September 2014 Arizona Thoracic Society Notes

The September 2014 Arizona Thoracic Society meeting was held on Wednesday, 9/24/14 at the Kiewit Auditorium on the University of Arizona Medical Center campus in Tucson beginning at 5:30 PM. This was a dinner meeting with case presentations. There were about 21 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

Four cases were presented:

1. Mohammad Dalabih presented a 22 year old hypoxic man with a history of asthma and abdominal pain. A bubble echocardiogram showed bubbles in the left ventricle within 3 heartbeats. Thoracic CT scan showed a pulmonary arteriovenous malformation (AVMs). The patient underwent coil embolization and improved. Dr. Dalabih reviewed the diagnosis and management of pulmonary AVMs (1). Aarthi Ganesh presented a 70 year old woman complaining of dyspnea on exertion. A chest x-ray showed complete opacification of the right hemithorax and a thoracic CT scan showed a large right pleural effusion with right lung atelectasis. After thoracentesis was nondiagnostic, she underwent video-assisted thorascopic surgery (VATS). Although she clinically appeared to have mesothelioma, histology was consistent with a pseudomesotheliomatous adenocarcinoma. She is currently undergoing treatment with platinum based agents.
2. Gordon Carr presented a 75 year old woman with dyspnea. Chest x-ray showed interstitial disease with a possible usual interstitial pneumonia (UIP) pattern on CT scan. Dr. Carr reviewed the initial evaluation and diagnosis of the interstitial lung disease (2). VATS showed a bronchocentric process with some fibrosis in the periphery most consistent with chronic hypersensitivity pneumonitis. The likely source was thought to be mold in her indoor pool area.
3. James Knepler presented a 55 year old woman with breast cancer and bone metases receiving tamoxifen. She also had a history of multiple sclerosis and was receiving on interferon-beta 1a. A positron emission tomography (PET) scan showed increased uptake in several mediastinal lymph nodes. Endobronchial ultrasound (EBUS) guided aspiration biopsy was non-diagnostic. Endobronchial biopsy showed granulomas. It was felt the most likely diagnosis was interferon-induced sarcoidosis. Several case reports have recently been published.

There being no further business the meeting was adjourned about 7:00 PM. The next meeting will be Phoenix on Wednesday, October 22, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

References

1. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158(2):643-61. [CrossRef] [PubMed]
2. Selman M, Pardo A. Update in diffuse parenchymal lung disease 2012. Am J Respir Crit Care Med. 2013;187(9):920-5. [CrossRef] [PubMed] 

Reference as: Robbins RA. September 2014 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2014;9(3):191-2. doi: http://dx.doi.org/10.13175/swjpcc127-14 PDF

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

February 2014 Arizona Thoracic Society Notes

The February 2014 Arizona Thoracic Society was a dinner meeting sponsored by Select Specialty Hospital and held on Wednesday, 2/26/2014 at Shea Hospital beginning at 6:30 PM. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Gerald Swartzberg was presented a plaque as the Arizona Thoracic Society clinician of the year by George Parides (Figure 1).

Figure 1. George Parides (left), Arizona Representative to the ATS Council of Chapter Representatives, presenting a plaque to Gerald Swartzberg (right), Arizona Thoracic Society Clinician of the Year.

A discussion was held about having a wine tasting in San Diego at the ATS International Conference. Peter Wagner (Slurping Around with PDW) has agreed to lead the conference. It was decided to extend invitations to the New Mexico, Colorado and California Thoracic Societies along with the Mayo Clinic.

A question was raised about guideline development. It was felt that we should review the Infectious Disease Society of America Valley Fever guidelines and determine if the Arizona Thoracic Society might have something to contribute.

