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

November 2013 Arizona Thoracic Society Notes

The November Arizona Thoracic Society meeting was held on Wednesday, 11/20/2013 at Shea Hospital beginning at 6:30 PM. There were 26 in attendance representing the pulmonary, critical care, sleep, nursing, radiology, and infectious disease communities.

As per the last meeting a separate area for upcoming meetings has been created in the upper left hand corner of the home page on the SWJPCC website.

A short presentation was made by Timothy Kuberski MD, Chief of Infectious Disease at Maricopa Medical Center, entitled “Clinical Evidence for Coccidioidomycosis as an Etiology for Sarcoidosis”. Isaac Yourison, a medical student at the University of Arizona, will be working with Dr. Kuberski on his scholarly project. Mr. Yourison hypothesizes that certain patients diagnosed with sarcoidosis in Arizona really have coccidioidomycosis. It would be predicted that because of the immunosuppression, usually due to steroids, the sarcoidosis patients would eventually express the Coccidioides infection. The investigators will be collaborating with the University of Washington to perform polymerase chain reaction (PCR) on tissue samples diagnosed with sarcoidosis for Coccidioides.

There were 4 cases presented:

1. The first case was presented by Lewis Wesselius from the Mayo Clinic Arizona. The patient was a 56 year old woman with rheumatoid arthritis and a prior history of bronchiectasis. In 2009 she was diagnosed with Mycobacterium avium-intracellulare (MAI) on bronchoscopy and started on azithromycin, ethambutol, and rifabutin. She had been on etanercept which was held after her diagnosis of MAI.  She had a negative sputum culture for MAI in September 2012 and her MAI medications were stopped. However, in May 2013 she had increasing symptoms and bronchoscopy demonstrated Pseudomonas and nontuberculous mycobacterium (NTB). She subsequently moved to Phoenix and a CT scan showed the size of her lung nodules to be increased. Bronchoscopic cultures showed Pseudomonas and Mycobacterium abscessus only sensitive to amikacin. She was treated with tigecycline and inhaled amikacin. A repeat CT scan indicated some decrease in size of lung nodules. Dr. Wesselius gave a short presentation on bronchiectasis associated with rheumatoid arthritis and NTB infection in these patients.
2. The second case was presented by Gerry Swartzberg. Dr. Schwartzberg showed a chest x-ray and asked the audience to guess the diagnosis. Jasminder Mand was the first to correctly guess allergic bronchopulmonary aspergillosis (ABPA) because of the finger in glove sign which best seen in the right upper lobe. The density forms from mucous impaction in a more central bronchus and has been referred to as a rabbit ear appearance, Mickey Mouse appearance, toothpaste shaped opacities, Y-shaped opacities, and V-shaped opacities. Dr. Mand also referred to this as the Churchill sign since it looks like the “V” gesture often associated with Churchill. The patient was begun on corticosteroids and a repeat chest x-ray taken about a month later showed near clearing of the opacities.
3. Dr. Schwartzberg presented a second case of an elderly woman in her 80’s with a history of bronchiectasis. Chest x-ray and CT scan showed several rapidly expanding lung masses. The radiographic appearance was not particularly suggestive of a diagnosis. There was a concern for malignancy and the majority thought bronchoscopy would be appropriate.
4. The last case was presented by Joshua  Jewell, a third year pulmonary fellow in the Good Samaritan/VA program. The patient was a middle-aged man who had a history of diffusely metastatic hepatocellular cancer including to his lung and mediastinal lymph nodes. He was also diagnosed with sleep apnea and begun on continuous positive airway pressure (CPAP). He had increasing size of his neck and presented to the pulmonary clinic. Palpation revealed crepitus and a chest x-ray and CT scan confirmed the presence of subcutaneous air and a pneumomediastinum. Dr. Jewell hypothesized that the air was introduced or at least was exacerbated by the CPAP possibly from a ball valve mechanism. Most in the audience agreed this was a reasonable explanation but none had observed this phenomenon previously.

There being no further business the meeting was adjourned at about 8:30 PM. The next meeting is scheduled for Saturday, December 14, 8-12 AM in Tucson at the Kiewit Auditorium at the University of Arizona Medical Center.  The next meeting in Phoenix will be held on Wednesday, January 22, 2014, 6:30 PM at Scottsdale Shea hospital.

Richard A. Robbins, M.D.

Reference as: Robbins RA. November 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013:7(5):311-2. doi: http://dx.doi.org/10.13175/swjpcc167-13 PDF

May 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 5/15/2013 at Scottsdale Shea beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep, thoracic surgery, and radiology communities.

Dr. George Parides will have served his 2 year tenure as Arizona Thoracic Society President by July, 2013. However, he will be unable to attend the June meeting and for this reason Presidential elections were held. Dr. Lewis Wesselius was nominated and unanimously elected as President.

Three cases were presented:

1. Dr. Gerald Schwartzberg presented the case of a 49 year old woman with a history of Valley Fever in 2009. She was a nonsmoker and had no other known medical diseases.  However, she developed shortness of breath beginning earlier this year along with a cough productive of clear, jelly-like sputum. Her physical was normal. Pulmonary function testing revealed restrictive disease with significant improvements in the FEV1 and FVC after bronchodilators.  Eosinophils were increased in her CBC at 12%. IgE was moderately increased at 286 IU/ml.  Chest x-ray was normal. A high resolution thoracic CT scan revealed scattered bronchiectasis and mucoid impaction.  Some speculated that this could be a case of allergic bronchopulmonary aspergillosis (ABPA) although all agreed that the level of IgE was lower than commonly occurs with ABPA. It was felt that an Aspergillus specific IgE might be useful. It was also suggested that the coccidiomycosis might have caused the bronchiectasis, noting that mycosis other than Aspergillus sp. may cause the syndrome similar to ABPA which has been termed allergic bronchopulmonary mycosis.
2. Dr. Jud Tillinghast presented a case of 45 year old woman who worked as a nurse practioner. She had developed rheumatoid arthritis a few years earlier and was being treated with plaquenil and steroids. Recently she had developed shortness of breath. A few squeaks were normal on auscultation of the lungs. Pulmonary function testing was normal. However, a thoracic CT scan revealed a mosaic pattern consistent with air trapping. An open lung biopsy was performed and was consistent with constrictive bronchiolitis. The biopsy did not show inflammation but obliteration of the small bronchioles. Considerable discussion centered on treatment with most agreeing that there were no known efficacious treatments. 
3. Dr. Allen Thomas presented a case of a 72 year old man with 2 small pulmonary nodules discovered incidentally in Northern California. However, at the time of discovery he was in the process of moving to Arizona and presented a year later. Follow up thoracic CT scan revealed multiple small nodules and mediastinal nodes. Mediastinoscopy revealed noncaseating granulomas. A repeat CT showed that the mediastinal nodes have resolved but the nodules persisted. A PET scan showed markedly enhanced uptake by the nodules and in the mediastinum raising a question of carcinoma. Most felt that this was likely a manifestation of sarcoidosis and not necessarily an indication of cancer.

There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, June 26. The July meeting will be in Tucson on July 24^th at 6:30 PM. Location to be determined.  

Rick Robbins

Arizona CCR Representative

Reference as: Robbins RA. May 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2013;6(5):237-8. PDF