September 2019 Arizona Thoracic Society Notes

The September 2019 Arizona Thoracic Society meeting was held on Wednesday, September 18, 2019 at the Banner University Medical Center Phoenix beginning at 6:00PM. There were 16 in attendance representing the pulmonary, critical care, sleep, radiology communities.

An announcement was made that cases of acute lung injury suspected of being secondary to vaping should be reported to Poison Control (1-800-222-1222) or to the State Department of Health (602-364-3587).

There were 3 case presentations:

1. Warren Carll DO, a second-year pulmonary fellow from the Mayo Clinic Arizona, presented a case of a 26-year-old man who complained of a 4-month history of hemoptysis. He had a past medical history of gastroesophageal reflux disease and frequent eye infections. His hemoptysis was up to ½ cup per day and he presented to the Mayo Clinic emergency room when he became frustrated that his outpatient work up was proceeding slowly. Physical examination showed erythematous and injected conjunctiva. His thoracic CT scan showed bilateral ground glass opacities with areas showing a reverse halo sign. Bronchoscopy showed only an increased number of neutrophils on the bronchoalveolar lavage. Laboratory evaluation showed positive cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) at 1:1024 and a proteinase 3 (PR3) of >8U (normal <1). A diagnosis of granulomatosis with polyangiitis (GPA, formerly called Wegener's granulomatosis) was made and the patient responded to corticosteroids and was discharged with a plan for rituximab as an outpatient. Dr. Kevin Leslie discussed the pathology of GPA and pointed out that it is a capillaritis and despite the name well-formed, sarcoid-like granulomas are rarely seen.
2. Kurt Olson MD, a third-year pulmonary fellow at the University of Arizona Phoenix presented a 52-year-old woman who complained of progressive dyspnea and a dry cough for 2 years. She had a past medical history of gastroesophageal reflux disease. Thoracic CT scan showed bronchiectasis with fibrosis most prominent in the lower lungs and an enlarged esophagus. Antinuclear antibodies (ANA) and anti-Scl-70 (also known as antitopoisomerase 1) were both positive. Discussion centered around a recent report in the New England Journal of Medicine showing that nintedanib slowed the rate of decline in the forced vital capacity in scleroderma (1)
3. Dr. Lewis Wesselius presented a 51-year-old immunocompromised host from a heart transplant who presented with a week long history of increasing shortness of breath. His chest X-ray was unremarkable but his SpO2 was found to be decreased.  However, a thoracic CT scan showed ground glass opacities with peripheral sparing. Bronchoscopy with bronchoalveolar lavage was negative for infection. His chest x-ray worsened over 3 days and he was treated with high dose corticosteroids, however, he continued to decline. At about this time it was discovered he had been vaping cannabinoid oil. He gradually improved and his chest x-ray cleared. However, on outpatient follow-up he still had a decreased exercise capacity and his DLco was decreased on pulmonary function testing.

Steve Tseng DO, a third-year fellow at University of Arizona Phoenix, presented a summary of the experience at Banner University Medical Center Phoenix of bronchoscopic lung volume reduction using endobronchial valves. To date they have treated over 50 patients with about 50% showing an improvement in FEV1 of >15% after 3-6 months.

The meeting was adjourned about 8:00PM. The next meeting will be in about 2 months with location and time to be announced.

Reference

1. Distler O, Highland KB, Gahlemann M, et al. Nintedanib for systemic sclerosis-associated interstitial lung disease. N Engl J Med. 2019 Jun 27;380(26):2518-28. [CrossRef] [PubMed]

Cite as: Arizona Thoracic Society. September 2019 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2019;19(3):99-100. doi: https://doi.org/10.13175/swjpcc059-19 PDF 

March 2015 Arizona Thoracic Society Notes

The March 2015 Arizona Thoracic Society meeting was held on Wednesday, March 25, 2014 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, radiology and oncology communities.

Dr. Richard Robbins made a presentation entitled "The History of Exhaled Nitric Oxide Measurement" focusing on the development of exhaled nitric oxide in the early 1990's.

