January 2012 Arizona Thoracic Society Notes

The January Arizona Thoracic Society meeting was held on 1/11/2012 at Scottsdale Shea beginning at 6:30 PM. There were 30 in attendance representing the pulmonary, radiology, thoracic surgery and allergy communities.

Al Thomas was voted to be clinician of the year nominee from Arizona.

A progress report for 2011 was given by Rick Robbins on the Southwest Journal of Pulmonary and Critical Care (for a summary of the presentation click here).

Multiple cases were presented:

1. George Parides presented a 64 year old with a second PPD which was positive. A discussion regarding interpretation of PPDs ensued.
2. Gerald Swartzberg presented two cases-both had in common a markedly elevated IgE level. These cases created a discussion of the differential diagnosis of an elevated IgE and how to approach patients with this laboratory abnormality.
3. Paul Conomos presented 2 cases. One was a patient with a pericardial cyst and the other a subcarinal mass. Discussion centered on how to manage patients with asymptomatic subcarinal masses.
4. Cristian Jivcu presented a case of a left upper lobe 7 cm mass. Bronchoscopy with bronchoalveolar lavage was negative. The patient was followed with complete resolution.
5. Henry Luedy presented a 79 yo with an interstitial lung disease probably secondary to chronic aspiration for 5 years with complete radiologic resolution.
6. Joshua Jewell presented a case of pneumonia with empyema. Rather than decoritcation the patient was treated with thoracostomy drainage and TPA and DNAase with complete resolution over several weeks.
7. Manny Mathew followed with a similar case of a pleural effusion treated with TPA which also resolved. Discussion occurred on when it was appropriate to treat patients conservatively with chest tube drainage compared to aggressively with decortication.

There being no further business the meeting adjourned at 8:00 PM. The next meeting will be on Tuesday, February 21, 6:30 PM at Scottsdale Shea.

Richard A. Robbins, M.D.

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

November 2011 Arizona Thoracic Society Notes

The November Arizona Thoracic Society meeting was held on 11/8/2011 at Scottsdale Shea beginning at 6:30 PM. There were 22 in attendance representing the pulmonary and radiology communities.

Three cases were presented:

1. Henry Luedy, a pulmonary fellow from Good Samaritan/VA, presented a case of Lemiere’s disease. Lemierre's disease is a form of thrombophlebitis usually caused by Fusobacterium and usually affects young, healthy adults. Lemierre's disease develops most often after a sore throat caused by some bacterium of the Streptococcus genus has created a peritonsillar abscess. Deep in the abscess, anaerobic bacteria which are part of the normal oral flora such as Fusobacterium can flourish. These anaerobic bacteria penetrate from the abscess into the neighboring jugular vein in the neck and there they cause sepsis or septic emboli.

2. Alexis Christie, a pulmonary fellow at the Mayo Clinic, presented an unusual case of pulmonary embolism. Discussion centered on unusual presentations of pulmonary embolism.

3. Rick Robbins presented a case of lymphocytic interstitial pneumonia developing in a man with long standing systemic lupus erythematosis.

At the end of the case presentations, George Parides was elected the new Arizona Thoracic Society president. He thanked the outgoing president, Rick Helmers, for his service. Rick will be leaving for Chicago at the end of November.

A discussion of the goals and objectives of the Arizona thoracic society ensued. Jud Tillinghast raised the possibility of an educational meeting involving physicians with interest in pulmonary, critical care and sleep medicine throughout the Southwest. Many thought such a meeting might be valuable. Dr. Robbins will contact members of the pulmonary community and determine if there is any interest.

There being no being further business the meeting was adjourned at 7:45. The next meeting is scheduled for Wednesday, January 11, 2012, at Scottsdale Shea. Meetings are scheduled for 10 months of 2012 as follows:

Wednesday, January 11

Tuesday, February 21

Tuesday, March 20

Tuesday, April 17

Tuesday, May 15

Tuesday, June 19

No meeting in July

Tuesday, August 21

Tuesday, September 18

Tuesday, October 16

Tuesday, November 20

No meeting in December.

Richard A. Robbins, M.D.

October 2011 Arizona Thoracic Society Notes

The October Arizona Thoracic Society meeting was held on 10/18/2011 at Scottsdale Shea beginning at 6:45 PM. There were 17 in attendance representing the pulmonary and radiology communities.

Prior to the case presentations, a discussion was initiated by Ewa Lupa-Laskus regarding the usefulness of procalcitonin, particularly in the ICU. The consensus of the group was that, although it was of moderate sensitivity and specificity, it added to the armamentarium for clinical decision-making, particularly regarding continuing or stopping antibiotics. Numerous physicians reported difficulty in getting laboratories to run the test. Strategies were discussed regarding how to obtain this test sufficiently quickly to be clinically useful.

It was discussed why the attendance was low. Part of this was attributed to cancellation of the September meeting because of a last moment loss of sponsorship. However, we now have sponsorship through 2012. It was felt that an e-mail reminder, either the day before or the day of the meeting, might improve attendance. Also, a newsletter summarizing the meeting, publications in the Southwest Journal of Pulmonary and Critical Care, appropriate announcements, etc were thought to be good ideas. This will be distributed by e-mail through Mary Kurth.

