May 2012 Arizona Thoracic Society Notes

The May 2012 Arizona Thoracic Society meeting was held on 5/16/2012 at Scottsdale Shea beginning at 6:30 PM. Attendees representing the pulmonary, critical care, sleep, infectious disease, radiology, and nursing communities were present.

This was the first meeting on Wednesday. The meetings will usually be held the last Wednesday of every month, pending availability of a meeting room at Shea and conflicts with holidays.

Congressman David Schweikert has accepted an invitation to speak at the Arizona Thoracic Society. Because of the Congressman’s schedule, it was decided to hold a special meeting on 8/8. The August meeting scheduled for 8/29 was to go on as planned.

Six cases were presented:

1. Dr. Timothy Kuberski: An African-American male presented with knee pain. Chest radiography showed a very subtle opacity over the left upper chest, not clearly intraparenchymal. Thoracic CT showed a fluid collection centered around the left sternoclavicular joint and costomanubrial junction, extending medially into the superior mediastinum, posteriorly into the thorax (but remaining extraparenchymal and extrapleural), into superficially into the left pectoralis musculature. This focus showed low attenuation, consistent with abscess. The abscess was drained, and contrast injection through the catheter showed that all the aforementioned spaces were in communication with one another, with cranial extension into the left lower neck. No organisms could be recovered from this collection, but pneumococcus was recovered from aspiration of the knee fluid and blood. There was speculation that the chest wall lesion could be related to actinomycosis, but testing this far has not revealed this organism.
2. Gerry Schwartzberg presented two cases of coccidioidomycosis on chest radiography, one of which produced a pleural effusion in a Filipino man. The organism was not isolated from the thoracentesis fluid, but Judd Tillinghast noted he once had similar case that underwent video-assisted thoracoscopic surgery that showed pleural surface plaques containing the organism.
3. Tom Colby presented two cases: A 39-year-old woman presented with chest pain and lymphadenopathy in the thorax. Reportedly, multiple fine needle aspiration biopsies were non-diagnostic. Evaluation for immunodeficiency and autoimmune disease was unrevealing. Thoracic CT initially showed a mass-like opacity in the right lower lobe, possibly with peribronchial lymphadenopathy and areas of patchy ground-glass opacity. A small pleural effusion was also present, as was smooth interlobular septal thickening. The patient presented later with hemoptysis and pleuritic chest pain. Repeat thoracic CT showed a complex cystic mass in the right lower lobe, arising in the area of mass-like opacity seen previously. The patient underwent right lower lobectomy. The final diagnosis was pulmonary lymphangioma with rupture into a bronchus, allowing the lesion to become air-filled.
4. Dr. Colby also presented a case of a 28-year-old man presented with a right lower lobe mass and dyspnea. He was a non-smoker, with a history of asthma requiring multiple hospitalizations as a child as well asteroid use. He noted several episodes of “bronchitis” every year as an adult. His pulmonary function testing showed mild reversible obstruction. A PET scan reportedly showed increased uptake (maximum standard uptake value of 8) in the right lower lobe mass. Bronchoscopy was reportedly unrevealing, but sputum cultures did show normal flora and 1 colony of Aspergillus. His thoracic CT showed an area of consolidation in the superior segment of the right lower lobe tracking along the bronchovascular bundle; the superior segment bronchus could not be visualized at all. Review of the pathology showed goblet cell hyperplasia, Charcot-Leyden crystals, allergic mucin, bronchiocentric granulomatosis, and eosinophilic pneumonia. The patient was subsequently diagnosed with allergic bronchopulmonary aspergillosis.
5. Al Thomas presented a case of a patient who underwent chest radiography and was diagnosed with a “narrowed” trachea, which prompted thoracic CT. The narrowed trachea simply represented a “saber sheath” trachea”, but a focal opacity was noted along the posterior tracheal wall. The patient underwent bronchoscopy, which showed a verrucous lesion along the posterior tracheal wall with a “fish egg” appearance. Biopsies subsequently showed the lesion to represent squamous papilloma.
6. A case was presented of an 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.

There being no further cases, the meeting was adjourned at 8:00 PM. The next meeting is scheduled for Wednesday, June 27.

Michael B. Gotway, M.D.

Vice President

Arizona Thoracic Society

Reference as: Gotway MB. May 2012 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2012;4:174-6. (Click here for a PDF version of the Notes)