September 2015 Arizona Thoracic Society Notes

The September 2015 Arizona Thoracic Society meeting was held on Wednesday, September 23, 2015 at the Scottsdale Shea Hospital beginning at 6:00 PM. This was a dinner meeting with case presentations. There were 13 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

There were 6 case presentations:

1. Dr. Gerald Schwartzberg presented a case of a 58-year-old woman with a history of Mycobacterium avium presented with cough and malaise. CT revealed a history of lower love centrilobular nodules and scattered ground glass opacities and some bronchiectasis. Sputum revealed Aspergillus fumigatus. IgE was normal but IgA was deficient at 20 mg/dl (normal 80-350 mg/dl). She was started on itraconazole and clinically improved. Many questioned whether the Aspergillus was the cause of her pneumonia and some questioned the association of the IgA deficiency with her overall clinical picture.
2. Dr. Schwartzberg presented a second case of a 92-year-old former opera singer who had a past diagnosis of asthma but without airflow obstruction, gastroesophageal reflux disease, and myelodysplastic syndrome. CT scan revealed mosaic areas most consistent with hypoperfusion secondary to air trapping. Complete pulmonary function testing revealed only a markedly decreased DLco. She had oxygen desaturation with exercise. Clinically she did not respond to a bronchodilator. Most were perplexed as the cause of her overall clinical picture.
3. Dr. Schwartzberg presented a third case of a morbidly obese 61-year-old woman who presented with shortness of breath. CT scan showed some scattered lung nodules in her lower lobes. Laboratory evaluation including cocci serologies were negative. A needle biopsy of one of the lung nodules was nondiagnostic and she was empirically begun on fluconazole. She clinically improved. Many thought this could be possibly Valley fever and she should be followed.
4. Dr. Alan Thomas presented a 66-year-old man with a history of lymphoma about 10 years earlier who presented with some enlarging lymph nodes. Thoracic CT scan was performed as part of his evaluation and showed some areas of emphysema with scattered ground glass opacities. It was felt the radiologic pattern was most consistent with respiratory bronchiolitis with fibrosis (2).
5. Dr. Thomas also presented a case of an 82-year-old former smoker who quit about a year ago who presented with weight loss and minimal cough. Thoracic CT scan showed a large pleural mass with pleural effusion surrounding the right lung as well as pleural plaques. He did have a history of asbestos exposure in the Navy. Thoracentesis showed a nondiagnostic exudative effusion. A biopsy was performed which was consistent with a large cell neuroendocrine tumor.
6. Dr. Lewis Wesselius presented a 65-year-old man with exertional dyspnea and possible interstitial lung disease. He has a history of a Ross procedure (replacement of a bicuspid aortic valve with the pulmonic valve) and obstructive sleep apnea. Chest x-ray was unremarkable. Complete pulmonary function testing was normal. Thoracic CT scan showed peripheral reticulations especially in the lower lobes. A video-assisted thorascopic biopsy (VATS) was performed. Histology showed scattered fibroblast foci with scattered fibrosis with airway centricity. It was unclear whether this was usual interstitial fibrosis or chronic hypersensitivity pneumonitis. He was started on prednisone because his picture was felt to be most consistent with chronic hypersensitivity pneumonitis (1). Unfortunately, chronic hypersensitivity pneumonitis with features of UIP appears to carry a worse prognosis.

There being no further business, the meeting was adjourned about 7:30 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, November 18 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Reddy TL, Mayo J, Churg A. Respiratory bronchiolitis with fibrosis. High-resolution computed tomography findings and correlation with pathology. Ann Am Thorac Soc. 2013;10(6):590-601. [CrossRef] [PubMed]
2. Myers JL. Hypersensitivity pneumonia: the role of lung biopsy in diagnosis and management. Mod Pathol. 2012;25 Suppl 1:S58-67. [CrossRef] [PubMed]

Cite as: Robbins RA. September 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(3):117-8. doi: http://dx.doi.org/10.13175/swjpcc124-15 PDF

April 2014 Arizona Thoracic Society Notes

The April 2014 Arizona Thoracic Society meeting was held on Wednesday, 4/23/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 15 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

It was announced that there will be a wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting. The tasting will be led by Peter Wagner and is scheduled for the Cobalt Room in the Hilton San Diego Bayfront on Tuesday, May 20, from 4-8 PM.

Guideline development was again discussed. The consensus was to await publication of the IDSA Cocci Guidelines and respond appropriately.

