December 2020 Arizona Thoracic Society Notes

For a recording of the December 3, 2020 Arizona Thoracic Society meeting click here.

September 2019 Arizona Thoracic Society Notes

The September 2019 Arizona Thoracic Society meeting was held on Wednesday, September 18, 2019 at the Banner University Medical Center Phoenix beginning at 6:00PM. There were 16 in attendance representing the pulmonary, critical care, sleep, radiology communities.

An announcement was made that cases of acute lung injury suspected of being secondary to vaping should be reported to Poison Control (1-800-222-1222) or to the State Department of Health (602-364-3587).

There were 3 case presentations:

1. Warren Carll DO, a second-year pulmonary fellow from the Mayo Clinic Arizona, presented a case of a 26-year-old man who complained of a 4-month history of hemoptysis. He had a past medical history of gastroesophageal reflux disease and frequent eye infections. His hemoptysis was up to ½ cup per day and he presented to the Mayo Clinic emergency room when he became frustrated that his outpatient work up was proceeding slowly. Physical examination showed erythematous and injected conjunctiva. His thoracic CT scan showed bilateral ground glass opacities with areas showing a reverse halo sign. Bronchoscopy showed only an increased number of neutrophils on the bronchoalveolar lavage. Laboratory evaluation showed positive cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) at 1:1024 and a proteinase 3 (PR3) of >8U (normal <1). A diagnosis of granulomatosis with polyangiitis (GPA, formerly called Wegener's granulomatosis) was made and the patient responded to corticosteroids and was discharged with a plan for rituximab as an outpatient. Dr. Kevin Leslie discussed the pathology of GPA and pointed out that it is a capillaritis and despite the name well-formed, sarcoid-like granulomas are rarely seen.
2. Kurt Olson MD, a third-year pulmonary fellow at the University of Arizona Phoenix presented a 52-year-old woman who complained of progressive dyspnea and a dry cough for 2 years. She had a past medical history of gastroesophageal reflux disease. Thoracic CT scan showed bronchiectasis with fibrosis most prominent in the lower lungs and an enlarged esophagus. Antinuclear antibodies (ANA) and anti-Scl-70 (also known as antitopoisomerase 1) were both positive. Discussion centered around a recent report in the New England Journal of Medicine showing that nintedanib slowed the rate of decline in the forced vital capacity in scleroderma (1)
3. Dr. Lewis Wesselius presented a 51-year-old immunocompromised host from a heart transplant who presented with a week long history of increasing shortness of breath. His chest X-ray was unremarkable but his SpO2 was found to be decreased.  However, a thoracic CT scan showed ground glass opacities with peripheral sparing. Bronchoscopy with bronchoalveolar lavage was negative for infection. His chest x-ray worsened over 3 days and he was treated with high dose corticosteroids, however, he continued to decline. At about this time it was discovered he had been vaping cannabinoid oil. He gradually improved and his chest x-ray cleared. However, on outpatient follow-up he still had a decreased exercise capacity and his DLco was decreased on pulmonary function testing.

Steve Tseng DO, a third-year fellow at University of Arizona Phoenix, presented a summary of the experience at Banner University Medical Center Phoenix of bronchoscopic lung volume reduction using endobronchial valves. To date they have treated over 50 patients with about 50% showing an improvement in FEV1 of >15% after 3-6 months.

The meeting was adjourned about 8:00PM. The next meeting will be in about 2 months with location and time to be announced.

Reference

1. Distler O, Highland KB, Gahlemann M, et al. Nintedanib for systemic sclerosis-associated interstitial lung disease. N Engl J Med. 2019 Jun 27;380(26):2518-28. [CrossRef] [PubMed]

Cite as: Arizona Thoracic Society. September 2019 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2019;19(3):99-100. doi: https://doi.org/10.13175/swjpcc059-19 PDF 

November 2018 Arizona Thoracic Society Notes

The November 2018 Arizona Thoracic Society meeting was held on Wednesday, November 28, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 10 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting  the Tobacco 21 bill was discussed. This bill has been twice held up in the Arizona House of Representatives Commerce Committee by the committee chairman. It was noted that one of the healthcare executives had financially supported the reelection campaign of the commerce committee chairman. A decision was made to send a letter to the healthcare executive pointing the pro-tobacco stance of the committee chairman. CME for the Arizona Thoracic Society meetings was also discussed. CME case presentations that had been previously approved will be presented and CME granted through the University of Arizona.

