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 

November 2017 Arizona Thoracic Society Notes

The November 2017 Arizona Thoracic Society meeting was held on Wednesday, November 15, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with a lecture followed by case presentations. There were 15 in attendance representing the pulmonary, critical care, sleep, allergy, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

1. CME offered by the Southwest Journal of Pulmonary and Critical Care Medicine (SWJPCC) is currently offered to only the Southwest state thoracic societies and the Mayo Clinic. After discussion it was felt that this restriction of access was no longer appropriate and CME credits should be available to all.
2. Efforts continue to obtain CME for the Arizona Thoracic Society meetings. Our Chapter Representative, Dr. Gerry Schwartzberg, is approaching this with the American Thoracic Society. Locally, HonorHealth sent out a survey on CME needs. Members were encouraged to fill out the survey suggesting HonorHealth offer CME for these meetings.
3. No one was able to attend the last Tobacco 21 meeting in late October. In order to keep the Arizona Thoracic Society in the loop, Dr. Rick Robbins will contact the American Lung Association to clarify if any legislation has been proposed for this year. 
4. Dr. Robbins also proposed conducting a survey of members through the SWJPCC rating various insurance plans.

“Eosinophils: A Potent Contributor to Disease in Severe Asthma” was presented by Kevin Murphy, MD from the University of Nebraska Medical Center in Omaha.

Dr. Murphy reviewed the pathophysiology of eosinophils in asthma making use of a figure from Nat Immunol 2015;16:45-56. He also described the clinical usage of benralizumab made by AstraZeneca, the sponsor of the talk. Benralizumab induces apoptosis of eosinophils. On Tuesday, the FDA approved benralizumab for the add-on maintenance treatment of patients age 12 years and over with severe asthma with an eosinophilic phenotype. Questions included how an eosinophilic phenotype was defined and if the monoclonal antibody might work in asthma with a neutrophilic phenotype. Although data was lacking it was thought by Dr. Murphy that benralizumab would probably not be beneficial in a neutrophilic phenotype.

There were 4 case presentations:

1. Dr. Paul Conomos presented a middle-aged woman with long-standing rheumatoid arthritis who has been multiple therapies but none with the success of biologic therapies. She has a history of an atypical Mycobacterium in the skin in 2007 and on chest x-ray she has progressive lung nodules. She was asymptomatic. Bronchoscopy was nondiagnostic and a needle biopsy of one of the nodules showed granuloma. Discussion on whether to proceed to video-assisted thorascopic surgery (VATS). The majority felt that continued observation was the most appropriate course at this time.
2. Dr. Lewis Wesselius presented a 52-year-old woman from Iowa with a previous diagnosis of possible sarcoidosis. She complained of a cough and heaviness in her chest. Thoracic CT showed a left hilar mass. Bronchoscopy with endobronchial ultrasound was done in Iowa but was nondiagnostic. A follow-up CT scan showed progression of the mass and that a left lung lesion had developed. Bronchoscopy was nondiagnostic. Histoplasmosis complement-fixing antibodies were positive at 1:16 (normal < 1:8). Needle biopsy of the mass showed chronic inflammation and VATS showed fibrosis with granulomatous inflammation. No cultures from any of the procedures were positive. She was placed on itraconazole and has clinically improved. Dr. Wesselius proposed that perhaps the patient has fibrosis with a variance of fibrosing mediastinitis (1).
3. Dr. Wesselius presented a 67-ear-old woman he had seen that afternoon with cough and sputum production who had nonpitting edema. Thoracic CT scan showed bronchiectasis but no pleural effusions. The patient’s fingernails were discolored yellow typical of yellow nail syndrome.
4. Dr. Rick Robbins presented a 69-year-old man from Bismarck, ND who presented with cough and a rash typical erythema nodosum on the right ankle which had been present for 6 months. Chest x-ray showed multiple nodules in the right lung.  Both coccidioidomycosis IgM and IgG were positive. The patient was begun on fluconazole and after a week felt better. In the context of Dr. Gerry Schwartzberg’s recent Medical Image of the Week: Erythema Nodosum, Uncle Jun was right, “They come in threes.” This case would be the third in addition to Dr. Schwartzberg’s two cases.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix in January (date TBA) at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins, MD

Reference

1. Koksal D, Bayiz H, Mutluay N, Koyuncu A, Demirag F, Dagli G, Berktas B, Berkoglu M. Fibrosing mediastinitis mimicking bronchogenic carcinoma. J Thorac Dis. 2013 Feb;5(1):E5-7. [CrossRef] [PubMed]

Cite as: Robbins RA. November 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(5):225-6. doi: https://doi.org/10.13105/swjpcc141-17 PDF

September 2017 Arizona Thoracic Society Notes

The September 2017 Arizona Thoracic Society meeting was held on Wednesday, September 27, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

There was a discussion of the Tobacco 21 bill which had been introduced the last session in the Arizona State Legislature. Since it seems likely that the bill will be reintroduced, the Arizona Thoracic Society will support the bill in the future. Dr. Rick Robbins announced that the SWJPCC has applied to be included in PubMed. In addition, Dr. Robbins was assigned the task of tracking down the campaign contributions to congressional members from the tobacco PAC before the next election.

