August 2014 Arizona Thoracic Society Notes

The August 2014 Arizona Thoracic Society meeting was held on Wednesday, 8/27/14 at Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were about 30 in attendance representing the pulmonary, critical care, sleep and radiology communities.

A presentation was given by Julie Reid of the American Lung Association in Arizona on their Lung Force initiative. This is an initiative to make women more aware that lung cancer is the number one cause of cancer deaths in women. There will be a fund raising Lung Force Walk on November 15, 2014 in Phoenix. More information can be found at http://www.lungforce.org/walk-events or http://www.lung.org/associations/states/arizona/local-offices/phoenix/ or contact Julie Reid at JReid@Lung Arizona.org or (602) 258-7505.

A discussion was instigated by Dr. Parides on whether there is an increased risk of clinical Valley Fever in patients previously treated who begin therapy with biological therapy for rheumatoid arthritis. The common practice has been to initiate azole antifungal therapy in patients who begin biologics for rheumatoid arthritis. Although all agreed there was an increased risk of Valley Fever in patients treated with biological therapy, none were aware of any patients who developed Valley Fever who had previously been treated with azole therapy. This was extended to similar discussions including whether patients who had previously been treated for a +PPD need anti-tuberculosis therapy. This has been common practice, but again, none were aware of any cases or literature.

Lewis Wesselius presented a 66 year old man with a history of multiple pneumonias and skin infections. The patient was short with a prominent forehead. Immunoglobulin evaluation revealed a normal IgG and IgM but a markedly elevated IgE of 7419 kIU/mL (normal <380 kIU/mL). The patient was diagnosed with hyperimmunogloublin E syndrome, also known as Job's syndrome. For a review of this case as well as a differential diagnosis of elevated IgE please see the "September 2014 Pulmonary Case of the Month: A Case for Biblical Scholars" which will be posted on 9/1/14.

There being no further business the meeting was adjourned about 7:45 PM. The next meeting will be Tucson on Wednesday, September 24. Time and location to be announced.

Richard A. Robbins, MD

Reference as: Robbins RA. August 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;9(2):145. doi: http://dx.doi.org/10.13175/swjpcc114-14 PDF

June 2014 Arizona Thoracic Society Notes

The June 2014 Arizona Thoracic Society meeting was held on Wednesday, 6/25/14 at the Bio5 building on the University of Arizona Medical Center campus in Tucson beginning at 5:30 PM. This was a dinner meeting with case presentations. There were about 33 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

Four cases were presented:

1. Eric Chase presented a 68 year old incarcerated man shortness of breath, chest pain and productive cough.  The patient was a  poor historian. He was supposed to be receiving morphine for back pain but this had been held. He also had a 45 pound weight loss over the past year. His PMH was positive for COPD, hypertension, congestive heart failure, chronic back pain and  hepatitis C. Past surgical history included a back operation and some sort of chest operation. On physical examination he was  tachypneic, tachycardic  and multiple scars over his neck, back and chest including a median sternotomy scan. Subcutaneous emphysema was present. Laboratory evaluation was most remarkable for a lactate of 4.6 mg/dL. Chest x-ray revealed subcutaneous and mediastinal air, LLL consolidation, and a left pleural effusion.  Thoracentesis of the pleural effusion showed a high amylase and a low pH. A chest tube was placed. Esophagram showed contrast draining through the left chest and chest tube. CT scan was consistent with a colonic interposition graft with a graft to pleural fistula. The patient was deemed to be a poor surgical candidate and a jejunostomy tube was placed.
2. Mohammad Dalabih presented a 72 year old woman with asthma who had no response to asthma medications. Spirometry was consistent with moderate restriction. A thoracic CT scan showed two small nodules along with mosaic attenuation. A lung wedge biopsy showed nonmalignant appearing cells with tumorlets and bronchitis. The cells were CD56 positive. A diagnosis of diffuse interstitial pulmonary neuroendocrine hyperplasia (DIPNECH). Dr. Dalabih reviewed DIPNECH which usually presents in middle aged women with symptoms of cough and dyspnea; obstructive abnormalities on pulmonary function testing; and radiographic imaging showing pulmonary nodules, ground-glass attenuation, and bronchiectasis. In general, the clinical course remains stable; however, progression to respiratory failure can occur. Long-term follow- up studies and the best treatment remains unknown. The April 2014 Pulmonary Case of the Month also presented a case of DIPNECH (1).
3. Mohammad Alzoubaidi presented the case of a 61 year old woman with right upper quadrant pain who was found to have a large liver lesion on abdominal CT scan. She suffered a cardiac arrest shortly after the CT scan and her hemoglobin decreased to 5.6 g/dL. Angiography revealed multiple pseudoaneursyms with the largest apparently bleeding. Coil embolization was performed but a couple of days later her shock recurred. A repeat angiogram showed enlargement of the known pseudoaneursyms and several new ones. She was begun on corticosteroids for a presumed vasculitis. Unfortunately, she continued to bleed and died. Autopsy was consistent with fibromuscular dysplasia.  Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory disease of the blood vessels resulting in constriction and dilatation (pseudoaneursyms) (2). The cause and best treatment are unknown.
4. John Bloom presented a 22 year old Somali man that grew up in India who came to the US about 15 months before presentation. He was relatively asymptomatic but was found to have supraclavicular adenopathy on a "wellness" physical examination. Biopsy of the lymph nodes was recommended but he refused. He presented about a month later with neck and back pain. Physical examination revealed by adenopathy and a fever of 38.2º C. His white blood cell count was 12,600 cells/µL. Thoracic CT showed a miliary pattern with vertebral destruction. Laminectomy with cord stabilization was performed. Biopsy was negative for acid fast bacilli but positive for GMS+ organisms consistent with coccidioidomycosis. A large cervical paraspinal abscess just below the skull was drained and a large mediastinal abscess was also seen on CT scan. Discussion ensued about whether drainage was appropriate for the mediastinal mass, but most thought not.  The case illustrates that Valley Fever is common and in most chest differential diagnosis in the Southwest.

