November 2014 Arizona Thoracic Society Notes

The November 2014 Arizona Thoracic Society meeting was held on Wednesday, November 19, 2014 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were about 30 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities. Jud Tillinghast was nominated as the Arizona Thoracic Society physician of the year.

Three cases were presented:

1. George Parides presented a case of a 70-year-old woman with a 3 areas of ground glass picked up incidentally on CT scan. She had some wheezing. A needle biopsy revealed adenocarcinoma.  The biopsy and radiologic pattern were consistent with adenocarcinoma in situ or minimally invasive adenocarcinoma. Discussion centered around treatment. Most felt that if the areas could be removed that surgical resection was indicated (1).
2. Lewis Wesselius presented a 60-year-old man with Marfan's syndrome and a history of an aortic valve replacement on chronic anticoagulation with a thyroid papillary carcinoma. The patient underwent a total thyroidectomy. Post-operatively he developed a large mass-like area in the right lower lung. It was unclear whether this was in the lung parenchymal or in the pleural space. A preliminary differential diagnosis of abscess, parenchymal hemorrhage or pleural hemorrhage was made. His INR was in the appropriate therapeutic range. A chest tube was placed with minimal drainage and no change in the radiographic appearance. Video-assisted thorascopic surgery (VATS) was performed and a large intraparenchymal hematoma was found which was removed. A review of the literature revealed a small number of reports of spontaneous intraparenchymal hemorrhages but none associated with Marfan's (2,3).
3. Jasminder Mand presented a case of an asymptomatic 66-year-old man with inspiratory crackles and a mildly reduced diffusing capacity on pulmonary function testing. He had a past minimal smoking history. His CT scan showed areas of ground glass and reticulation surrounding of septal emphysema. An open lung biopsy was performed which was consistent with usual interstitial pneumonia (UIP). The patient raised the question of whether he should be treated with nintedanib or pirfenidone. There was disagreement amongst the audience with some favoring treatment while others favored following the patient.

There being no further business the meeting was adjourned about 8:00 PM. There is no meeting in December. The next meeting will be Phoenix on Wednesday, January, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

References

1. Tsushima Y, Suzuki K, Watanabe S, Kusumoto M, Tsuta K, Matsuno Y, Asamura H. Multiple lung adenocarcinomas showing ground-glass opacities on thoracic computed tomography. Ann Thorac Surg. 2006;82(4):1508-10. [CrossRef] [PubMed]
2. Riachy M, Mal H, Taillé C, Dauriat G, Groussard O, Cazals-Hatem D, Biondi G, Fournier M. Non-traumatic pulmonary haematoma complicating oral anticoagulation therapy. Respirology. 2007;12(4):614-6. [CrossRef] [PubMed]
3. Chakraborty AK, Dreisin RB. Pulmonary hematoma secondary to anticoagulant therapy. Ann Intern Med. 1982;96(1):67-9. [CrossRef] [PubMed]

Reference as: Robbins RA. November 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;9(5):289-90. doi: http://dx.doi.org/10.13175/swjpcc153-14 PDF

September 2014 Arizona Thoracic Society Notes

The September 2014 Arizona Thoracic Society meeting was held on Wednesday, 9/24/14 at the Kiewit Auditorium on the University of Arizona Medical Center campus in Tucson beginning at 5:30 PM. This was a dinner meeting with case presentations. There were about 21 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

Four cases were presented:

1. Mohammad Dalabih presented a 22 year old hypoxic man with a history of asthma and abdominal pain. A bubble echocardiogram showed bubbles in the left ventricle within 3 heartbeats. Thoracic CT scan showed a pulmonary arteriovenous malformation (AVMs). The patient underwent coil embolization and improved. Dr. Dalabih reviewed the diagnosis and management of pulmonary AVMs (1). Aarthi Ganesh presented a 70 year old woman complaining of dyspnea on exertion. A chest x-ray showed complete opacification of the right hemithorax and a thoracic CT scan showed a large right pleural effusion with right lung atelectasis. After thoracentesis was nondiagnostic, she underwent video-assisted thorascopic surgery (VATS). Although she clinically appeared to have mesothelioma, histology was consistent with a pseudomesotheliomatous adenocarcinoma. She is currently undergoing treatment with platinum based agents.
2. Gordon Carr presented a 75 year old woman with dyspnea. Chest x-ray showed interstitial disease with a possible usual interstitial pneumonia (UIP) pattern on CT scan. Dr. Carr reviewed the initial evaluation and diagnosis of the interstitial lung disease (2). VATS showed a bronchocentric process with some fibrosis in the periphery most consistent with chronic hypersensitivity pneumonitis. The likely source was thought to be mold in her indoor pool area.
3. James Knepler presented a 55 year old woman with breast cancer and bone metases receiving tamoxifen. She also had a history of multiple sclerosis and was receiving on interferon-beta 1a. A positron emission tomography (PET) scan showed increased uptake in several mediastinal lymph nodes. Endobronchial ultrasound (EBUS) guided aspiration biopsy was non-diagnostic. Endobronchial biopsy showed granulomas. It was felt the most likely diagnosis was interferon-induced sarcoidosis. Several case reports have recently been published.

