November 2016 Arizona Thoracic Society Notes

The November 2016 Arizona Thoracic Society meeting was held on Wednesday, November 17, 2016 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Two cases were presented:

1. Dr. Lewis Wesselius presented a case of a 29-year-old man from India on a work visa who complained of right pleuritic pain. Chest x-ray showed a large right pleural effusion. CT scan confirmed the presence of effusion with minimal lung parenchyma changes or mediastinal adenopathy. Gold quantiferon was positive and coccidioidomycosis serology was negative. Thoracentesis showed a lymphocytic predominant effusion and adenosine deaminase was borderline high. No acid-fast bacilli (AFB) were seen in the fluid. PCR for M. tuberculosis was negative. The pleural biopsy did show AFB and eventually grew M. tuberculosis. The patient was started on a 4 drug regimen. Dr. Wesselius gave a short presentation on the sensitivity of the various diagnostic tests for M. tuberculosis.
2. Dr. Richard Robbins presented the case of a 45-year-old Iraqi war veteran who was referred for COPD based on abnormal blood gases. The arterial blood gases showed a PaO2 40 mm Hg, PaCO2 82 mm Hg, pH 7.12, HCO3 34 mEq/L, and SaO2 76. The patient was diagnosed with hypoventilation probably secondary to narcotic abuse which he took for chronic back pain. He was admitted to the ICU but unfortunately administered high flow oxygen and was intubated. He was subsequently given naloxone but became awake and combative. After sedation and small doses of morphine, he was quickly liberated from mechanical ventilation, transferred to the floor and discharged. He did complain to the patient advocate on discharge about the smaller doses of narcotics he was give. A discussion followed regarding narcotic abuse, patient satisfaction, and mortality.

Dr. Parides has been approached regarding having the Arizona Thoracic Society meetings at Select Hospital in Scottsdale. In addition, he has been in contact with Dr. Rajeev Saggar at Banner University Medical Center Phoenix regarding having Arizona Thoracic Society meetings with a video link to Tucson.

Dr. Parides presented a plaque to Dr. Lewis Wesselius who is the Arizona Thoracic Society clinician of the year (Figure 1).

Figure 1. Dr. George Parides (left) presented a plaque to Dr. Lewis Wesselius as Arizona Thoracic Society Clinician of the Year.

A discussion was held regarding the recent American College of Graduate Medical Education (ACGME) decision to allow first year house officers to work 28 hours while on call rather than 16 (1). This is based on a study published in the New England Journal of Medicine in February, 2016 (2). After much discussion, a motion was made by Dr. Parides and seconded by Dr. Alp Umar to draft a letter to the ACGME during this public comment period favoring that ACGME decisions on resident work hours being made on data rather than emotion or politics.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, January 25, 2016 at 6:30 PM location to be announced prior to the meeting.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Robbins RA. ACGME proposes dropping the 16 hour resident shift limit. Southwest J Pulm Crit Care. 2016;13(5):216-7. [CrossRef]
2. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016 Feb 25;374(8):713-27.  [CrossRef] [PubMed]

Cite as: Robbins RA. November 2016 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2016;13(5):246-7. doi: https://doi.org/10.13175/swjpcc119-16 PDF 

October 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 10/24/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

An announcement was made that the Colorado Thoracic Society has accepted an invitation to partner with the Arizona and New Mexico Thoracic Societies in the Southwest Journal of Pulmonary and Critical Care Medicine.

Discussions continue to be held regarding a combined Arizona Thoracic Society meeting with Tucson either in Casa Grande or electronically.

Six cases were presented:

Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 48 year old female who had been ill for 2 weeks. A CT of the chest revealed a left lower lobe nodule and a CT of the abdomen showed hydronephrosis and a pelvic mass. Carcinoembryonic antigen (CEA) was elevated. All turned out to be coccidioidomycosis on biopsy.  CEA decreased after the pelvic mass was resected.

Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a 60 year old man with a past medical history of a transbronchial biopsy showing nonspecific interstitial lung disease. CT scan showed bilateral hilar lymphadenopathy and multifocal ground glass opacities. Multiple serologies were all negative. Biopsy revealed both hypersensitivity pneumonitis and sarcoidosis. It was pointed out by Drs. Michael Gotway and David August that the usual presentation of sarcoidosis in the lung is bilateral lymphadenopathy with multiple small nodules in a peribronchovascular distribution along with irregular thickening of the interstitium. Although multifocal ground glass opacities have been reported with sarcoidosis, it is unusual.

Dr. George Parides presented two cases of patients with rheumatoid arthritis receiving biologic therapy. One presented with a positive QuantiFERON test for tuberculosis and the other with a positive PPD. Management was discussed. None were aware of any data but the majority thought that stopping the biologics, if possible, and treating with INH for 9 months was probably appropriate.

Dr. Colby presented a second case of a 52 year old heavy smoker with shortness of breath while playing basketball. Chest CT showed ground glass opacities with minimal fibrosis. A lung biopsy showed various areas consistent with desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease or nonspecific interstitial pneumonitis with scarring.  Dr. Colby stated that smokers with interstitial disease can have different patterns on biopsy. Drs. Gotway and August pointed out that the lung CT pattern is also often heterogenous.

Dr. Lewis Wesselius presented a 49 year old female admitted for hypoxia, lethargy, and an abnormal chest x-ray. She had a prior diagnosis of systemic lupus erythematosis (SLE) with a reported diagnosis of lupus pneumonitis made 3-4 years ago. There was a history of multiple episodes of pneumonia (25 in 5 years), a prior stroke and mitral valve disease with valve replacement. Chest CT showed multiple areas of ground glass opacities and bronchoscopy with bronchoalveolar lavage resulted in a bloody return. Serologies were inconsistent with SLE but anti-phospolipid antibodies were present. Dr. Wesselius reviewed antiphospholipid antibody syndrome (APS) which can occur as a primary condition or in the setting of an underlying systemic autoimmune disease such as SLE. Manifestations include deep venous thrombosis (32%), thrombocytopenia (22%), livedo reticularis (20%), stroke (13%), pulmonary embolus (9%), fetal loss (8%), transient ischemic attack (7%), hemolytic anemia (7%), and rarely alveolar hemorrhage. Treatment includes high dose corticosteroids, cyclophosphamide, mycophenolate, IVIG, and plasmapharesis. A recent report (Lupus 2012, 21:438-40) advocated Rituximab, a chimeric monoclonal antibody against the protein CD20, which is primarily found on the surface of B cells, for recurrent diffuse alveolar hemorrhage in primary APS.

There being no further business, the meeting was adjourned. The next meeting is November 28 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. October 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:218-9. 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)