There being no further business the meeting was adjourned about 6:45 PM. There will be no meeting in July. The next meeting in Phoenix will be a case presentation conference on August 27, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

References

1. Wesselius LJ. April 2014 pulmonary case of the month: DIP-what? Southwest J Pulm Crit Care. 2014;8(4):195-203. [CrossRef]
2. Slovut DP, Olin JW. Fibromuscular dysplasia. N Engl J Med. 2004;350(18):1862-71. [CrossRef] [PubMed] 

Reference as: Robbins RA. June 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(6):356-7. doi: http://dx.doi.org/10.13175/swjpcc084-14 PDF

March 2014 Arizona Thoracic Society Notes

The March 2014 Arizona Thoracic Society meeting was a special meeting. In conjunction with the Valley Fever Center for Excellence and the Arizona Respiratory Center the Eighteenth Annual Farness Lecture was held in the Sonntag Pavilion at St. Joseph's Hospital at 6 PM on Friday, April 4, 2014. The guest speaker was Antonio "Tony" Catanzaro, MD from the University of California San Diego and current president of the Cocci Study Group. There were 57 in attendance representing the pulmonary, critical care, sleep, and infectious disease communities.

Dr. Antonio Catanzaro

After opening remarks by Arizona Thoracic Society president, Lewis Wesselius (a former fellow under Dr. Catanzaro at UCSD), John Galgiani, director of the Valley Fever Center for Excellence, gave a brief history of the Farness lecture before introducing Dr. Catanzaro. The lecture is named for Orin J. Farness, a Tucson physician, who was the first to report culture positive coccidioidomycosis (cocci or Valley Fever). The title of Dr. Catanzaro's talk was "Coccidioidomycosis, Why I Have Found It So Interesting". Dr. Catanzaro came to San Diego from Georgetown to study the immunology of sarcoidosis. Much to his surprise, he found little sarcoidosis in San Diego and was looking for a new direction. While attending the California Thoracic Society meeting, Tony met Dr. Hans Einstein from Bakersfield, California, the leading authority on Valley Fever. He persuaded Tony to attend the Cocci Study Group meeting, held in conjunction with the California Thoracic Society meeting. Dr. Catanzaro reviewed his investigations of Valley Fever including transfer factor, hypercalcemia associated with Valley Fever and treatment with ketoconoazole, fluconazole, itraconazole, and posaconazole (1-4). Prominently mentioned Hans Einstein from Bakersfield, John Galgiani from Tucson, Bernie Levine from Phoenix and J. Burr Ross also from Phoenix.

