medications

• Warfarin
• Atorvastatin
• Hydrochlorothiazide
• Ramipril
• Atenolol

Radiography

The initial chest radiograph is shown in Figure 1.

Figure 1. Initial chest x-ray.

Which of the following should be done at this time? (Click on the correct answer to be directed to the second of eight pages)

1. Chest CT scan
2. Left upper lobectomy
3. Comparison to old chest x-rays
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ, Beamer SE. June 2020 pulmonary case of the month: twist and shout. Southwest J Pulm Crit Care. 2020;20(6):179-87. doi: https://doi.org/10.13175/swjpcc038-20 PDF