Three cases were presented:

Lewis Wesselius from the Mayo Clinic Arizona presented a 19 year old man with shortness of breath and fever. He was seen in the Emergency Department and had a normal chest x-ray but returned 6 days later with a diffuse nodular pneumonia. Bronchoscopy with bronchoalveolar lavage revealed blood but all cultures with negative. He underwent video-assisted thorascopic lung (VATS) biopsy. Histologically the biopsy showed massive neutrophilic infiltration, hemorrhage, and small, angiocentric abscess formation. This was considered compatible with pyoderma gangrenosum of the lung (1). He had dramatic improvement with corticosteroids.

Elijah Poulos, a second year fellow at the Good Samaritan/VA program, presented a case of a non-resolving lung infiltrate in the left lower lobe after 6 weeks. CT scan showed a patchy, nodular consolidation with hazy borders. The patient was asymptomatic. Lung biopsy showed adenocarcinoma. He was referred to thoracic surgery for possible resection.  A discussion ensued reminding everyone that carcinoma is a consideration in non-resolving lung lesions and that adenocarcinoma is becoming more common (2).

Dr. Poulos also presented a 66 year old who is retired but a semi-retired handyman/farmer who had a persistent nonproductive cough. CT scan showed a diffuse increase in interstitial markings. Pulmonary function testing revealed restrictive lung disease. Bronchoscopy with bronchoalveolar lavage was unremarkable. He was treated with fluticasone nasal spray and improved. Most advised a VATS biopsy to establish a diagnosis.

Richard A. Robbins, M.D.

References

1. Kanoh S, Kobayashi H, Sato K, Motoyoshi K, Aida S. Tracheobronchial pulmonary disease associated with pyoderma gangrenosum. Mayo Clin Proc. 2009;84(6):555-7. [CrossRef] [PubMed] 
2. Lortet-Tieulent J, Soerjomataram I, Ferlay J, Rutherford M, Weiderpass E, Bray F. International trends in lung cancer incidence by histological subtype: Adenocarcinoma stabilizing in men but still increasing in women. Lung Cancer. 2014 Jan 25. pii: S0169-5002(14)00044-0. [PubMed]

Reference as: Robbins RA. February 2014 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2014;8(2):138-9. doi: http://dx.doi.org/10.13175/swjpcc026-14 PDF

January 2012 Arizona Thoracic Society Notes

The January Arizona Thoracic Society meeting was held on 1/11/2012 at Scottsdale Shea beginning at 6:30 PM. There were 30 in attendance representing the pulmonary, radiology, thoracic surgery and allergy communities.

Al Thomas was voted to be clinician of the year nominee from Arizona.

A progress report for 2011 was given by Rick Robbins on the Southwest Journal of Pulmonary and Critical Care (for a summary of the presentation click here).

Multiple cases were presented:

1. George Parides presented a 64 year old with a second PPD which was positive. A discussion regarding interpretation of PPDs ensued.
2. Gerald Swartzberg presented two cases-both had in common a markedly elevated IgE level. These cases created a discussion of the differential diagnosis of an elevated IgE and how to approach patients with this laboratory abnormality.
3. Paul Conomos presented 2 cases. One was a patient with a pericardial cyst and the other a subcarinal mass. Discussion centered on how to manage patients with asymptomatic subcarinal masses.
4. Cristian Jivcu presented a case of a left upper lobe 7 cm mass. Bronchoscopy with bronchoalveolar lavage was negative. The patient was followed with complete resolution.
5. Henry Luedy presented a 79 yo with an interstitial lung disease probably secondary to chronic aspiration for 5 years with complete radiologic resolution.
6. Joshua Jewell presented a case of pneumonia with empyema. Rather than decoritcation the patient was treated with thoracostomy drainage and TPA and DNAase with complete resolution over several weeks.
7. Manny Mathew followed with a similar case of a pleural effusion treated with TPA which also resolved. Discussion occurred on when it was appropriate to treat patients conservatively with chest tube drainage compared to aggressively with decortication.

There being no further business the meeting adjourned at 8:00 PM. The next meeting will be on Tuesday, February 21, 6:30 PM at Scottsdale Shea.

Richard A. Robbins, M.D.

Reference as: Robbins RA. January 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;4:4. (Click here for a PDF version of the Notes)