There were 3 case presentations:

1. Dr. Richard Robbins presented for Dr. Robert Raschke a case of a 54-year-old man with neck pain that eventually proved to be a paraspinous abscess.
2. Dr. Mike Gotway presented a 36-year-old woman who presented with respiratory failure. She eventually proved to have been self-injecting hydrocodone.
3. Dr. Lewis Wesselius presented a 28-year-old man from Tennessee with enlarging lung nodules who had been treated for presumed histoplasmosis, but was clinically worsening. Lung biopsy demonstrated metastatic angiosarcoma. 

The meeting was adjourned about 8:30 PM. The next meeting will be on January 23, 2019 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Cite as: Robbins RA. November 2018 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2018;17(6):149. doi: https://doi.org/10.13175/swjpcc119-18 PDF

September 2018 Arizona Thoracic Society Notes

The September 2018 Arizona Thoracic Society meeting was held on Wednesday, September 26, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were representatives in attendance from the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting attendance was again discussed.

There were 3 case presentations:

1. Dr. Gerry Schwartzberg presented a case of a woman in her 70’s with diffuse cystic lung disease. She had a monoclonal gammopathy of undetermined significance due to light chain disease and the possibility of amyloidosis causing cystic lung disease was discussed.  
2. Dr. Lewis Wesselius presented a 28-year-old man from Tennessee with enlarging lung nodules who had been treated for presumed histoplasmosis, but was having hemoptysis and clinically worsening. Lung biopsy demonstrated metastatic angiosarcoma.  
3. Dr. Wesselius also presented a 44-year-old woman with diabetes and cavitary pulmonary coccidioidomycosis which involved both left upper lobe and left lower lobe which had progressed despite 400 mg/day of fluconazole who had been referred in 2012 for possible thoracotomy. Surgery was deferred since it would have required a left pneumonectomy. The fluconazole dose was increased, and cavity resolved gradually over 6 years.  This led to discussion of indications for surgery in cavitary coccidioidomycosis. 

The meeting was adjourned about 8 PM. The next meeting will be on November 28 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Lewis J. Wesselius, MD
President, Arizona Thoracic Society

Cite as: Wesselius LJ. September 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;17:116. doi: https://doi.org/10.13175/swjpcc109-18 PDF 

July 2018 Arizona Thoracic Society Notes

The July 2018 Arizona Thoracic Society meeting was held on Wednesday, July 25, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 8 in attendance representing the pulmonary, critical care, sleep, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

• The dwindling attendance at these meetings. It was decided to again reach out to the pulmonary fellowship programs at Mayo, University of Arizona Phoenix and University of Arizona Tucson.
• The two recent cases of pharmacists refusing to dispense medications was discussed without coming to a consensus. One physician said he would refuse to submit prescriptions to the Peoria Walgreens.
• Discussion regarding the Tobacco 21 which had been killed in committee by Rep. Jeff Weninger was tabled until the next meeting.

There were 2 case presentations:

1. Dr. Lewis Wesselius presented a 67-year-old woman who had increasing shortness of breath. She was started on prednisone by another physician and her dyspnea improved although it recurred when her prednisone was tapered. Unfortunately, she gained 30 lbs. while on the prednisone. The patient did not smoke. She had a few crackles at her right base but otherwise the physical examination was normal. She desaturated with exercise. Her CT scan showed ground glass opacities with multiple small cysts. PFTs were restrictive with a DLCO of 55% of predicted. She was further questioned about additional symptoms and stated she had dry mouth and eyes for years. Rheumatology consultation was ordered, her SSP and SSA were both positive, and she had a diagnosis of Sjogren’s syndrome made. Because she was symptomatic it was thought she needed to treatment but she did not want to take prednisone again. For this reason, she was begun on mycophenolate.
2. Dr. Gerald Schwartzberg presented a 62-year-old man who was seen in the office with shortness of breath. Physical examination was normal and he had normal PFTs. He was admitted to the hospital a couple of weeks later after a trip with a pulmonary embolus. Discussion centered on when a CT angiogram should be ordered. There was a consensus that a CT-angiogram did not need to be done in all patients complaining of dyspnea but no consensus on criteria for whom it should be ordered.

The meeting was adjourned about 8 PM. The next meeting will be on September 26 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins MD

Editor, SWJPCC

Cite as: Robbins RA. July 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;17(1):41. doi: https://doi.org/10.13175/swjpcc095-18 PDF