November 2018 Arizona Thoracic Society Notes

The November 2018 Arizona Thoracic Society meeting was held on Wednesday, November 28, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 10 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting  the Tobacco 21 bill was discussed. This bill has been twice held up in the Arizona House of Representatives Commerce Committee by the committee chairman. It was noted that one of the healthcare executives had financially supported the reelection campaign of the commerce committee chairman. A decision was made to send a letter to the healthcare executive pointing the pro-tobacco stance of the committee chairman. CME for the Arizona Thoracic Society meetings was also discussed. CME case presentations that had been previously approved will be presented and CME granted through the University of Arizona.

There were 3 case presentations:

1. Dr. Richard Robbins presented for Dr. Robert Raschke a case of a 54-year-old man with neck pain that eventually proved to be a paraspinous abscess.
2. Dr. Mike Gotway presented a 36-year-old woman who presented with respiratory failure. She eventually proved to have been self-injecting hydrocodone.
3. Dr. Lewis Wesselius presented a 28-year-old man from Tennessee with enlarging lung nodules who had been treated for presumed histoplasmosis, but was clinically worsening. Lung biopsy demonstrated metastatic angiosarcoma. 

The meeting was adjourned about 8:30 PM. The next meeting will be on January 23, 2019 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Cite as: Robbins RA. November 2018 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2018;17(6):149. doi: https://doi.org/10.13175/swjpcc119-18 PDF

July 2018 Arizona Thoracic Society Notes

The July 2018 Arizona Thoracic Society meeting was held on Wednesday, July 25, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 8 in attendance representing the pulmonary, critical care, sleep, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

• The dwindling attendance at these meetings. It was decided to again reach out to the pulmonary fellowship programs at Mayo, University of Arizona Phoenix and University of Arizona Tucson.
• The two recent cases of pharmacists refusing to dispense medications was discussed without coming to a consensus. One physician said he would refuse to submit prescriptions to the Peoria Walgreens.
• Discussion regarding the Tobacco 21 which had been killed in committee by Rep. Jeff Weninger was tabled until the next meeting.

There were 2 case presentations:

1. Dr. Lewis Wesselius presented a 67-year-old woman who had increasing shortness of breath. She was started on prednisone by another physician and her dyspnea improved although it recurred when her prednisone was tapered. Unfortunately, she gained 30 lbs. while on the prednisone. The patient did not smoke. She had a few crackles at her right base but otherwise the physical examination was normal. She desaturated with exercise. Her CT scan showed ground glass opacities with multiple small cysts. PFTs were restrictive with a DLCO of 55% of predicted. She was further questioned about additional symptoms and stated she had dry mouth and eyes for years. Rheumatology consultation was ordered, her SSP and SSA were both positive, and she had a diagnosis of Sjogren’s syndrome made. Because she was symptomatic it was thought she needed to treatment but she did not want to take prednisone again. For this reason, she was begun on mycophenolate.
2. Dr. Gerald Schwartzberg presented a 62-year-old man who was seen in the office with shortness of breath. Physical examination was normal and he had normal PFTs. He was admitted to the hospital a couple of weeks later after a trip with a pulmonary embolus. Discussion centered on when a CT angiogram should be ordered. There was a consensus that a CT-angiogram did not need to be done in all patients complaining of dyspnea but no consensus on criteria for whom it should be ordered.

The meeting was adjourned about 8 PM. The next meeting will be on September 26 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins MD

Editor, SWJPCC

Cite as: Robbins RA. July 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;17(1):41. doi: https://doi.org/10.13175/swjpcc095-18 PDF

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 

March 2017 Arizona Thoracic Society Notes

The March 2017 Arizona Thoracic Society meeting was held on Wednesday, March 22, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There 11 attendance representing the pulmonary, critical care, sleep, thoracic surgery and radiology communities.

There was a discussion of supporting the Tobacco 21 bill which had been introduced into the Arizona State Legislature. The bill was assigned to the House Commerce Committee but was not scheduled for a hearing by the Chair-Representative, Jeff Weninger from Chandler. It seems likely that the bill will be reintroduced in the future and the Arizona Thoracic Society will support the bill in the future.

Three cases were presented:

1. Dr. Bridgett Ronan presented a 57-year-old man with cough and shortness of breath. His physical examination and spirometry were unremarkable. A thoracic CT scan showed large calcified and noncalcified pleural plaques and mediastinal lymphadenopathy. A bronchoscopy showed some mild thickening and a cobblestone appearance of the LUL bronchus. Bronchoalveolar lavage was unremarkable. Biopsy of the LUL bronchus showed noncaseating granuloma. Discussion ensued of whether this was sarcoidosis. Most agreed that calcified pleural plaque-like lesions would be unusual for sarcoidosis and that further investigation with complete pulmonary function testing and perhaps VATS was warranted. Most favored not treating the patient empirically with corticosteroids.
2. Dr. Lewis Wesselius presented a 41-year-old man was referred because of cough, hemoptysis and recurrent pneumothorax. His thoracic CT showed scattered nodules, some cavitated, with surrounding ground glass opacities. He eventually came to open lung biopsy. A tentative diagnosis of Ehlers-Danlos was made. This will be the April 2017 Pulmonary Case of the Month (click to be directed to the case which will be posted on 4/1/17). Please see the entire case presentation for details and discussion.
3. Dr. Rick Robbins presented a case from Dr. Michael Gotway of a 48-year-old non-smoking woman with a history of hysterectomy and right oophorectomy, and cholecystectomy, otherwise previously healthy, who presented with a spontaneous pneumothorax. Her thoracic CT scan showed multiple small cysts. She also had follicular lesions on her face. Biopsy of the facial lesions revealed fibrofolliculomas, or hamartomas of the hair disc. Fibrofolliculomas with lung cysts are relatively specific for Birt Hogg Dubé syndrome. This case was the November 2015 Imaging Case of the Month (click to be directed to the full presentation). Please see the entire case presentation for details and discussion.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, May 24, 2017 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins, MD

Cite as: Robbins RA. March 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;14(3):125-6. doi: https://doi.org/10.13175/swjpcc038-17 PDF