May 2012 Arizona Thoracic Society Notes

The May 2012 Arizona Thoracic Society meeting was held on 5/16/2012 at Scottsdale Shea beginning at 6:30 PM. Attendees representing the pulmonary, critical care, sleep, infectious disease, radiology, and nursing communities were present.

This was the first meeting on Wednesday. The meetings will usually be held the last Wednesday of every month, pending availability of a meeting room at Shea and conflicts with holidays.

Congressman David Schweikert has accepted an invitation to speak at the Arizona Thoracic Society. Because of the Congressman’s schedule, it was decided to hold a special meeting on 8/8. The August meeting scheduled for 8/29 was to go on as planned.

Six cases were presented:

1. Dr. Timothy Kuberski: An African-American male presented with knee pain. Chest radiography showed a very subtle opacity over the left upper chest, not clearly intraparenchymal. Thoracic CT showed a fluid collection centered around the left sternoclavicular joint and costomanubrial junction, extending medially into the superior mediastinum, posteriorly into the thorax (but remaining extraparenchymal and extrapleural), into superficially into the left pectoralis musculature. This focus showed low attenuation, consistent with abscess. The abscess was drained, and contrast injection through the catheter showed that all the aforementioned spaces were in communication with one another, with cranial extension into the left lower neck. No organisms could be recovered from this collection, but pneumococcus was recovered from aspiration of the knee fluid and blood. There was speculation that the chest wall lesion could be related to actinomycosis, but testing this far has not revealed this organism.
2. Gerry Schwartzberg presented two cases of coccidioidomycosis on chest radiography, one of which produced a pleural effusion in a Filipino man. The organism was not isolated from the thoracentesis fluid, but Judd Tillinghast noted he once had similar case that underwent video-assisted thoracoscopic surgery that showed pleural surface plaques containing the organism.
3. Tom Colby presented two cases: A 39-year-old woman presented with chest pain and lymphadenopathy in the thorax. Reportedly, multiple fine needle aspiration biopsies were non-diagnostic. Evaluation for immunodeficiency and autoimmune disease was unrevealing. Thoracic CT initially showed a mass-like opacity in the right lower lobe, possibly with peribronchial lymphadenopathy and areas of patchy ground-glass opacity. A small pleural effusion was also present, as was smooth interlobular septal thickening. The patient presented later with hemoptysis and pleuritic chest pain. Repeat thoracic CT showed a complex cystic mass in the right lower lobe, arising in the area of mass-like opacity seen previously. The patient underwent right lower lobectomy. The final diagnosis was pulmonary lymphangioma with rupture into a bronchus, allowing the lesion to become air-filled.
4. Dr. Colby also presented a case of a 28-year-old man presented with a right lower lobe mass and dyspnea. He was a non-smoker, with a history of asthma requiring multiple hospitalizations as a child as well asteroid use. He noted several episodes of “bronchitis” every year as an adult. His pulmonary function testing showed mild reversible obstruction. A PET scan reportedly showed increased uptake (maximum standard uptake value of 8) in the right lower lobe mass. Bronchoscopy was reportedly unrevealing, but sputum cultures did show normal flora and 1 colony of Aspergillus. His thoracic CT showed an area of consolidation in the superior segment of the right lower lobe tracking along the bronchovascular bundle; the superior segment bronchus could not be visualized at all. Review of the pathology showed goblet cell hyperplasia, Charcot-Leyden crystals, allergic mucin, bronchiocentric granulomatosis, and eosinophilic pneumonia. The patient was subsequently diagnosed with allergic bronchopulmonary aspergillosis.
5. Al Thomas presented a case of a patient who underwent chest radiography and was diagnosed with a “narrowed” trachea, which prompted thoracic CT. The narrowed trachea simply represented a “saber sheath” trachea”, but a focal opacity was noted along the posterior tracheal wall. The patient underwent bronchoscopy, which showed a verrucous lesion along the posterior tracheal wall with a “fish egg” appearance. Biopsies subsequently showed the lesion to represent squamous papilloma.
6. A case was presented of an older woman presented with a history of aspirating a calcium pill. Due to social factors, she delayed presenting to her physician (she wanted to attend a relative’s wedding). Thoracic CT sowed a high density structure, consistent with a calcium tablet, in the bronchus intermedius. The tablet was easily removed with bronchoscopic retrieval, but review of the coronal images on CT showed two tablets adjacent to one another (the patient did not remember aspirating the first tablet). The second tablet was much more difficult to remove, requiring over one hour. Extensive discussion regarding various methods for bronchoscopic removal of airway foreign bodies took place. Al Thomas concluded that a loop snare provides the best results.