Two cases were presented by Lewis Wesselius from the Mayo Clinic:

A 22-year-old woman was referred after developing respiratory failure over 2 weeks. She was intubated because of respiratory failure. Thoracic CT revealed “crazy paving,” which is characteristic finding in pulmonary alveolar proteinosis (PAP). It consists of patchy, bilateral geographic areas of ground-glass opacity associated with interlobular septal thickening. Although the CT scan was suggestive, it was not diagnostic of PAP but a prior lung biopsy was consistent with the diagnosis. For this reason the patient underwent whole lung lavage and was begun on GM-CSF. She improved, was extubated and discharged from the hospital. A serum anti-GM-CSF antibody returned positive. Although she improved, she was unable to continue the GM-CSF therapy because for financial reasons.  She had recurrence of her disease requiring lung lavage but did not improve to the extent she had previously. Discussion centered on diagnosis and management of PAP.

2.   A late middle-aged man with an incidental finding on chest x-ray

A 61-year-old man was seen in the ER because of chest pain. This was not cardiac in origin and spontaneously resolved. Pulmonary function testing revealed a reduction in the DLCO and a thoracic CT for pulmonary embolism showed typical crazy paving. Lung biopsy was typical of PAP.  Although GM-CSF therapy was offered, the patient refused because he was asymptomatic. His DLCO spontaneously improved, follow up thoracic CT showed improvement in ground-glass opacity and associated interlobular septal thickening, and he remains well without therapy.

At the end of the case presentations, George Parides presented a plaque to the president of the Arizona Thoracic Society, Rick Helmers, thanking him for his service. Rick will be leaving for Chicago at the end of November.

There being no being further business the meeting was adjourned at 7:45. The next meeting is scheduled for Tuesday, November 8, at Scottsdale Shea.

Richard A. Robbins, M.D.

Michael B. Gotway, M.D.

August 2011 Arizona Thoracic Society Notes

The August Arizona Thoracic Society was held on 8/16/2011 at Scottsdale Shea beginning at 6:55 PM. There were 25 in attendance representing the pulmonary, radiology, and surgery communities.

Nine cases were presented:

1. Spontaneous Pneumothorax Secondary to Aspergilloma

Jud Tillinghast and Michael Caskey presented a case of a 65-year-old man with right upper lobe pneumonia on chest x-ray who was asymptomatic. Repeat chest x-ray showed resolution of the pneumonia, however, shortly afterwards he presented with a large right pneumothorax. CT scan of the chest showed right apical cystic changes and some areas of ground glass densities in the right upper lobe. A video-assisted thoracotomy was performed and a whitish fibrotic mass was viewed at the right apex. This was resected. Pathology revealed Aspergillus species. The patient was placed on voriconazole and made an uneventful recovery.  Drs. Tillinghast and Caskey hypothesized that one of the cystic lesions at the right apex developed an Aspergilloma and eventually ruptured causing the pneumothorax. A discussion of how long to continue the voriconazole ensued.

2. Young Woman with Hypoxemia and Hemoptysis.

Paul Conomos presented a second case of a 21-year-old woman who presented with shortness of breath, cough and hemoptysis. Her SpO2 was 87% and a CXR revealed a left lung tubular-shaped density with an enlarged left pulmonary artery. CT angiography showed several large arteriovenous (AV) malformations in the left lower lobe with several smaller lesions. The lesion was successfully embolized by coiling and the patient’s SpO2 improved to 98%.

3. Chest Masses in Identical Twins.

Dr. Conomos presented a second case of a 71-year-old woman found to have an approximate 5 cm right upper lobe mass with smaller right upper and left lower lobe nodules Biopsies of the larger right upper lobe mass and the left lower lobe nodule both revealed adenocarcinoma. Shortly thereafter, the patient’s identical twin also presented with a right middle lobe nodule- also adenocarcinoma (with bronchioloalveolar features), as well as several other suspicious-appearing pulmonary nodules, 

4. Slowly Growing Lung Mass.

Dr. Conomos presented a third case of a right lower lobe mass which was slightly enlarged compared to a previous chest x-ray in 2006. Positron emission tomography (PET) scanning showed a standardized uptake value (SUV) of 26. Needle biopsies were twice nondiagnostic. Resection revealed inflammatory  myofibroblastic tumor, also known as an inflammatory pseudotumor or plasma cell granuloma.

5. Severe Bronchiolitis Obliterans (Swyer-James Syndrome) in a 33-Year-Old.

David August presented the case of a 33-year-old man who complained of cough and had localized left upper lobe cystic bronchiectasis on chest x-ray. CT scanning also revealed left lower pulmonary artery atresia or obliteration. Discussion focused on the association of the pulmonary artery atresia / obliteration and the focal bronchiectasis.

6. Innumerable Pulmonary Cysts.

Henry Leudy and Allen Thomas presented a 63-year-old pipe smoker with a previous history of anal carcinoma who became short of breath after borrowing some bad tobacco from a friend. Chest x-ray revealed innumerable pulmonary cysts, as did thoracic CT. Images of the lung bases obtained from an abdominal CT performed in 2007 when the patient underwent resection of a 9 cm anal adenocarcinoma was unremarkable. Transbronchial biopsy showed adenocarcinoma consistent with metastatic disease. Most felt this was a very unusual radiographic appearance for metastatic disease.