George Parides, Arizona Chapter Representative, gave a presentation on Hill Day. Representatives of the Arizona, New Mexico and Washington Thoracic Societies met with their Congressional delegations, including Rep. David Schweikert, to discuss the Cigar Bill, NIH funding, and the Medicare Sustainable Growth Rate Factor (SGR). Dr. Parides also spoke about the need for increased funding for Graduate Medical Education.

Four cases were presented:

1. Jud Tillinghast presented a case of a middle aged man who suffered a cervical cord injury 6-7 years ago resulting in paraplegia. The patient had just moved from California and was referred because of an abnormal chest x-ray. After his injury the patient had a great deal of pain and repeated episodes of aspiration. The patient was asymptomatic. The chest x-ray showed haziness surrounding the right hilum. A CT scan showed RLL, LLL, and RML consolidation which was essentially unchanged from a thoracic CT performed 6 months earlier. A biopsy was performed and consistent with lipoid pneumonia. On further questioning the patient recalled taking mineral oil for the first 2-3 years after his injury to relieve constipation induced by narcotics for pain.
2. Gerald Schwartzberg presented a 79 year old man with very severe COPD who presented with hemoptysis. Chest x-ray showed bilateral lower lobe consolidation with an air-fluid level in the right chest. Bronchoalveolar lavage revealed only Aspergillus. A discussion ensued and many were unconvinced that the consolidations resulted from Aspergillus. Since the patient was relatively asymptomatic except from the dyspnea from his COPD, the consensus was to perform a repeat thoracic CT scan.
3. Lewis Wesselius presented a 71 year old woman with dyspnea since late 2013. She had a cardiac pacemaker placed in 2008. Her physical exam was unremarkable. Her SpO2 was 96% on room air but decreased to 84% with exercise. Chest x-ray and pulmonary function testing were unremarkable (a DLco was unable to be performed. Echocardiogram revealed a large patent foramen ovale (PFO).
4. Allen Thomas presented a 65 year old with dyspnea. The patient had a history of cardiomegaly with diastolic dysfunction and a bipolar disorder treated with lithium, lamotrigine, gabapentin. Chest x-ray showed bilateral interstitial infiltrates. CT scan showed sub-pleural patchy ground-glass opacities combined with irregular reticular opacities reminiscent of nonspecific interstitial pneumonia (NSIP). Collage vascular work up was negative. Review of the website Pneumotox (http://www.pneumotox.com) showed reports of interstitial disease with lamotrigine. The medication was stopped an follow-up CT scan showed near resolution of the abnormalities.

There being no further business the meeting was adjourned about 8:15 PM. The next meeting is scheduled to be a case presentation conference for May 28, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

Reference as: Robbins RA. April 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(4):236-7. doi: http://dx.doi.org/10.13175/swjpcc054-14 PDF

August 2013 Arizona Thoracic Society Notes

The August Arizona Thoracic Society meeting was held on Wednesday, 8/28/2013 at Shea Hospital beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, and pathology communities.

A brief discussion was held about the audio-visual aids available. It was generally agreed that our current projector is inadequate. Judd Tillinghast will inquire about using a hospital overhead projector. If that is not possible, it was agreed to purchase a new projector.Plans for telecasting the meeting between Phoenix and Tucson continue. A trial of a link between Shea and the University in Tucson failed. Once the link is successfully established, it is hoped that the meeting can be telecasted.

There were 6 cases presented:

1. Dr. Thomas Colby, pulmonary pathologist from Mayo Clinic Arizona, presented the case of a 10 year old boy with chronic dyspnea for > 4 yrs. He had growth retardation since age 1, a skin rash since age 2 on the limbs, nail dystrophy since age 3 on hands and feet, lacrimal duct stenosis, erythematous lesions on the pinnae, phimosis, interstitial lung disease on radiography, weakly positive p-ANCA, elevated erythrocyte sedimentation rate, and hypergammaglobulinemia. He came to lung biopsy. The patient was diagnosed with dyskeratosis congenita which is a disorder of poor telomere maintenance (1). Specifically, the disease is related to one or more mutations which directly or indirectly affect the vertebrate telomerase RNA component (TERC). This patient’s manifestations are fairly typical of the disease. Short telomere length was confirmed.

2. Dr. Colby presented a second case of a 14 year old boy with a history of osteosarcoma. Pulmonary nodules developed and biopsy showed metastatic osteosarcoma. He was given systemic chemotherapy but now has residual nodules that were biopsied. One of the pulmonary nodule resembled bronchoalveolar cell carcinoma.  This is an apparent complication following chemotherapy in adolescent patients (2).

