October 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 10/24/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

An announcement was made that the Colorado Thoracic Society has accepted an invitation to partner with the Arizona and New Mexico Thoracic Societies in the Southwest Journal of Pulmonary and Critical Care Medicine.

Discussions continue to be held regarding a combined Arizona Thoracic Society meeting with Tucson either in Casa Grande or electronically.

Six cases were presented:

Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 48 year old female who had been ill for 2 weeks. A CT of the chest revealed a left lower lobe nodule and a CT of the abdomen showed hydronephrosis and a pelvic mass. Carcinoembryonic antigen (CEA) was elevated. All turned out to be coccidioidomycosis on biopsy.  CEA decreased after the pelvic mass was resected.

Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a 60 year old man with a past medical history of a transbronchial biopsy showing nonspecific interstitial lung disease. CT scan showed bilateral hilar lymphadenopathy and multifocal ground glass opacities. Multiple serologies were all negative. Biopsy revealed both hypersensitivity pneumonitis and sarcoidosis. It was pointed out by Drs. Michael Gotway and David August that the usual presentation of sarcoidosis in the lung is bilateral lymphadenopathy with multiple small nodules in a peribronchovascular distribution along with irregular thickening of the interstitium. Although multifocal ground glass opacities have been reported with sarcoidosis, it is unusual.

Dr. George Parides presented two cases of patients with rheumatoid arthritis receiving biologic therapy. One presented with a positive QuantiFERON test for tuberculosis and the other with a positive PPD. Management was discussed. None were aware of any data but the majority thought that stopping the biologics, if possible, and treating with INH for 9 months was probably appropriate.

Dr. Colby presented a second case of a 52 year old heavy smoker with shortness of breath while playing basketball. Chest CT showed ground glass opacities with minimal fibrosis. A lung biopsy showed various areas consistent with desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease or nonspecific interstitial pneumonitis with scarring.  Dr. Colby stated that smokers with interstitial disease can have different patterns on biopsy. Drs. Gotway and August pointed out that the lung CT pattern is also often heterogenous.

Dr. Lewis Wesselius presented a 49 year old female admitted for hypoxia, lethargy, and an abnormal chest x-ray. She had a prior diagnosis of systemic lupus erythematosis (SLE) with a reported diagnosis of lupus pneumonitis made 3-4 years ago. There was a history of multiple episodes of pneumonia (25 in 5 years), a prior stroke and mitral valve disease with valve replacement. Chest CT showed multiple areas of ground glass opacities and bronchoscopy with bronchoalveolar lavage resulted in a bloody return. Serologies were inconsistent with SLE but anti-phospolipid antibodies were present. Dr. Wesselius reviewed antiphospholipid antibody syndrome (APS) which can occur as a primary condition or in the setting of an underlying systemic autoimmune disease such as SLE. Manifestations include deep venous thrombosis (32%), thrombocytopenia (22%), livedo reticularis (20%), stroke (13%), pulmonary embolus (9%), fetal loss (8%), transient ischemic attack (7%), hemolytic anemia (7%), and rarely alveolar hemorrhage. Treatment includes high dose corticosteroids, cyclophosphamide, mycophenolate, IVIG, and plasmapharesis. A recent report (Lupus 2012, 21:438-40) advocated Rituximab, a chimeric monoclonal antibody against the protein CD20, which is primarily found on the surface of B cells, for recurrent diffuse alveolar hemorrhage in primary APS.

There being no further business, the meeting was adjourned. The next meeting is November 28 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. October 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:218-9. 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

April 2011 Arizona Thoracic Society Notes

A dinner meeting was held at Scottsdale Shea Medical Center on April 12, 2011 from 6:30-8:00 PM. Twenty-seven were in attendance including representatives from the pulmonary and chest radiology communities. Six cases were presented and discussed:

1. Alexis Christie and Rick Helmers presented a case of acute respiratory failure in a 51 year old woman who had an “ARDS”-like picture, an initially negative bronchoscopy with bronchoalveolar lavage and a non-specific open lung biopsy. The bronchoalveolar lavage eventually cultured influenza A. Discussion centered on whether the patient should have received corticosteroids.

2. Lew Wesselius presented a 55 year old man evaluated for renal transplant secondary to chronic renal failure from polycystic kidney disease. The patient was asymptomatic but found to have lower lung nodules on CT which were thought to be pulmonary arteriovenous malformations. The patient was referred for embolization. The invasive radiologist identified these as pulmonary varices. No therapy was given. A brief review of pulmonary varices was done by Dr. Wesselius and Mike Gotway discussed the radiographic appearance.

3. Gerald Swartzberg presented a case of a 64 year old woman with a rash on her palms, fever and multiple pulmonary nodules. Cultures and coccidiomycosis serology were negative. The patient was found to have coccidiomycosis on video-assisted thoracic surgery. Discussion centered on the 70% sensitivity of coccidiomycosis serology.

4. Gerald Swartzberg presented a second case of a 55 year old man with dyspnea, a 20 pack-year smoking history, and lower lobe fibrosis. The PFTs were presented which demonstrated a mixed obstructive and restrictive disease with a diffusing capacity of 47% of predicted. Most thought this was a case of COPD with idiopathic pulmonary fibrosis. Management was discussed.

5. John Roehrs presented a case of 52 year old woman with dyspnea with a normal chest x-ray and spirometry. However, on echocardiogram pulmonary hypertension was found with right atrial and ventricular enlargement. A bubble study demonstrated an atrial septal defect. Right-sided cardiac catherization confirmed the elevated pulmonary artery pressure and demonstrated an O2 step up at the atrial level. Discussion centered on therapy with most suggesting cardiology evaluation for a percutaneous closure of the ASD.

6. Christian Jivcu and Manny Mathew presented a case dyspnea of a man who had Hodgkin’s disease in 1987 who had received radiation therapy. CXR revealed bilateral pleural effusions which were exudative. A chest CT scan revealed mediastinal lymphadenopathy. At operation he was found to have mesothelioma which even in retrospect was not recognizable on his CT scan. The patient had no known asbestos exposure. Discussion focused on the association between prior radiation therapy and mesothelioma.

Richard A. Robbins, MD