7. Calcification Within a Carcinoid Tumor.

Dr. Thomas presented a second case of a 57-year-old with a tubular mass with calcification Bronchoscopy revealed a fleshy tumor in the right lower lobe bronchus which proved to be carcinoid on histological examination. Dr. Thomas presented a series that calcification was not unusual in carcinoid tumors.

8. Anti-Inflammatory Therapy for Radiation Pneumonitis.

Thomas Ardiles presented a case of a 72-year-old man who developed cough while receiving radiation therapy for mesothelioma.  His chest x-ray was compatible with radiation pneumonitis and he was begun on high dose prednisone. However, he developed mental status changes and was begun on azathioprine as the steroids were tapered without improvement. He was subsequently begun on azithromycin because of the drug’s anti-inflammatory effects with resolution of his symptoms.

9. Multiple Lung, Soft Tissue and Brain Lesions in a Patient Receiving Interferon for Hepatitis B.

Dr. Ardiles presented a second case of a 31-year-old that developed multiple bilateral small lung nodules and some scattered cutaneous and subcutaneous nodules which were noted on CT scanning. Two months later a follow up CT showed some resolution of the nodules, but most were unchanged. However, because he was complaining of headaches, brain MRI was performed and showed multiple small lesions also. Biopsy of one of the soft tissue lesions revealed cysticercosis which is due to the eggs of Taenia solium, the pork tapeworm.

The meeting adjourned at 8:30 PM.

Richard A. Robbins, MD

June 2011 Arizona Thoracic Society Notes

The June Arizona Thoracic Society was held on 6/21/2011 at Scottsdale Shea beginning at 6:55 PM. There were thirteen in attendance representing the pulmonary, radiology, and surgery communities.

Five cases were presented:

1. Jon Ruzi presented a case of an intravascular foreign body detected at chest radiography, found to represent a fractured strut from an inferior vena cava filter. The patient presented with a linear metallic foreign body on a chest radiograph, new from 2 years earlier. The dictated report suggested and airway foreign body, but the patient’s complex hospitalization at St. Joseph’s Medical Center, between time of the radiograph showing the abnormality and the prior showing nothing raised the possibility of an intravascular foreign body. Retrieval undertaken at St. Joseph’s confirmed an embolized strut from a fractured inferior vena cava filter. Much discussion ensued regarding this occurrence, with Judd Tillinghast indicating a recent paper showed a 10% incidence of such of an event, but the group concurring that the real life frequency must be substantially less.

2. Dr. Ruzi also presented an adenocarcinoma of the right lower lobe in a patient with scleroderma. A patient with scleroderma and lung involvement presented with persistent cough and non-resolving right lower lobe consolidation. CT showed findings consistent with non-specific interstitial pneumonia, with more focal right lower lobe opacity consisting of smooth interlobular septal thickening and intralobular interstitial thickening. The focal nature of the process is inconsistent with scleroderma-related lung disease. Bronchoscopy showed adenocarcinoma. The group noted that the pattern of carcinoma in this case is consistent with what has been previously referred to as bronchoalveolar carcinoma, particularly when the latter presents as a pneumonia-like process. The CT findings suggest that the disease is localized and potentially amenable to resection. The patient has been referred to oncology.

3. Dr. Ruzi presented a third case of an infection with coccidioidomycosis and actinomycosis, presenting as a complex cavitary lesion associated with nodules. A 39-year-old man with diabetes and untreated sleep apnea presented with a slowly enlarging right apical opacity on chest radiography. CT was performed and showed that the cavity had significantly complex internal architecture, suggesting a tissue invasive process. Small nodules in the right upper lobe suggested additional foci of granulomatous infection; the process appeared suggestive of an invasive fungal infection. Serologies indicate recent coccidioidomycosis infection, and bronchoscopy also recovered Actinomyces. Much discussion ensued regarding the accuracy of serologies and optical density testing for coccidioidomycosis infection among the various facilities that perform such testing. The group seemed to include that both infections may be at play in this patient.

4. Ewa Lupa-laskus presented 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.

5. Andy Goldstein presented an older woman with ovarian carcinoma and a large left pleural effusion presented for a clinical trial for chemotherapy. Prior to study, the patient underwent chest-abdomen-pelvis CT scanning, which showed that the large left pleural effusion now contained pockets of gas. Thoracentesis had been performed recently, but not between the scan showing pleural fluid only and the follow up scan showing hydropneumothorax. The patient’s enrollment in the clinical trial was put on hold, pending investigation. The group postulated that infection could have been introduced at the time of first thoracentesis but not taken hold until the time of the second scan. The patient remains asymptomatic. This raised the question that how likely is it that a patient could be comparatively asymptomatic but be harboring an anaerobic infection? The group concluded that such patients have been seen and further investigation with sampling / pleural fluid drainage is warranted

The meeting adjourned at 8:05 PM.

Michael B. Gotway, MD