3. Dr. Colby presented the pathology of a patient from the Phoenix VA who underwent lung biopsy for interstitial disease. The pathology was typical for IgG4-related disease with a plasma cell rich lymphohistiocytic infiltrate in the bronchovascular sheath and histopathology showing diffusely stained positive for IgG4 plasma cells (3).

4. Dr. Suresh Uppalapu, a second year pulmonary fellow from Good Samaritan/VA, presented a 59 year old Sudanese male who was transferred to the Good Samaritan ICU in shock. His presenting complaints to the transferring hospital were acute mental status changes, weakness, and chills. He was intubated for hypercarbic respiratory failure. His brother related that the patient had just returned from Sudan three weeks earlier. He had a prior history of a splenectomy. He was hypothermic with a temperature of 32.3°C and a SpO2 of 91% on 100% FiO2 and PEEP of 8. His Glasgow Coma Scale was 3 (lowest possible score). He had many abnormalities on laboratory evaluation, most notably a creatinine of 5.1 mg/dL and a lactic acid of 26.3 mg/dL. The peripheral smear showed malaria parasites typical of falciparum malaria (figure 1).

Figure 1. Peripheral smear showing a gametocyte (red arrow) and trophozoites in various stages from falciparum malaria.

He developed hemoptysis and eventually expired. A preliminary autopsy report has detected aspergillosis in the lung. Invasive aspergillosis has been reported in cases of severe falciparum malaria (4).

5. Dr. Heemesh Seth, also a second year pulmonary fellow from Good Samaritan/VA, presented a case of a 57 year old man with cirrhosis secondary to hepatitis C diagnosed in 1998. He presented with a large right hydrothorax.  Multiple thoracentesis were performed (Table 1).

Table 1. Summary of multiple thoracentesis.

Blood cultures were positive for acinetobacter as was the initial culture from the thoracentesis. He was treated with cephepime. It was felt that his effusion and empyema were most likely secondary to translocation of bacteria to the pleural space from spontaneous bacterial peritonitis. A discussion ensued regarding whether to perform tube thoracostomy. Data is sparse with most literature not favoring a chest tube (5). However, in this patient’s case a chest tube was eventually inserted when he failed to improve. It drained about 2 liters of fluid but the drainage then became minimal and the tube was removed. The patient developed hepato-renal syndrome but was felt not to be a liver transplant candidate. He was transferred to hospice.

6. Dr. Seth also presented a second case of a 66 year old Hispanic man who presented with a large left pleural effusion.  He had a past medical history of systemic lupus erythematosis (SLE) with possible rheumatoid arthritis and was being treated with adalimumab, methotrexate, and prednisone. A thoracentesis was done and 2 liters of clear amber fluid was removed. Although be developed fever to 102°F he felt much better the next morning and was discharged. However, his coccidioidomycosis serologies were positive for both IgG and IgM and his complement fixation test were positive at 1:4. Pleural fluid cytology was positive for LE cells. He was continued on prednisone and treated with fluconazole. A discussion developed of whether the effusion was secondary to SLE, coccidioidomycosis, or both. No one knew data but it was felt that it was most prudent to continue the present course while following the patient and awaiting cultures.

There being no further business the meeting was adjourned at about 8:15 PM. The next meeting is scheduled for Wednesday, September 25, 6:30 PM in Phoenix at Scottsdale Shea Hospital.  

Richard A. Robbins, M.D.

References

1. Dokal I. Dyskeratosis congenita in all its forms. Br J Haematol. 2000;110(4):768-79. [CrossRef] [PubMed] 
2. Travis WD, Linnoila RI, Horowitz M, Becker RL Jr, Pass H, Ozols R, Gazdar A. Pulmonary nodules resembling bronchioloalveolar carcinoma in adolescent cancer patients. Mod Pathol. 1988;1(5):372-7. [PubMed]
3. Hurley JR, Leslie KO. IgG4-Related systemic disease of the pancreas with involvement of the lung: a case report and literature review. Southwest J Pulm Crit Care. 2013;7(2):117-130. [CrossRef]
4. Hocqueloux L, Bruneel F, Pages CL, Vachon F. Fatal invasive aspergillosis complicating severe Plasmodium falciparum malaria. Clin Infect Dis. 2000;30(6):940-2. [CrossRef] [PubMed] 
5. Alonso JC. Pleural effusion in liver disease. Semin Respir Crit Care Med. 2010;31(6):698-705. [CrossRef] [PubMed] 

Reference as: Robbins RA. August 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2013;7(2):114-6. doi: http://dx.doi.org/10.13175/swjpcc117-13 PDF