March 2018 Arizona Thoracic Society Notes

The March 2018 Arizona Thoracic Society meeting was held on Wednesday, March 28, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 12 in attendance representing the pulmonary, critical care, sleep, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

1. The Tobacco 21 which had been introduced into the Arizona House was killed in committee by Rep. Jeff Weninger, Chairman of the Commerce Committee.
2. Council of Chapter Representatives (CCR) Meeting and “Hill Day” was cancelled due to inclement weather. It will probably be rescheduled for the summer.

An update on pirfenidone in IPF was presented by Jessica Castle, PhD, Medical Science Liaison with Genentech. Dr. Castle discussed the antifibrotic, anti-inflammatory, and anti-oxidant effects of pirfenidone.

Data was also presented from post-hoc analysis from pirfenidone trials.

• Overall no difference in morality data
• Reduction in respiratory hospitalizations
• Reduction in deaths after respiratory hospitalizations
• Quantitative Image Analysis showed a decrease in fibrosis with pirfenidone

Lastly, Dr. Castle introduced several ongoing trials with combination therapy for IPF.

There were 3 case presentations:

1. Dr. Tim Kuberski, Chief of Infectious Disease at Maricopa, presented a 45-year-old Caucasian man who collapsed in the market and was brought to Maricopa Medical Center. He had evolving gangrene of his distal extremities which proved to be secondary to Yersinia pestis. He received continuous sympathetic blockade to treat his gangrene (1). The patient’s gangrene of his toes resolved but he did require amputation of his fingers and reconstruction of his ears and nose.
2. Dr. Richard Robbins presented a 54-year-old man with triad asthma, eosinophilia and coronary artery spasm. He was begun on montelukast and was doing well. He presented a series from New Zealand of 15 patients with eosinophilia and coronary artery spasm (2). Four of the patients were noted to have asthma. No one could recall a similar case.
3. Dr. Lewis Wesselius presented an 72-year-old woman who was a life-long nonsmoker with progressive dyspnea over 3-4 years. She had bibasilar crackles on physical examination and a low DLco on pulmonary function testing. Thoracic CT scan showed subtle changes of bibasilar reticulation. This did not appear to be UIP. Biopsy showed rather uniform changes with alveolar wall thickening but not areas characteristic for a definitive diagnosis. The consensus was that her case was most likely chronic hypersensitivity pneumonitis.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix on May 23 at 6:30 PM at HonorHealth Rehabilitation Hospital. This will be a planning meeting to structure Arizona Thoracic Society meetings and activities.

Richard A. Robbins MD

Editor, SWJPCC

References

1. Kuberski T, Robinson L, Schurgin A. A case of plague successfully treated with ciprofloxacin and sympathetic blockade for treatment of gangrene. Clin Infect Dis. 2003 Feb 15;36(4):521-3. [CrossRef] [PubMed]
2. Wong CW, Luis S, Zeng I, Stewart RA. Eosinophilia and coronary artery vasospasm. Heart Lung Circ. 2008 Dec;17(6):488-96. [CrossRef] [PubMed]

Cite as: Robbins RA. March 2018 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2018;16(3):170-1. doi: https://doi.org/10.13175/swjpcc051-18 PDF 

January 2018 Arizona Thoracic Society Notes

The January 2018 Arizona Thoracic Society meeting was held on Wednesday, January 24, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 11 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting several issues were discussed:

1. CME for Arizona Thoracic Society Meetings. Dr. Robbins will be going to Washington and will meet with the ATS concerning obtaining CME for the Arizona Thoracic Society meetings.
2. Tobacco 21. It was unclear if any action was occurring. Dr. Parides said he would check.
3. Council of Chapter Representatives (CCR) Meeting and “Hill Day”. Dr. Robbins will be attending the CCR meeting March 21-22 for Dr. Schwartzberg. This includes meeting with the Arizona Congressional representatives. Those that have issues they wish presented to either the ATS leadership or their legislators should contact Dr. Robbins at rickrobbins@cox.net. 

There were 4 case presentations:

