September 2017 Arizona Thoracic Society Notes

The September 2017 Arizona Thoracic Society meeting was held on Wednesday, September 27, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

There was a discussion of the Tobacco 21 bill which had been introduced the last session in the Arizona State Legislature. Since it seems likely that the bill will be reintroduced, the Arizona Thoracic Society will support the bill in the future. Dr. Rick Robbins announced that the SWJPCC has applied to be included in PubMed. In addition, Dr. Robbins was assigned the task of tracking down the campaign contributions to congressional members from the tobacco PAC before the next election.

There were 7 case presentations:

1. Ashley L. Garrett, MD, pulmonary fellow at Mayo, presented an elderly man with insulin-dependent diabetes who felt he had inhaled a pill. He takes multiple medications and was unsure which pill he might have inhaled. Since the inhalation, he was bothered by coughing.  His chest x-ray was normal. Bronchoscopy revealed severe left lower lobe bronchitis. No pill fragments were seen. He was managed conservatively and his coughing has nearly resolved. A discussion of pill aspiration ensued with an article published in Chest forming the basis for discussion (1).
2. Paul Conomos, M.D. presented a case of a 57-year-old woman who is largely asymptomatic but has had worsening bronchiectasis on serial CT scans since 2006. She is a nonsmoker. The CT scans show typical tree-in-bud bronchiectasis most marked in the right upper lobe but present in scattered areas throughout both right and left lungs. Her pulmonary function tests showed mild-moderate obstruction. Bronchoscopy times three with bronchoalveolar lavage and cultures has been unrevealing. Alpha-1 antitrypsin levels and esophageal pH monitoring were normal. Sweat chloride was equivocal at 44 and 50 millimoles per liter. Gene sequencing was recommended but too expensive for the patient ($2500, her copay $900). Discussion focused on whether further work up should be done and whether treatment was necessary. Most felt the work up was fairly comprehensive and that treatment was probably not indicated since she was not symptomatic.
3. Dr. Conomos also presented a second case of an 18-year-old from the Congo who presented with a chronic cough and hemoptysis. PPD was reported by the patient as negative. Physical examination was unremarkable. Chest x-ray showed a right lower lobe mass and thoracic CT scan showed right lower lobe (RLL) bronchiectasis with a question of a foreign body. Bronchoscopy showed obstruction in the lateral subsegment of the RLL with a mass with what appeared to be a stone. The patient was referred to thoracic surgery but returned 6 days later with fever and pleuritic chest pain. Chest x-ray showed RLL pneumonia. The patient underwent a RLL lobectomy. A foreign body was present. In retrospect, his mother recalled him inhaling a super glue cap when he was 7 or 8 years old. He was doing well post-operatively.
4. Dr. Gerald Schwartzberg presented 3 cases. The first was 43-year-old woman who developed erythema nodosum after a month history of sharp pleuritic chest pain and multiple other systemic complaints. Her eosinophil count was 13% and cocci serologies were weakly positive. Discussion centered on treatment. Most favored treatment although it was agreed that data supporting treatment was lacking.
5. Dr. Schwartzberg presented a second case of 75-year-old woman with mild COPD on albuterol only. She was a smoker and complained of a cough productive of green sputum. Chest x-ray revealed a large left mass with mucoid impaction. Bronchoscopy revealed hyphae with 45º branches typical of Aspergillus on biopsy. Thoracic CT scan showed bronchiectasis. An IgE was suggested. Several were suspicious of lung cancer and suggested a needle biopsy of the mass.
6. The last of Dr. Schwartzberg’s cases was a 92-year-old man who was found to have a polyp on upper GI endoscopy and a chest x-ray which showed a mass. Biopsies of both stained positive for melanin and were consistent with malignant melanoma. He was referred to oncology. Discussion centered on whether he should receive treatment.
7. Dr. Lewis Wesselius presented a 67-year-old man with a right neck mass found in 2015. Biopsy revealed a high-grade sarcomatoid cancer. At that time a CT/PET of the chest was negative. About 6 months later a CT/PET revealed new areas of tracer accumulation within the liver. His chemotherapy was switched to ipilimumab and nivolumab. A repeat CT/PET showed symmetric bilateral mediastinal lymphadenopathy. An endobronchial bronchial ultrasound (EBUS) biopsy of the nodes showed noncaseating granuloma consistent with sarcoidosis. He was begun on corticosteroids and nodes and liver lesions resolved on CT/PET. Discussion centered on sarcoidosis induced by these newer checkpoint inhibitors. It was speculated that drug-induced sarcoidosis might be observed more commonly as these agents are more frequently used (2,3).

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, November 15, 2017 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins, MD

References

1. Kinsey CM, Folch E, Majid A, Channick CL. Evaluation and management of pill aspiration: case discussion and review of the literature. Chest. 2013 Jun;143(6):1791-5. [CrossRef] [PubMed]
2. Reuss JE, Kunk PR, Stowman AM, Gru AA, Slingluff CL Jr, Gaughan EM. Sarcoidosis in the setting of combination ipilimumab and nivolumab immunotherapy: a case report & review of the literature. J Immunother Cancer. 2016 Dec 20;4:94. [CrossRef] [PubMed]
3. Danlos FX, Pagès C, Baroudjian B, et al. Nivolumab-induced sarcoid-like granulomatous reaction in a patient with advanced melanoma. Chest. 2016 May;149(5):e133-6. [CrossRef] [PubMed]

Cite as: Robbins RA. September 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(3):122-4. doi: https://doi.org/10.13175/swjpcc118-17 PDF

May 2015 Arizona Thoracic Society Notes

The May 2015 Arizona Thoracic Society meeting was held on Wednesday, May 27, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Ms. Georgann VanderJagt, RN, MSN gave an update on clinical trials at Dignity Health including idiopathic pulmonary fibrosis and alpha-1 antitrypsin deficiency. To contact Ms. VanderJagt call her office at 602-406-3825, her cell at 602-615-2377 or by email at georgann.vaderjagt@digniftyhealth.org.  