The Cocci Study Group meeting was held the following day, Saturday, April 5th at the University of Arizona College of Medicine, Phoenix. The next meeting of the Arizona Thoracic Society is on Wednesday, April 23, 2014, 6:30 PM at Shea Hospital.

Richard A. Robbins, M.D.

References

1. Catanzaro A, Einstein H, Levine B, Ross JB, Schillaci R, Fierer J, Friedman PJ. Ketoconazole for treatment of disseminated coccidioidomycosis. Ann Intern Med. 1982 Apr;96(4):436-40. [CrossRef] [PubMed]
2. Catanzaro A, Galgiani JN, Levine BE, Sharkey-Mathis PK, Fierer J, Stevens DA, Chapman SW, Cloud G. Fluconazole in the treatment of chronic pulmonary and nonmeningeal disseminated coccidioidomycosis. NIAID Mycoses Study Group. Am J Med. 1995;98(3):249-56. [CrossRef]  [PubMed]
3. Galgiani JN, Catanzaro A, Cloud GA, Johnson RH, Williams PL, Mirels LF, Nassar F, Lutz JE, Stevens DA, Sharkey PK, Singh VR, Larsen RA, Delgado KL, Flanigan C, Rinaldi MG. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med. 2000;133(9):676-86. [CrossRef] [PubMed]
4. Catanzaro A, Cloud GA, Stevens DA, Levine BE, Williams PL, Johnson RH, Rendon A, Mirels LF, Lutz JE, Holloway M, Galgiani JN. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clin Infect Dis. 2007;45(5):562-8. [CrossRef] [PubMed]

Reference as: Robbins RA. March 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(4):223-4. doi: http://dx.doi.org/10.13175/swjpcc038-14 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

November 2012 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 11/28/2012 at Scottsdale Shea beginning at 6:30 PM. There were 20 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

Dr. George Parides stated he was unable to find further information on treating patients begun on biologicals for RA who developed a + QuantiFERON.

Four cases were presented:

1. Dr. Suresh Uppalapu, a pulmonary fellow at Good Samaritan/VA, presented a case of a 29 yo woman with a rash and a myriad of nonspecific complaints. She had recently been a contestant in a reality TV show. Just prior to admission she developed a neurologic complaints including incontinence. Her CXR was negative but CT of the chest showed scattered areas of ground glass opacities peripherally. A MRI of the brain revealed nonspecific abnormalities. CBC showed an elevated eosinophil count of 8%. Coccidioidomycosis antigen was negative. An LP was performed which showed a protein of 144 mg/dL, a glucose of 33 mg/dL, and 553 cells/mm3 with 79% eosinophils. Biopsy revealed angiostrongylus. She is being treated with albendazole and steroids and is improving.
2. Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a case of a 61 yo man who presented with fever, chills and renal failure. He had diffuse patch ground glass opacities and a WBC scan localized to the lung. Open lung biopsy showed intravascular lymphocytes which stained positively for the B cell marker CD79a. The patient is receiving chemotherapy
3. Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 56 yo homeless man with schizophrenia and alcoholism who was found to have Mycobacterium kansasii about a year ago. He was begun on INH, rifampin, ethambutol, and PZA. He was lost to follow up but returned with a LUL cavity and respiratory failure. He was intubated and placed on mechanical ventilation. Bronchoalveolar lavage was AFB+. He was again begun on INH, rifampin, ethambutol, and PZA. When he failed to improve after several weeks he was treated with moxifloxacin, azithromycin and amikacin. A repeat BAL was Coccidioidomycosis antigen positive although the serum Coccidioidomycosis antigen negative. He was treated with amphotericin and was improving.
4. Dr. Jessica Hurley, a pulmonary fellow at St. Joseph, presented a 60 yo woman who underwent lung transplantation in May, 2012 for sarcoidosis. She developed progressive hypoxia and was intubated. CT scan showed multiple small nodules surrounded by ground glass opacities and mediastinal adenopathy. A VATS biopsy was performed which showed spindle shaped CD34+ positive cells consistent with Kaposi’s sarcoma. Her Mycophenolate was stopped and she was begun on doxorubicin.

There being no further business, the meeting was adjourned at about 8 PM. There being no meeting in December, the next meeting is Wednesday, January 23, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. November 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:270-1. PDF