1. Dr. Gerry Swartzberg presented a follow-up of a now 74-year-old who was presented in 2014 who was asymptomatic but with a CT scan showing cysts.  No diagnosis was made at that time. She has been followed for the last 3 years. She now has some shortness of breath with exertion. It was discovered that she had cockatiels. A complete “bird” hypersensitivity was recommended but the patient declined because of cost. A repeat CT in late 2017 showed that the cysts had enlarged. A pigeon serum serologic test was positive. Dr. Gotway pointed out that lung cysts can occur with hypersensitivity pneumonitis (1). A biopsy was performed which showed necrotizing granulomas without any organisms. Although she got rid of her cockatiels, further history reveals that the patient still feeds pigeons.  The consensus (although by no means unanimous) was this was likely hypersensitivity pneumonitis with an unusual presentation. It was thought that a trial of steroids might be beneficial.
2. Dr. Lewis Wesselius presented a 75-year-old woman with a thymic carcinoid tumor diagnosed in 2015. She was treated with resection and radiation therapy. CT scan showed changes consistent with radiation pneumonitis. Bronchoscopy with transbronchial biopsy showed “organizing pneumonitis”. She was treated with corticosteroids for 1 month. CT scan showed some improvement and the steroids were tapered. Her symptoms recurred and she was again started on corticosteroids with improvement but after tapering her steroids, her symptoms again recurred. CT scan showed marked worsening of the lung infiltrates. A bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy was performed. The BAL showed 12% eosinophils and the biopsy was consistent with chronic eosinophilic pneumonia.
3. Dr. Wesselius also presented a 79-year-old woman who had a right upper lobe resection for non-small cell lung cancer. A follow-up CT scan sometime later showed ground glass opacities (GGOs). A decision was made to follow the GGO’s but a year later CT scan showed worsening of the lesions. Navigational bronchoscopy was nondiagnostic. After a tumor board conference, she received radiation therapy for presumed carcinoma. She was followed but again had increasing shortness of breath. CT scan showed changes consistent with radiation pneumonitis. A long discussion ensued about empiric radiation therapy.
4. Dr. George Parides presented a woman with a clinical history consistent with idiopathic pulmonary fibrosis (IPF) and a CT scan which showed ground glass opacities. Most felt that this was IPF. Pirfenidone was started. A discussion about therapies, including experimental therapies for IPF ensued.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix on March 28 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins MD

Editor, SWJPCC

Reference

1. Franquet T, Hansell DM, Senbanjo T, Remy-Jardin M, Müller NL. Lung cysts in subacute hypersensitivity pneumonitis. J Comput Assist Tomogr. 2003 Jul-Aug;27(4):475-8.[CrossRef] [PubMed]

Cite as: Robbins RA. January 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;16(1):51-2. doi: https://doi.org/10.13175/swjpcc018-18 PDF 

September 2015 Arizona Thoracic Society Notes

The September 2015 Arizona Thoracic Society meeting was held on Wednesday, September 23, 2015 at the Scottsdale Shea Hospital beginning at 6:00 PM. This was a dinner meeting with case presentations. There were 13 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

There were 6 case presentations:

1. Dr. Gerald Schwartzberg presented a case of a 58-year-old woman with a history of Mycobacterium avium presented with cough and malaise. CT revealed a history of lower love centrilobular nodules and scattered ground glass opacities and some bronchiectasis. Sputum revealed Aspergillus fumigatus. IgE was normal but IgA was deficient at 20 mg/dl (normal 80-350 mg/dl). She was started on itraconazole and clinically improved. Many questioned whether the Aspergillus was the cause of her pneumonia and some questioned the association of the IgA deficiency with her overall clinical picture.
2. Dr. Schwartzberg presented a second case of a 92-year-old former opera singer who had a past diagnosis of asthma but without airflow obstruction, gastroesophageal reflux disease, and myelodysplastic syndrome. CT scan revealed mosaic areas most consistent with hypoperfusion secondary to air trapping. Complete pulmonary function testing revealed only a markedly decreased DLco. She had oxygen desaturation with exercise. Clinically she did not respond to a bronchodilator. Most were perplexed as the cause of her overall clinical picture.
3. Dr. Schwartzberg presented a third case of a morbidly obese 61-year-old woman who presented with shortness of breath. CT scan showed some scattered lung nodules in her lower lobes. Laboratory evaluation including cocci serologies were negative. A needle biopsy of one of the lung nodules was nondiagnostic and she was empirically begun on fluconazole. She clinically improved. Many thought this could be possibly Valley fever and she should be followed.
4. Dr. Alan Thomas presented a 66-year-old man with a history of lymphoma about 10 years earlier who presented with some enlarging lymph nodes. Thoracic CT scan was performed as part of his evaluation and showed some areas of emphysema with scattered ground glass opacities. It was felt the radiologic pattern was most consistent with respiratory bronchiolitis with fibrosis (2).
5. Dr. Thomas also presented a case of an 82-year-old former smoker who quit about a year ago who presented with weight loss and minimal cough. Thoracic CT scan showed a large pleural mass with pleural effusion surrounding the right lung as well as pleural plaques. He did have a history of asbestos exposure in the Navy. Thoracentesis showed a nondiagnostic exudative effusion. A biopsy was performed which was consistent with a large cell neuroendocrine tumor.
6. Dr. Lewis Wesselius presented a 65-year-old man with exertional dyspnea and possible interstitial lung disease. He has a history of a Ross procedure (replacement of a bicuspid aortic valve with the pulmonic valve) and obstructive sleep apnea. Chest x-ray was unremarkable. Complete pulmonary function testing was normal. Thoracic CT scan showed peripheral reticulations especially in the lower lobes. A video-assisted thorascopic biopsy (VATS) was performed. Histology showed scattered fibroblast foci with scattered fibrosis with airway centricity. It was unclear whether this was usual interstitial fibrosis or chronic hypersensitivity pneumonitis. He was started on prednisone because his picture was felt to be most consistent with chronic hypersensitivity pneumonitis (1). Unfortunately, chronic hypersensitivity pneumonitis with features of UIP appears to carry a worse prognosis.