There being no further cases, the meeting was adjourned at 8:00 PM. The next meeting is scheduled for Wednesday, June 27.

Michael B. Gotway, M.D.

Vice President

Arizona Thoracic Society

Reference as: Gotway MB. May 2012 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2012;4:174-6. (Click here for a PDF version of the Notes)

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)

March 2012 “Hill Day” and Council of Chapter Representatives Meeting Notes

As part of “Hill Day” the Council of Chapter Representatives meant on March 28-29, 2012 in Washington, D.C.

The meeting began with a bus trip to the Rayburn House Office Building at 7 AM sharp on Wednesday. A breakfast meeting was held with presentations by one of the ATS lobbyists, Gary Ewart; Rep. Jim McDermott (D, WA), a former psychiatrist, on the Affordable Care Act (ACA); and representatives from the EPA and AMA.

Richard Robbins, Arizona CCR representative, and Ann Schneidman, RN from Hospice of the Valley, along with Dale Dirks from the ATS and Dr. Christine Fukui from Hawaii traveled to the Congressional offices. The group met with several representatives from the Arizona Congressional Delegation including:

• Rep. Ben Quayle (R-AZ-3) and Rachel Dresen, Rep. Quayle’s legislative director
• Rep. Raúl Grijalva (D-AZ-7) and Kelsey Mishkin, Rep. Grijalva’s legislative assistant
• Cassie Sonn, legislative assistant office of Rep. David Schweikert (R-AZ-5)
• Judith Gheuens, health counsel to the office of Sen. Jon Kyl (R-AZ)
• Greg Kuhn, legislative correspondent office of Sen. John McCain (R-AZ)

Four issues were discussed and ATS handout on each was presented:

• Medicare Sustainable Growth Rate (SGR) (click here for ATS handout)
• Clean Air Act (click here for ATS handout)
• Lung Disease Research Funding (click here for ATS handout)
• VA Research Funding (click here for ATS handout)

The Council of Chapter Representatives (CCR) met on Thursday, March 29. Nine attendees and 3 ATS staff were in attendance with one representative participating by conference call. The meeting was called to order at 9:00 AM by Dona Upson, Chair CCR.

The ATS President’s address was given by Nick Hill, ATS President 2011-2. His remarks included a discussion of ATS goals including the ATS’ new emphasis on advocacy.

An advocacy update was presented by Gary Ewart, ATS Government Relations.  

Eric Yeager, from Colorado, was selected for the ATS Outstanding Clinician Award for 2012. Our own Al Thomas was one of the finalists along with Mitchell Rashkin from Ohio.

CCR business discussions included:

• Committee Updates
• CCR Representatives on Committees for 2012-3
• A report from Dona Upson on the new requirements for recertification by the American Board of Internal Medicine (not yet announced) which will take effect on January, 2013. ATS is striving to meet those requirements beginning with the ATS 2012 International Meeting.
• Renaming of Wegner’s granulomatosis
• An announcement that it will shortly be possible for members to change their identifier information (telephone, address, e-mail, etc.) on the ATS website.

The meeting was adjourned at 11:30 AM.

Richard A. Robbins, MD

Arizona, CCR Representative

Reference as: Robbins RA. March 2012 "Hill Day" and Council of Chapter Representatives meeting notes. Southwest J Pulm Crit Care 2012;4:69-70. (Click here for PDF version)

March 2012 Arizona Thoracic Society Notes

The March 2012 Arizona Thoracic Society meeting was held on 3/20/2012 at Scottsdale Shea beginning at 6:30 PM. There were 21 in attendance representing the pulmonary, allergy, radiology, and thoracic surgery communities.

Dr. Allen Thomas, the Arizona nominee for ATS Clinician of the Year, was recognized. Voting for will be on 3/29/2012 at the ATS Council of Chapter Representatives meeting in Washington, D.C.

Multiple cases were presented:

1. Dr. George Parides presented a case of 46 year old female who complained of mild shortness of breath. A chest x-ray revealed a large left pleural effusion. Thoracentesis showed that the fluid was an exudate but cytology and cultures were negative. A repeat chest x-ray showed a large left lower lobe mass and a CT scan showed a 24X21 cm mass in the left lower chest. Surgical resection was performed and was a benign fibrous tumor of the pleura on histology. Discussion ensued that there have been several of these reported at the Arizona Thoracic Society and perhaps these are not as rare as commonly thought. Rick Helmers pointed out that these tumors can be associated with hypoglycemia.

