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

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