There were 7 case presentations:

1. Ashley L. Garrett, MD, pulmonary fellow at Mayo, presented an elderly man with insulin-dependent diabetes who felt he had inhaled a pill. He takes multiple medications and was unsure which pill he might have inhaled. Since the inhalation, he was bothered by coughing.  His chest x-ray was normal. Bronchoscopy revealed severe left lower lobe bronchitis. No pill fragments were seen. He was managed conservatively and his coughing has nearly resolved. A discussion of pill aspiration ensued with an article published in Chest forming the basis for discussion (1).
2. Paul Conomos, M.D. presented a case of a 57-year-old woman who is largely asymptomatic but has had worsening bronchiectasis on serial CT scans since 2006. She is a nonsmoker. The CT scans show typical tree-in-bud bronchiectasis most marked in the right upper lobe but present in scattered areas throughout both right and left lungs. Her pulmonary function tests showed mild-moderate obstruction. Bronchoscopy times three with bronchoalveolar lavage and cultures has been unrevealing. Alpha-1 antitrypsin levels and esophageal pH monitoring were normal. Sweat chloride was equivocal at 44 and 50 millimoles per liter. Gene sequencing was recommended but too expensive for the patient ($2500, her copay $900). Discussion focused on whether further work up should be done and whether treatment was necessary. Most felt the work up was fairly comprehensive and that treatment was probably not indicated since she was not symptomatic.
3. Dr. Conomos also presented a second case of an 18-year-old from the Congo who presented with a chronic cough and hemoptysis. PPD was reported by the patient as negative. Physical examination was unremarkable. Chest x-ray showed a right lower lobe mass and thoracic CT scan showed right lower lobe (RLL) bronchiectasis with a question of a foreign body. Bronchoscopy showed obstruction in the lateral subsegment of the RLL with a mass with what appeared to be a stone. The patient was referred to thoracic surgery but returned 6 days later with fever and pleuritic chest pain. Chest x-ray showed RLL pneumonia. The patient underwent a RLL lobectomy. A foreign body was present. In retrospect, his mother recalled him inhaling a super glue cap when he was 7 or 8 years old. He was doing well post-operatively.
4. Dr. Gerald Schwartzberg presented 3 cases. The first was 43-year-old woman who developed erythema nodosum after a month history of sharp pleuritic chest pain and multiple other systemic complaints. Her eosinophil count was 13% and cocci serologies were weakly positive. Discussion centered on treatment. Most favored treatment although it was agreed that data supporting treatment was lacking.
5. Dr. Schwartzberg presented a second case of 75-year-old woman with mild COPD on albuterol only. She was a smoker and complained of a cough productive of green sputum. Chest x-ray revealed a large left mass with mucoid impaction. Bronchoscopy revealed hyphae with 45º branches typical of Aspergillus on biopsy. Thoracic CT scan showed bronchiectasis. An IgE was suggested. Several were suspicious of lung cancer and suggested a needle biopsy of the mass.
6. The last of Dr. Schwartzberg’s cases was a 92-year-old man who was found to have a polyp on upper GI endoscopy and a chest x-ray which showed a mass. Biopsies of both stained positive for melanin and were consistent with malignant melanoma. He was referred to oncology. Discussion centered on whether he should receive treatment.
7. Dr. Lewis Wesselius presented a 67-year-old man with a right neck mass found in 2015. Biopsy revealed a high-grade sarcomatoid cancer. At that time a CT/PET of the chest was negative. About 6 months later a CT/PET revealed new areas of tracer accumulation within the liver. His chemotherapy was switched to ipilimumab and nivolumab. A repeat CT/PET showed symmetric bilateral mediastinal lymphadenopathy. An endobronchial bronchial ultrasound (EBUS) biopsy of the nodes showed noncaseating granuloma consistent with sarcoidosis. He was begun on corticosteroids and nodes and liver lesions resolved on CT/PET. Discussion centered on sarcoidosis induced by these newer checkpoint inhibitors. It was speculated that drug-induced sarcoidosis might be observed more commonly as these agents are more frequently used (2,3).

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, November 15, 2017 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins, MD

References

1. Kinsey CM, Folch E, Majid A, Channick CL. Evaluation and management of pill aspiration: case discussion and review of the literature. Chest. 2013 Jun;143(6):1791-5. [CrossRef] [PubMed]
2. Reuss JE, Kunk PR, Stowman AM, Gru AA, Slingluff CL Jr, Gaughan EM. Sarcoidosis in the setting of combination ipilimumab and nivolumab immunotherapy: a case report & review of the literature. J Immunother Cancer. 2016 Dec 20;4:94. [CrossRef] [PubMed]
3. Danlos FX, Pagès C, Baroudjian B, et al. Nivolumab-induced sarcoid-like granulomatous reaction in a patient with advanced melanoma. Chest. 2016 May;149(5):e133-6. [CrossRef] [PubMed]

Cite as: Robbins RA. September 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(3):122-4. doi: https://doi.org/10.13175/swjpcc118-17 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