2. Gerald Swartzberg presented on diaphragmatic paralysis. The initial sniff test had been negative but a repeat was positive. Discussion ensued about the sensitivity and specificity of the sniff test. Although no one could recall specific numbers, most thought that the sniff test was fairly good. This evolved into a discussion of the usefulness of diaphragmatic placation (render the flaccid hemidiaphragm taut by oversewing the membranous central tendon and the muscular components of the diaphragm) and how long to wait for phrenic nerve generation before performing placation.

3. John Roehrs presented a case of 75 yo rock miner from Globe who had very severe oxygen dependent COPD and pulmonary hypertension. He was found to have a lung nodule which was followed and increased in size after 6 months and was now 2 cm. PET scan showed the nodule to have increased uptake of about 2.8 SUV. Treatment of the patient was extensively discussed. Most thought that an operative intervention was contraindicated because of his COPD and pulmonary hypertension. Obtaining a coccidioidomycosis serology was suggested although most thought this likely a lung cancer. Following the patient without intervention was suggested by most.

4. Dr. Swartzberg presented a second case of a 32 year old Filipino man who was referred by a dermatologist had biopsied a skin lesion on the chest and found coccidioidomycosis. He was treated for 6 months with fluconazole and the coccidioidomycosis complement fixation tests had been 1:2 to 1:4. Al Thomas pointed out that he had seen several patients with apparent direct inoculation into the skin. Discussion ensued about how long to treat coccidioidomycosis in this situation. Although there was agreement that there was no data available, most advocated longer rather than shorter treatment.

There being no further cases, the meeting was adjourned at 8:00 PM. The next meeting is scheduled for April 17.

Richard A. Robbins, M.D.

Reference as: Robbins RA. March 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;4:67-8. (Click here for a PDF version of the Notes)

February 2012 Arizona Thoracic Society Notes

The February Arizona Thoracic Society meeting was held on 2/21/2012 at Scottsdale Shea beginning at 6:30 PM. There were 25 in attendance representing the pulmonary, radiology, and thoracic surgery communities.

A presentation on elevated IgE was given by Dr. Cristian Jivcu a second year pulmonary fellow at the Good Samarian/VA program to follow up the two cases presented last month Dr. Swartzberg. (Click here for the slides used in the presentation)

Multiple cases were presented:

Dr. Gerald Swartzberg presented two cases. The first was an 86 yo with an enlarging mass in the right lower chest. Biopsy had previously revealed the mass to be a benign spindle cell tumor. There was no invasion of the chest wall or evidence of metastases consistent with the tumor’s benign pathology. Despite the tumor appearing to occupy nearly ¼ of the lower chest, the patient was asymptomatic. Most continued observation although thoracic surgery thought it could be safely debulked.

The second case presented by Dr. Swartzberg was a 58 yo with a pulmonary embolism who had been anticoagulated for 6 years. Unfortunately, the patient had a recurrent embolism after the anticoagulation was stopped. The patient is now back on anticoagulation and asymptomatic but had a removable inferior vena cava filter placed. Discussion centered on whether it was appropriate to remove the filter. None knew of a randomized trial and no consensus could be reached.

Dr. Cristian Jivcu presented a case of a 52 yo patient with ulcerative colitis who initially presented at another VA with shortness of breath and fever. Work up eventually resulted in VATS lung biopsy which revealed organizing pneumonia. The patient was started on corticosteroids and transferred to the Phoenix VA where he was admitted and became increasingly short of breath. CT scan revealed a “reverse halo” sign. A routine blood gas detected 12% methemoglobin. At that time it was discovered the patient had been started on dapsone for PCP prophylaxis. The symptoms improved when the dapsone was stopped.

Dr. Syed Zaidi presented two cases from Maricopa Medical Center. The first was a 36 yo with a 2 week history of cough and fever. Chest X-ray was thought to be abnormal in the right lower chest and for this reason a CT scan was ordered. An interlobar pulmonary sequestration was discovered with the blood supply arising from below the diaphragm. Discussion centered on whether the sequestered lung should be removed.

Dr. Zaidi’s second case as a 23 yo with AIDS and a past medical history of pneumocystis pneumonia, Kaposi’s sarcoma and Candida infection who presented with severe cough. CT scan showed adenopathy in the mediastinum and scattered groundglass opacities. Bronchoscopy showed an ulcerating mass in the right bronchus intermedius. Biopsy revealed Mycobacterium avium-intracellulare. Dr. Zaidi’s literature review revealed that endobronchial lesions secondary to M. avium-intracellulare had previously been reported in AIDS and other immunocompromised patients.  

There being no further business the meeting adjourned at 8:00 PM. The next meeting will be on Tuesday, March 20, 6:30 PM at Scottsdale Shea.

Richard A. Robbins, M.D.

Reference as: Robbins RA. February 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;4:40-1. (Click here for a PDF version of the Notes)