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 

June 2011 Arizona Thoracic Society Notes

The June Arizona Thoracic Society was held on 6/21/2011 at Scottsdale Shea beginning at 6:55 PM. There were thirteen in attendance representing the pulmonary, radiology, and surgery communities.

Five cases were presented:

1. Jon Ruzi presented a case of an intravascular foreign body detected at chest radiography, found to represent a fractured strut from an inferior vena cava filter. The patient presented with a linear metallic foreign body on a chest radiograph, new from 2 years earlier. The dictated report suggested and airway foreign body, but the patient’s complex hospitalization at St. Joseph’s Medical Center, between time of the radiograph showing the abnormality and the prior showing nothing raised the possibility of an intravascular foreign body. Retrieval undertaken at St. Joseph’s confirmed an embolized strut from a fractured inferior vena cava filter. Much discussion ensued regarding this occurrence, with Judd Tillinghast indicating a recent paper showed a 10% incidence of such of an event, but the group concurring that the real life frequency must be substantially less.

2. Dr. Ruzi also presented an adenocarcinoma of the right lower lobe in a patient with scleroderma. A patient with scleroderma and lung involvement presented with persistent cough and non-resolving right lower lobe consolidation. CT showed findings consistent with non-specific interstitial pneumonia, with more focal right lower lobe opacity consisting of smooth interlobular septal thickening and intralobular interstitial thickening. The focal nature of the process is inconsistent with scleroderma-related lung disease. Bronchoscopy showed adenocarcinoma. The group noted that the pattern of carcinoma in this case is consistent with what has been previously referred to as bronchoalveolar carcinoma, particularly when the latter presents as a pneumonia-like process. The CT findings suggest that the disease is localized and potentially amenable to resection. The patient has been referred to oncology.

3. Dr. Ruzi presented a third case of an infection with coccidioidomycosis and actinomycosis, presenting as a complex cavitary lesion associated with nodules. A 39-year-old man with diabetes and untreated sleep apnea presented with a slowly enlarging right apical opacity on chest radiography. CT was performed and showed that the cavity had significantly complex internal architecture, suggesting a tissue invasive process. Small nodules in the right upper lobe suggested additional foci of granulomatous infection; the process appeared suggestive of an invasive fungal infection. Serologies indicate recent coccidioidomycosis infection, and bronchoscopy also recovered Actinomyces. Much discussion ensued regarding the accuracy of serologies and optical density testing for coccidioidomycosis infection among the various facilities that perform such testing. The group seemed to include that both infections may be at play in this patient.

4. Ewa Lupa-laskus presented older woman presented with a history of aspirating a calcium pill. Due to social factors, she delayed presenting to her physician (she wanted to attend a relative’s wedding). Thoracic CT sowed a high density structure, consistent with a calcium tablet, in the bronchus intermedius. The tablet was easily removed with bronchoscopic retrieval, but review of the coronal images on CT showed two tablets adjacent to one another (the patient did not remember aspirating the first tablet). The second tablet was much more difficult to remove, requiring over one hour. Extensive discussion regarding various methods for bronchoscopic removal of airway foreign bodies took place. Al Thomas concluded that a loop snare provides the best results.

5. Andy Goldstein presented an older woman with ovarian carcinoma and a large left pleural effusion presented for a clinical trial for chemotherapy. Prior to study, the patient underwent chest-abdomen-pelvis CT scanning, which showed that the large left pleural effusion now contained pockets of gas. Thoracentesis had been performed recently, but not between the scan showing pleural fluid only and the follow up scan showing hydropneumothorax. The patient’s enrollment in the clinical trial was put on hold, pending investigation. The group postulated that infection could have been introduced at the time of first thoracentesis but not taken hold until the time of the second scan. The patient remains asymptomatic. This raised the question that how likely is it that a patient could be comparatively asymptomatic but be harboring an anaerobic infection? The group concluded that such patients have been seen and further investigation with sampling / pleural fluid drainage is warranted

The meeting adjourned at 8:05 PM.

Michael B. Gotway, MD