There being no further business, the meeting was adjourned about 7:30 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, November 18 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Reddy TL, Mayo J, Churg A. Respiratory bronchiolitis with fibrosis. High-resolution computed tomography findings and correlation with pathology. Ann Am Thorac Soc. 2013;10(6):590-601. [CrossRef] [PubMed]
2. Myers JL. Hypersensitivity pneumonia: the role of lung biopsy in diagnosis and management. Mod Pathol. 2012;25 Suppl 1:S58-67. [CrossRef] [PubMed]

Cite as: Robbins RA. September 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(3):117-8. doi: http://dx.doi.org/10.13175/swjpcc124-15 PDF

May 2015 Arizona Thoracic Society Notes

The May 2015 Arizona Thoracic Society meeting was held on Wednesday, May 27, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Ms. Georgann VanderJagt, RN, MSN gave an update on clinical trials at Dignity Health including idiopathic pulmonary fibrosis and alpha-1 antitrypsin deficiency. To contact Ms. VanderJagt call her office at 602-406-3825, her cell at 602-615-2377 or by email at georgann.vaderjagt@digniftyhealth.org.  

Dr. Michael Smith, the surgical director for the lung transplant program at Dignity Health, gave an overview of their lung transplant program. They are currently the fifth busiest transplant program in the US.  They have done 46 lung transplants so far this year. They are on a par with UCLA in number of transplants and survival has been at the National average. Average wait time is only abut 2 weeks. He also discussed recent and ongoing transplant protocols. To contact Dr. Smith call 602-406-7564.

There were 4 case presentations:

1. Jud Tillinghast presented a case of a large man who was short of breath. His CT scan showed multiple calcifications in the lower lobes. It was felt that clinically he was most likely aspirating as a cause of the calcifications.
2. Gerald Swartzberg presented a case of a large man who had some minimal dyspnea and an elevated right hemidiaphragm. His chest x-ray showed consolidation in this right lower lung. He had been seen at the Mayo Clinic and Dr. Lewis Wesselius reviewed his pathology from a needle biopsy of a right lower lobe nodule which was nonspecific. Reviewing his case he also had a biopsy from Sloan Kettering in 2006 which was also nonspecific. Further history was obtained and the patient admitted he was using Vick's Vaporub in his nose since he was 7 years old. It was unclear if this was the cause of his right lower lobe consolidation.
3. Dr. Swartzberg presented a second case of a 70-year-old woman with multiple medical problems. She has a cockatiel but is remarkably asymptomatic. A chest x-ray was taken showed nonspecific lower lobe changes. Pulmonary function tests showed a reduced vital capacity but a normal to high total lung capacity. A DLCO was not able to be obtained. CT scan showed small nodules with ground glass in her lower lobes. It was felt that most likely this was a hypersensitivity pneumonitis secondary to her bird. She got rid of the bird but did not improve.  The cause of her abnormal pulmonary radiology remains unclear.
4. Dr. Wesselius presented a case of a patient with a chronic cough which had been treated with antibiotics and corticosteroids. When he as on oral corticosteroids he was perhaps somewhat better. He was seen at the University of Massachusetts without a diagnosis being made. He subsequently moved to the Phoenix area and was evaluated at the Mayo Clinic. Chest x-ray showed consolidation in his right upper lobe. On bronchoscopy he had some whitish plaques along his trachea and main bronchi. Bronchoalveolar lavage showed 89% eosinophils and his transbronchial biopsy was consistent with chronic eosinophilic pneumonia. Apparently, this association has previously been sporadically reported. He was started on prednisone and improved.

Dr. Jud Tillinghast was acknowledged as the Arizona Thoracic Society Clinician of the Year and one of the four finalists as ATS Clinician of the Year.

After a brief discussion, the membership agreed to encourage and help Nevada form a state thoracic society.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, July 22 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. May 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(5):304-5. doi: http://dx.doi.org/10.13175/swjpcc075-15 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