April 2014 Arizona Thoracic Society Notes

The April 2014 Arizona Thoracic Society meeting was held on Wednesday, 4/23/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 15 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

It was announced that there will be a wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting. The tasting will be led by Peter Wagner and is scheduled for the Cobalt Room in the Hilton San Diego Bayfront on Tuesday, May 20, from 4-8 PM.

Guideline development was again discussed. The consensus was to await publication of the IDSA Cocci Guidelines and respond appropriately.

George Parides, Arizona Chapter Representative, gave a presentation on Hill Day. Representatives of the Arizona, New Mexico and Washington Thoracic Societies met with their Congressional delegations, including Rep. David Schweikert, to discuss the Cigar Bill, NIH funding, and the Medicare Sustainable Growth Rate Factor (SGR). Dr. Parides also spoke about the need for increased funding for Graduate Medical Education.

Four cases were presented:

1. Jud Tillinghast presented a case of a middle aged man who suffered a cervical cord injury 6-7 years ago resulting in paraplegia. The patient had just moved from California and was referred because of an abnormal chest x-ray. After his injury the patient had a great deal of pain and repeated episodes of aspiration. The patient was asymptomatic. The chest x-ray showed haziness surrounding the right hilum. A CT scan showed RLL, LLL, and RML consolidation which was essentially unchanged from a thoracic CT performed 6 months earlier. A biopsy was performed and consistent with lipoid pneumonia. On further questioning the patient recalled taking mineral oil for the first 2-3 years after his injury to relieve constipation induced by narcotics for pain.
2. Gerald Schwartzberg presented a 79 year old man with very severe COPD who presented with hemoptysis. Chest x-ray showed bilateral lower lobe consolidation with an air-fluid level in the right chest. Bronchoalveolar lavage revealed only Aspergillus. A discussion ensued and many were unconvinced that the consolidations resulted from Aspergillus. Since the patient was relatively asymptomatic except from the dyspnea from his COPD, the consensus was to perform a repeat thoracic CT scan.
3. Lewis Wesselius presented a 71 year old woman with dyspnea since late 2013. She had a cardiac pacemaker placed in 2008. Her physical exam was unremarkable. Her SpO2 was 96% on room air but decreased to 84% with exercise. Chest x-ray and pulmonary function testing were unremarkable (a DLco was unable to be performed. Echocardiogram revealed a large patent foramen ovale (PFO).
4. Allen Thomas presented a 65 year old with dyspnea. The patient had a history of cardiomegaly with diastolic dysfunction and a bipolar disorder treated with lithium, lamotrigine, gabapentin. Chest x-ray showed bilateral interstitial infiltrates. CT scan showed sub-pleural patchy ground-glass opacities combined with irregular reticular opacities reminiscent of nonspecific interstitial pneumonia (NSIP). Collage vascular work up was negative. Review of the website Pneumotox (http://www.pneumotox.com) showed reports of interstitial disease with lamotrigine. The medication was stopped an follow-up CT scan showed near resolution of the abnormalities.

There being no further business the meeting was adjourned about 8:15 PM. The next meeting is scheduled to be a case presentation conference for May 28, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

Reference as: Robbins RA. April 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(4):236-7. doi: http://dx.doi.org/10.13175/swjpcc054-14 PDF

January 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 1/23/2013 at Scottsdale Shea beginning at 6:30 PM. There were 25 in attendance representing the pulmonary, critical care, sleep, infectious disease, thoracic surgery and radiology communities.

Dr. George Parides presented a plaque to Al Thomas for being voted Arizona’s Clinician of the Year (Figure 1).

Figure 1. George Parides, Arizona Thoracic Society President, presenting a plaque to Allen Thomas, Arizona Thoracic Society Clinician of the Year.

Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, gave a PowerPoint slide presentation updating the membership on the Arizona Thoracic Society’s official journal.

Five cases were presented:

1. Tim Kuberski, chief of infectious disease at Maricopa Medical Center, presented a 29 year old diabetic who underwent a sinus operation for a sinus mass which proved to be a fungus ball. A biopsy was also done of the bone which showed osteomyelitis with cultures showing methicillin-sensitive Staphylococcus aureus. The patient received a 6 week course of daptomycin. Near the end of his daptomycin he began to complain of shortness of breath. Chest x-ray and thoracic CT scan showed peripheral lung consolidation with a “reverse batwing” appearance. The patient had 5% eosinophils in his blood. The symptoms and consolidation resolved with stopping the daptomycin. This was thought to be a drug reaction to the daptomycin.
2. Andrew Goldstein, thoracic surgery, presented a case of a 71 year old man who developed an upper respiratory tract infection after a hunting trip. His complaints led to a chest x-ray which showed fullness in the right hilum and a question of oligemia in the right lung. Review of the patient’s old chest x-rays showed RLL collapse for at least a couple of years Thoracic CT showed the RLL collapsed with a question of a mass in the bronchus intermedius. PET scanning did not show increased metabolic activity. Bronchoscopy showed a mass in bronchus intermedius. Multiple biopsies were non-diagnostic. A rigid bronchoscopy was performed with multiple biopsies which showed an endobronchial hamartoma. The mass was endobronchially resected until both the RML and RLL bronchus were patent. Post-operatively the RLL was expanded.
3. Heemesh Seth and John Roehrs, pulmonary at the Phoenix VA, presented a 34 year old man with progressive dyspnea since 2006 when was a Marine in Iraq injured by an IED. Chest x-ray and thoracic CT scan showed a mild left PA enlargement. Pulmonary function tests were normal. An echocardiogram showed pulmonic stenosis with a mild gradient and mild pulmonic regurgitation.  Referral to a pediatric cardiologist confirmed a diagnosis of pulmonic stenosis with pulmonic dilatation. Discussion regarding right heart catherization and optimal treatment ensued without a consensus being reached.
4. Elijah Poulos and Allen Thomas, pulmonary at the Phoenix VA, presented a case of a 57 year old man who had been admitted with atrial fibrillation and a rapid ventricular response. He had a past medical history of COPD and optic neuritis of uncertain etiology. A chest x-ray revealed a right pleural effusion and scattered right central peribronchial lung consolidation with less on left. The patient was asymptomatic. Various diagnoses were discussed including sarcoidosis and lymphoma but most felt that diagnosis would require biopsy.
5. Gerald Swartzberg presented three cases. All had been exposed to obnoxious fumes and developed vocal cord dysfunction. Most had diagnosed with asthma and all had extra thoracic obstruction on their flow-volume loops. Dr Schwartzberg reviewed irritant-associated vocal cord dysfunction and a discussion ensued regarding this poorly described disorder.

There being no further business, the meeting was adjourned at about 8 PM. The next meeting is Wednesday, February 27, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. January 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2013;6(1):38-40. PDF