September 2018 Arizona Thoracic Society Notes

The September 2018 Arizona Thoracic Society meeting was held on Wednesday, September 26, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were representatives in attendance from the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting attendance was again discussed.

There were 3 case presentations:

1. Dr. Gerry Schwartzberg presented a case of a woman in her 70’s with diffuse cystic lung disease. She had a monoclonal gammopathy of undetermined significance due to light chain disease and the possibility of amyloidosis causing cystic lung disease was discussed.  
2. Dr. Lewis Wesselius presented a 28-year-old man from Tennessee with enlarging lung nodules who had been treated for presumed histoplasmosis, but was having hemoptysis and clinically worsening. Lung biopsy demonstrated metastatic angiosarcoma.  
3. Dr. Wesselius also presented a 44-year-old woman with diabetes and cavitary pulmonary coccidioidomycosis which involved both left upper lobe and left lower lobe which had progressed despite 400 mg/day of fluconazole who had been referred in 2012 for possible thoracotomy. Surgery was deferred since it would have required a left pneumonectomy. The fluconazole dose was increased, and cavity resolved gradually over 6 years.  This led to discussion of indications for surgery in cavitary coccidioidomycosis. 

The meeting was adjourned about 8 PM. The next meeting will be on November 28 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Lewis J. Wesselius, MD
President, Arizona Thoracic Society

Cite as: Wesselius LJ. September 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;17:116. doi: https://doi.org/10.13175/swjpcc109-18 PDF 

May 2014 Arizona Thoracic Society Notes

The May 2014 Arizona Thoracic Society meeting was held on Wednesday, 5/28/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep and radiology communities.

A discussion was held regarding the Arizona Thoracic Society relationship with the American Lung Association. Several members volunteered to talk to the lung association regarding common ground to strengthen the relationship.

The wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting was a big success. There were about 55 at the meeting. The tasting will probably be held again next year.

At the ATS meeting data was presented that pirfenidone was effective in reducing the progression of idiopathic pulmonary fibrosis (IPF). The data was published in the New England Journal of Medicine on 8/29/14 (1). Lewis Wesselius is one of the investigators enrolling patients in a phase 3 trial while InterMune reapplies to the FDA for approval of pirfenidone in IPF.

Two cases were presented:

1. Lewis Wesselius from the Mayo Clinic Arizona presented a 53 year old woman with a chronic, nonproductive accompanied by malaise and a modest weight loss. She was treated for asthma without improvement.  She was a nonsmoker and had a SpO2 of 98% on room air. Her lungs were clear to auscultation.  Routine laboratory evaluation was unremarkable and exhaled nitric oxide was normal. Thoracic CT scan showed a subtle broncholitis. She was empirically treated for gastroesophageal reflux disease (GERD) without improvement. Bronchoalveolar lavage was performed and showed Nocardia asteroides. She had no evidence of immunocompromise. She was treated with sulfamethoxazole and trimethoprim which produced a rash and then minocycline for 4 months. Her cough resolved. However, when the minocycline was stopped her cough returned. She is currently receiving an additional course of minocycline planned for 6 months.
2. Suresh Uppalapu presented a 58 year old fireman with a complaint of dyspnea on exertion. He has a history of obstructive sleep apnea and lives at an elevation of 7000 feet. The patient had significant desaturation with exercise. Chest x-ray showed borderline cardiomegaly but was otherwise normal. Thoracic CT scan showed pulmonary artery enlargement and borderline right ventricular (RV) enlargement. Ultrasound of the hear showed an enlarged RV but it was difficult to measure PA pressure.  Right-sided heart catherization showed a mean pulmonary artery pressure of 35 cm H2O with a  step up in the oxygen saturation at the right atrium. Transesophageal echocardiogram (TEE) showed a patent foramen ovale (PFO).  Insertion of a balloon stopped the right to left shunting but resulted in a significant increase in the pulmonary artery pressure. He was referred for percutaneous closure of the PFO along with treatment of his pulmonary artery hypertension.

There being no further business the meeting was adjourned about 8:15 PM. The June meeting is scheduled for Tucson. There will be no meeting in July. The next meeting in Phoenix will be a case presentation conference on August 27, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

Reference

1. King TE Jr, Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med 2014;370:2083-92. [CrossRef] [PubMed] 

Reference as: Robbins RA. May 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(6): 297-8. doi: http://dx.doi.org/10.13175/swjpcc072-14 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

March 2011 Arizona Thoracic Society Notes

A dinner meeting was held at Scottsdale Shea Medical Center on March 15, 2011 from 6:30-8:00 PM. Fifteen were in attendance including representatives from the pulmonary and chest radiology communities. A brief presentation was made by Rick Robbins of current ATS activities. Five cases were presented and discussed: 1. Gerald Swartzberg presented a case of a 73 year old with dyspnea and severe restrictive physiology but without evidence of pulmonary fibrosis. Discussion centered on sniff testing and the possibility of bilateral diaphragmatic paralysis. 2. Henry Luedy presented a case of a thoracic duct-cutaneous fistula draining lymph percutaneously. The patient was not considered a surgical candidate and radiologic evaluation and nonsurgical interventions were discussed. 3. George Parides presented a case of a 47 year old with shrinking lung nodules and microscopic hematuria. Discussion centered on microscopic polyangitis and the most expeditious diagnostic tests. 4. George Parides presented a second case of a 79 year old who is asymptomatic but with an incidental finding of scattered lung nodules. Discussion centered on atypical mycobacterium and the necessity of diagnosis versus observation.  5. John Roehrs presented a case of a 53 year old woman with dyspnea and mild pulmonary hypertension discovered to have a patent foramen ovale. Discussion centered on management including correction and anticoagulation.

Richard A. Robbins, MD