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 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 5/15/2013 at Scottsdale Shea beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep, thoracic surgery, and radiology communities.

Dr. George Parides will have served his 2 year tenure as Arizona Thoracic Society President by July, 2013. However, he will be unable to attend the June meeting and for this reason Presidential elections were held. Dr. Lewis Wesselius was nominated and unanimously elected as President.

Three cases were presented:

1. Dr. Gerald Schwartzberg presented the case of a 49 year old woman with a history of Valley Fever in 2009. She was a nonsmoker and had no other known medical diseases.  However, she developed shortness of breath beginning earlier this year along with a cough productive of clear, jelly-like sputum. Her physical was normal. Pulmonary function testing revealed restrictive disease with significant improvements in the FEV1 and FVC after bronchodilators.  Eosinophils were increased in her CBC at 12%. IgE was moderately increased at 286 IU/ml.  Chest x-ray was normal. A high resolution thoracic CT scan revealed scattered bronchiectasis and mucoid impaction.  Some speculated that this could be a case of allergic bronchopulmonary aspergillosis (ABPA) although all agreed that the level of IgE was lower than commonly occurs with ABPA. It was felt that an Aspergillus specific IgE might be useful. It was also suggested that the coccidiomycosis might have caused the bronchiectasis, noting that mycosis other than Aspergillus sp. may cause the syndrome similar to ABPA which has been termed allergic bronchopulmonary mycosis.
2. Dr. Jud Tillinghast presented a case of 45 year old woman who worked as a nurse practioner. She had developed rheumatoid arthritis a few years earlier and was being treated with plaquenil and steroids. Recently she had developed shortness of breath. A few squeaks were normal on auscultation of the lungs. Pulmonary function testing was normal. However, a thoracic CT scan revealed a mosaic pattern consistent with air trapping. An open lung biopsy was performed and was consistent with constrictive bronchiolitis. The biopsy did not show inflammation but obliteration of the small bronchioles. Considerable discussion centered on treatment with most agreeing that there were no known efficacious treatments. 
3. Dr. Allen Thomas presented a case of a 72 year old man with 2 small pulmonary nodules discovered incidentally in Northern California. However, at the time of discovery he was in the process of moving to Arizona and presented a year later. Follow up thoracic CT scan revealed multiple small nodules and mediastinal nodes. Mediastinoscopy revealed noncaseating granulomas. A repeat CT showed that the mediastinal nodes have resolved but the nodules persisted. A PET scan showed markedly enhanced uptake by the nodules and in the mediastinum raising a question of carcinoma. Most felt that this was likely a manifestation of sarcoidosis and not necessarily an indication of cancer.

There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, June 26. The July meeting will be in Tucson on July 24^th at 6:30 PM. Location to be determined.  

Rick Robbins

Arizona CCR Representative

Reference as: Robbins RA. May 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2013;6(5):237-8. PDF