June 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 6/26/2013 at Scottsdale Shea beginning at 6:30 PM. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, announced that the journal had begun using digital object identifiers (DOI) through the CrossRef service. In addition, the content of the journal will be stored in the CLOCKSS Archive.

The Mayo Clinic in Rochester has asked to partner with the Southwest Journal of Pulmonary and Critical Care. The Arizona Thoracic Society endorsed this association.

Rick Robbins is stepping down as the Arizona representative to the Council of Chapter (CCR) Representatives. Dr. George Parides was unanimously elected CCR representative.

Dr. Lewis Wesselius presented the case of an 80 year old Asian man with a history of the recent onset of cough, weight loss, headache and an abnormal chest x-ray. He was a nonsmoker. Physical exam revealed a thin man but was otherwise unremarkable.  Laboratory showed only an elevated erythrocyte sedimentation rate. CBC was normal. Chest x-ray showed increased right perihilar densities and a small right pleural effusion. CT scan showed areas of dense consolidation in the right upper and middle lobes. Bronchoscopy was performed. No bronchial abnormality was noted. However, the cultures grew Crytococcus. Lumbar puncture showed elevated protein, slightly low glucose and slightly increased lymphocytes. A CD4 count was performed and was low at 150 cells/mm3. HIV was negative.

It was felt he had idiopathic CD4 lymphocytopenia which is a severe CD4 T-cell depletion resulting in a predisposition to opportunistic infections (1). The epidemiologic data do not suggest that the condition is caused by a transmissible agent. Unlike HIV infection, the decrease in the CD4 cell counts is often slow. The clinical spectrum ranges from an asymptomatic laboratory abnormality to life-threatening opportunistic infections. There cause is unknown and there is no proven treatment.

There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, July 24, 6:30 PM in Tucson at the Kiewit Auditorium on the University of Arizona campus.  

Richard A. Robbins, M.D.

Reference

1. Luo L, Li T. Idiopathic CD4 lymphocytopenia and opportunistic infection--an update. FEMS Immunol Med Microbiol. 2008;54(3):283-9. [CrossRef] [PubMed]  

Reference as: Robbins RA. June 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;6(6):306-7. doi: http://dx.doi.org/10.13175/swjpcc085-13 PDF

April 2012 Arizona Thoracic Society Notes

The April 2012 Arizona Thoracic Society meeting was held on 4/17/2012 at Scottsdale Shea beginning at 6:30 PM. There were 19 in attendance representing the pulmonary, critical care, sleep, infectious disease, radiology, and nursing communities.

Discussions were held regarding moving the meeting to another day of the week to allow the Mayo pathologists to attend. It was decided to try and move the meeting to the third Wednesday of every month, pending availability of a meeting room at Shea.

Because this is an election year and members of Congress made themselves available, it was thought it might be reasonable to invite members of Arizona’s Congressional delegation to an Arizona Thoracic Society meeting in order to discuss issues important to the medical community.

Three cases were presented:

1. Dr. Timothy Kuberski, who has recently been named chief of infectious disease at Maricopa Medical Center, presented a case of a 52 year old Native American male who complained of cough. He was taking lisinopril for hypertension and type 2 diabetes. Chest x-ray showed multiple small pulmonary nodules. IgM was positive for coccidioidomycosis but IgG and urinary antigen for coccidioidomycosis were negative. HIV was negative. He complained of headache and CT scan revealed hydrocephalus. Because it was unclear if he had coccidioidomycosis or tuberculosis he was treated for both. Eventually he was shown to have tuberculous meningitis. He is now on 5 drugs for tuberculosis including INH, rifampin, PZA, streptomycin and Levaquin. A comment was made that miliary patterns in coccidioidomycosis appeared to only occur in immunocompromised hosts. No one could recall seeing one that was not.
2. Allen Thomas from the Phoenix VA presented a case of a 61 year old with increasing dyspnea, cough, occasional blood-streaked sputum, night sweats and 30 lb weight loss. He had a history of dipolar disease, diabetes and had recently been evaluated for an abdominal mass that was not identified. Dry crackles were noted on lung exam. Chest x-ray was remarkably similar to the previous presentation with multiple small nodules noted which were new compared to a chest x-ray 2 years previously. He had an elevated WBC with a left shift. Sputum cultures, coccidioidomycosis serology, and a tuberculosis skin test were all negative. Bronchoscopy with BAL and transbronchial biopsies was all nondiagnostic. For this reason a VATS was performed. Cultures and special stains for organisms were all negative. The biopsy slides were sent to the Mayo group and they diagnosed cryptogenic organizing pneumonia (COP). Dr. Thomas presented literature that a miliary pattern in COP had rarely been reported. The patient was improved on oral corticosteroids.
3. Rick Robbins, retired pulmonologist, presented a case of a 31 yo previously health woman who presented with nonproductive cough, dyspnea, fever and arthralgias over 3 weeks. She had been empirically treated with a course of Levaquin and a course of Biaxin without improvement. She presented to the ER with increasing dyspnea and was found to have a markedly elevated WBC of 49,000 and a platelet count of over 1 million. Her only medication was valproic acid for prevention of migraine headaches. Physical exam revealed a moderately dyspneic woman despite a non-rebreathing mask. Diffuse crackles were heard on auscultation of the lungs. Bronchoscopy with BAL and cultures was negative as were HIV, coccidioidomycosis, Legionella, and Mycoplasma titers. ANA, RF, histoplasma urinary antigen, and blood cultures were also negative. She was transferred to the ICU and required endotracheal intubation. Because her diagnosis was unclear, a VATS was performed which revealed acute inflammation with eosinophils. She was begun on steroids and rapidly improved. She eventually admitted to smoking crack cocaine just prior to her hospital admission. It was noted that the course and presentation of acute eosinophilic pneumonia was variable and has been associated with use of crack cocaine. It was mentioned that a case of acute eosinophilic pneumonia had appeared as the April 2012 Imaging Case of the Month.

There being no further cases, the meeting was adjourned at 8:00 PM. The next meeting is tentatively scheduled for May 15 but may be moved to a Wednesday.

Richard A. Robbins, M.D.

Reference as: Robbins RA. April 2012 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2012;4:114-5. (Click here for a PDF version of the Notes)