Dr. Michael Smith, the surgical director for the lung transplant program at Dignity Health, gave an overview of their lung transplant program. They are currently the fifth busiest transplant program in the US.  They have done 46 lung transplants so far this year. They are on a par with UCLA in number of transplants and survival has been at the National average. Average wait time is only abut 2 weeks. He also discussed recent and ongoing transplant protocols. To contact Dr. Smith call 602-406-7564.

There were 4 case presentations:

1. Jud Tillinghast presented a case of a large man who was short of breath. His CT scan showed multiple calcifications in the lower lobes. It was felt that clinically he was most likely aspirating as a cause of the calcifications.
2. Gerald Swartzberg presented a case of a large man who had some minimal dyspnea and an elevated right hemidiaphragm. His chest x-ray showed consolidation in this right lower lung. He had been seen at the Mayo Clinic and Dr. Lewis Wesselius reviewed his pathology from a needle biopsy of a right lower lobe nodule which was nonspecific. Reviewing his case he also had a biopsy from Sloan Kettering in 2006 which was also nonspecific. Further history was obtained and the patient admitted he was using Vick's Vaporub in his nose since he was 7 years old. It was unclear if this was the cause of his right lower lobe consolidation.
3. Dr. Swartzberg presented a second case of a 70-year-old woman with multiple medical problems. She has a cockatiel but is remarkably asymptomatic. A chest x-ray was taken showed nonspecific lower lobe changes. Pulmonary function tests showed a reduced vital capacity but a normal to high total lung capacity. A DLCO was not able to be obtained. CT scan showed small nodules with ground glass in her lower lobes. It was felt that most likely this was a hypersensitivity pneumonitis secondary to her bird. She got rid of the bird but did not improve.  The cause of her abnormal pulmonary radiology remains unclear.
4. Dr. Wesselius presented a case of a patient with a chronic cough which had been treated with antibiotics and corticosteroids. When he as on oral corticosteroids he was perhaps somewhat better. He was seen at the University of Massachusetts without a diagnosis being made. He subsequently moved to the Phoenix area and was evaluated at the Mayo Clinic. Chest x-ray showed consolidation in his right upper lobe. On bronchoscopy he had some whitish plaques along his trachea and main bronchi. Bronchoalveolar lavage showed 89% eosinophils and his transbronchial biopsy was consistent with chronic eosinophilic pneumonia. Apparently, this association has previously been sporadically reported. He was started on prednisone and improved.

Dr. Jud Tillinghast was acknowledged as the Arizona Thoracic Society Clinician of the Year and one of the four finalists as ATS Clinician of the Year.

After a brief discussion, the membership agreed to encourage and help Nevada form a state thoracic society.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, July 22 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. May 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(5):304-5. doi: http://dx.doi.org/10.13175/swjpcc075-15 PDF

October 2013 Arizona Thoracic Society Notes

The October Arizona Thoracic Society meeting was held on Wednesday, 10/23/2013 at Shea Hospital beginning at 6:30 PM. There were 21 in attendance representing the pulmonary, critical care, sleep, and thoracic surgery communities.

A proposal was made to decrease the number of meetings from 10 to 8 per year. After a brief discussion, this was adopted. Dr. Parides will try and coordinate these changes with Tucson.

Meetings were announced for December in Tucson, January in Carmel, February in Albuquerque, and April in Phoenix. A suggestion was made to have a separate area for meetings on the SWJPCC website.

There were 2 cases presented-both by Nick Sparacino, a first year fellow at Good Samaritan/VA.  

1. The first case was a 48 year old man admitted to podiatry for chronic diabetic foot ulcers.  His preoperative chest x-ray revealed multiple pulmonary nodules. Importantly, he had a history of working in a brake pad factory for about 15 years, a strong family history of lung cancer and was currently actively smoking. Review of the chest x-ray and the CT scan revealed that pleural nodules only on the left. Additional history was obtained of a gunshot wound through the spleen into the chest. A liver-spleen scan showed high uptake in the nodules. The nodules were thought to be secondary to thoracic splenosis which occurs when splenic tissue is autoimplantated to the thoracic cavity following splenic injury (1). No further work up or therapy was thought to be needed.
2. The second case was a 66 year old man with 2-3 week history of shortness of breath, subjective fevers, sputum production, two falls without injury, and urinary incontinence. Chest x-ray showed right lower lobe pneumonia and CT scan of the chest showed narrowing of the bronchus intermedius. Bronchoscopy revealed a veruccous, obstructing mass in the bronchus intermedius that was suspicious for squamous cell carcinoma. However, on biopsy the mass separated from the bronchial wall and fractured. It was eventually removed piecemeal with the flexible fiberoptic bronchoscope (1). Pathology was consistent with a walnut.

There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, November 20, 6:30 PM in Phoenix at Scottsdale Shea Hospital. 

Richard A. Robbins, M.D.

References

1. Khan AM, Manzoor K, Gordon D, Berman A. Thoracic splenosis: A diagnosis by history and imaging. Respirology. 2008;13(3):481-3. [CrossRef] [PubMed]
2. Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchial foreign body aspiration in adults. South Med J. 2009;102(2):171-4. [CrossRef]

Reference as: Robbins RA. October 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(4):253-4. doi: http://dx.doi.org/10.13175/swjpcc144-13 PDF