There were 3 case presentations:

1. Sandra Till, a third year pulmonary fellow at the Good Samaritan/VA program, presented an elderly man admitted to the Phoenix VA with an exacerbation of chronic obstructive pulmonary disease (COPD). His CT findings showed with centrilobular emphysema, bronchial edema, and scattered ground glass opacities. It was felt that the CT findings most likely represented a bronchiolitis from his exacerbation of COPD.
2. Richard Robbins presented a 49 year old man with a positive PPD and Gold QuantiFERON who has extensive psoriasis and had biological therapy with etanercept recommended. He had an extensive past medical history of diabetes and sleep apnea secondary to obesity which resolved with gastric bypass. His liver was palpable at his right costal margin and his liver enzymes were mildly elevated. Chest x-ray was normal. Most felt that therapy for latent tuberculosis was indicated with some recommending isoniazid, others recommending rifampin and others recommending both drugs. He was treated for one month with isoniazid and his liver enzymes all declined into the normal range. He has begun etanercept and 6-9 months of isoniazid therapy are planned.
3. Stephanie Fountain, a second year internal medicine resident from the Good Samaritan/VA program presented an elderly man with a history of adenocarcinoma of the pancreas treated with chemotherapy and radiation in Chicago just prior to moving to Phoenix. He presented with abdominal pain secondary to an ileus which spontaneously improved. A CT scan performed during the abdominal evaluation showed multiple small nodules and some scattered ground glass opacities which was reminiscent of idiopathic interstitial pneumonia with cystic changes. Biopsy showed adenocarcinoma which special stains were most consistent with a pancreas primary. Discussion ensued about this unusual presentation CT presentation of metastatic pancreatic cancer.

The next meeting in Phoenix will be at Scottsdale Shea on Wednesday, May 27 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. March 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(3):149. doi: http://dx.doi.org/10.13175/swjpcc041-15 PDF

July 2013 Arizona Thoracic Society Notes

The first Arizona Thoracic Society meeting in Tucson was held on Wednesday, 7/24/2013 at Kiewit Auditorium on the University of Arizona Medical Center campus beginning at 6:30 PM. There were 36 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities. Dinner was sponsored by Accredo Health Group.

A brief discussion was held of plans to have the December 2013 meeting in Tucson on a weekend as part of the University of Arizona winter pulmonary meeting.

There were 4 cases presented:

1. Mohammad Dalabih presented a case of a 48 yo woman with respiratory failure cared for by Gordon Carr, Linda Snyder, and himself. Radiology findings were discussed by Isabel Oliva. Lung biopsy showed acute fibrinous and organizing pneumonia rather than ARDS and was presented by Richard Sobonya.
2. Franz Rischard presented a case of a 61 year old with progressive dyspnea and moderate COPD with evidence of pulmonary hypertension. Radiologic work up was presented by Dr. Oliva. It was determined the patient had primary hypertension and Dr. Rischard discussed how to separate pulmonary hypertension from COPD from primary pulmonary hypertension.
3. Nathaniel Reyes presented a 50 year old woman with a history of granulomatous polyangiitis (GPA, formerly known as Wegener’s granulomatosis) who was pANCA+ but cANCA-. She developed diffuse alveolar hemorrhage. Dr. Soboyna reviewed pathology of GPA. Dr. Reyes discussed the ANCA+ vasculities. Some rheumatologists no longer consider GPA and microscopic polyangitis separate diseases but part of the same spectrum.
4. Gordon Carr presented a case of a 65 year old man who died of an exacerbation of idiopathic pulmonary fibrosis (IPF). Dr. Sobonya reviewed the autopsy and pathology findings of IPF.

There being no further business the meeting was adjourned at about 8:15 PM. The next meeting is scheduled for Wednesday, August 28, 6:30 PM in Phoenix at Scottsdale Shea Hospital.  

Richard A. Robbins, M.D.

Reference as: Robbins RA. July 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(1):50. doi: http://dx.doi.org/10.13175/swjpcc095-13. PDF 

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