There being no further business the meeting was adjourned about 7:00 PM. The next meeting will be Phoenix on Wednesday, October 22, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

References

1. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158(2):643-61. [CrossRef] [PubMed]
2. Selman M, Pardo A. Update in diffuse parenchymal lung disease 2012. Am J Respir Crit Care Med. 2013;187(9):920-5. [CrossRef] [PubMed] 

Reference as: Robbins RA. September 2014 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2014;9(3):191-2. doi: http://dx.doi.org/10.13175/swjpcc127-14 PDF

August 2014 Arizona Thoracic Society Notes

The August 2014 Arizona Thoracic Society meeting was held on Wednesday, 8/27/14 at Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were about 30 in attendance representing the pulmonary, critical care, sleep and radiology communities.

A presentation was given by Julie Reid of the American Lung Association in Arizona on their Lung Force initiative. This is an initiative to make women more aware that lung cancer is the number one cause of cancer deaths in women. There will be a fund raising Lung Force Walk on November 15, 2014 in Phoenix. More information can be found at http://www.lungforce.org/walk-events or http://www.lung.org/associations/states/arizona/local-offices/phoenix/ or contact Julie Reid at JReid@Lung Arizona.org or (602) 258-7505.

A discussion was instigated by Dr. Parides on whether there is an increased risk of clinical Valley Fever in patients previously treated who begin therapy with biological therapy for rheumatoid arthritis. The common practice has been to initiate azole antifungal therapy in patients who begin biologics for rheumatoid arthritis. Although all agreed there was an increased risk of Valley Fever in patients treated with biological therapy, none were aware of any patients who developed Valley Fever who had previously been treated with azole therapy. This was extended to similar discussions including whether patients who had previously been treated for a +PPD need anti-tuberculosis therapy. This has been common practice, but again, none were aware of any cases or literature.

Lewis Wesselius presented a 66 year old man with a history of multiple pneumonias and skin infections. The patient was short with a prominent forehead. Immunoglobulin evaluation revealed a normal IgG and IgM but a markedly elevated IgE of 7419 kIU/mL (normal <380 kIU/mL). The patient was diagnosed with hyperimmunogloublin E syndrome, also known as Job's syndrome. For a review of this case as well as a differential diagnosis of elevated IgE please see the "September 2014 Pulmonary Case of the Month: A Case for Biblical Scholars" which will be posted on 9/1/14.

There being no further business the meeting was adjourned about 7:45 PM. The next meeting will be Tucson on Wednesday, September 24. Time and location to be announced.

Richard A. Robbins, MD

Reference as: Robbins RA. August 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;9(2):145. doi: http://dx.doi.org/10.13175/swjpcc114-14 PDF

June 2014 Arizona Thoracic Society Notes

The June 2014 Arizona Thoracic Society meeting was held on Wednesday, 6/25/14 at the Bio5 building on the University of Arizona Medical Center campus in Tucson beginning at 5:30 PM. This was a dinner meeting with case presentations. There were about 33 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

Four cases were presented:

1. Eric Chase presented a 68 year old incarcerated man shortness of breath, chest pain and productive cough.  The patient was a  poor historian. He was supposed to be receiving morphine for back pain but this had been held. He also had a 45 pound weight loss over the past year. His PMH was positive for COPD, hypertension, congestive heart failure, chronic back pain and  hepatitis C. Past surgical history included a back operation and some sort of chest operation. On physical examination he was  tachypneic, tachycardic  and multiple scars over his neck, back and chest including a median sternotomy scan. Subcutaneous emphysema was present. Laboratory evaluation was most remarkable for a lactate of 4.6 mg/dL. Chest x-ray revealed subcutaneous and mediastinal air, LLL consolidation, and a left pleural effusion.  Thoracentesis of the pleural effusion showed a high amylase and a low pH. A chest tube was placed. Esophagram showed contrast draining through the left chest and chest tube. CT scan was consistent with a colonic interposition graft with a graft to pleural fistula. The patient was deemed to be a poor surgical candidate and a jejunostomy tube was placed.
2. Mohammad Dalabih presented a 72 year old woman with asthma who had no response to asthma medications. Spirometry was consistent with moderate restriction. A thoracic CT scan showed two small nodules along with mosaic attenuation. A lung wedge biopsy showed nonmalignant appearing cells with tumorlets and bronchitis. The cells were CD56 positive. A diagnosis of diffuse interstitial pulmonary neuroendocrine hyperplasia (DIPNECH). Dr. Dalabih reviewed DIPNECH which usually presents in middle aged women with symptoms of cough and dyspnea; obstructive abnormalities on pulmonary function testing; and radiographic imaging showing pulmonary nodules, ground-glass attenuation, and bronchiectasis. In general, the clinical course remains stable; however, progression to respiratory failure can occur. Long-term follow- up studies and the best treatment remains unknown. The April 2014 Pulmonary Case of the Month also presented a case of DIPNECH (1).
3. Mohammad Alzoubaidi presented the case of a 61 year old woman with right upper quadrant pain who was found to have a large liver lesion on abdominal CT scan. She suffered a cardiac arrest shortly after the CT scan and her hemoglobin decreased to 5.6 g/dL. Angiography revealed multiple pseudoaneursyms with the largest apparently bleeding. Coil embolization was performed but a couple of days later her shock recurred. A repeat angiogram showed enlargement of the known pseudoaneursyms and several new ones. She was begun on corticosteroids for a presumed vasculitis. Unfortunately, she continued to bleed and died. Autopsy was consistent with fibromuscular dysplasia.  Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory disease of the blood vessels resulting in constriction and dilatation (pseudoaneursyms) (2). The cause and best treatment are unknown.
4. John Bloom presented a 22 year old Somali man that grew up in India who came to the US about 15 months before presentation. He was relatively asymptomatic but was found to have supraclavicular adenopathy on a "wellness" physical examination. Biopsy of the lymph nodes was recommended but he refused. He presented about a month later with neck and back pain. Physical examination revealed by adenopathy and a fever of 38.2º C. His white blood cell count was 12,600 cells/µL. Thoracic CT showed a miliary pattern with vertebral destruction. Laminectomy with cord stabilization was performed. Biopsy was negative for acid fast bacilli but positive for GMS+ organisms consistent with coccidioidomycosis. A large cervical paraspinal abscess just below the skull was drained and a large mediastinal abscess was also seen on CT scan. Discussion ensued about whether drainage was appropriate for the mediastinal mass, but most thought not.  The case illustrates that Valley Fever is common and in most chest differential diagnosis in the Southwest.

There being no further business the meeting was adjourned about 6:45 PM. There will be no meeting in July. The next meeting in Phoenix will be a case presentation conference on August 27, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

References

1. Wesselius LJ. April 2014 pulmonary case of the month: DIP-what? Southwest J Pulm Crit Care. 2014;8(4):195-203. [CrossRef]
2. Slovut DP, Olin JW. Fibromuscular dysplasia. N Engl J Med. 2004;350(18):1862-71. [CrossRef] [PubMed] 

Reference as: Robbins RA. June 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(6):356-7. doi: http://dx.doi.org/10.13175/swjpcc084-14 PDF

May 2014 Arizona Thoracic Society Notes

The May 2014 Arizona Thoracic Society meeting was held on Wednesday, 5/28/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep and radiology communities.

A discussion was held regarding the Arizona Thoracic Society relationship with the American Lung Association. Several members volunteered to talk to the lung association regarding common ground to strengthen the relationship.

The wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting was a big success. There were about 55 at the meeting. The tasting will probably be held again next year.

At the ATS meeting data was presented that pirfenidone was effective in reducing the progression of idiopathic pulmonary fibrosis (IPF). The data was published in the New England Journal of Medicine on 8/29/14 (1). Lewis Wesselius is one of the investigators enrolling patients in a phase 3 trial while InterMune reapplies to the FDA for approval of pirfenidone in IPF.

Two cases were presented:

1. Lewis Wesselius from the Mayo Clinic Arizona presented a 53 year old woman with a chronic, nonproductive accompanied by malaise and a modest weight loss. She was treated for asthma without improvement.  She was a nonsmoker and had a SpO2 of 98% on room air. Her lungs were clear to auscultation.  Routine laboratory evaluation was unremarkable and exhaled nitric oxide was normal. Thoracic CT scan showed a subtle broncholitis. She was empirically treated for gastroesophageal reflux disease (GERD) without improvement. Bronchoalveolar lavage was performed and showed Nocardia asteroides. She had no evidence of immunocompromise. She was treated with sulfamethoxazole and trimethoprim which produced a rash and then minocycline for 4 months. Her cough resolved. However, when the minocycline was stopped her cough returned. She is currently receiving an additional course of minocycline planned for 6 months.
2. Suresh Uppalapu presented a 58 year old fireman with a complaint of dyspnea on exertion. He has a history of obstructive sleep apnea and lives at an elevation of 7000 feet. The patient had significant desaturation with exercise. Chest x-ray showed borderline cardiomegaly but was otherwise normal. Thoracic CT scan showed pulmonary artery enlargement and borderline right ventricular (RV) enlargement. Ultrasound of the hear showed an enlarged RV but it was difficult to measure PA pressure.  Right-sided heart catherization showed a mean pulmonary artery pressure of 35 cm H2O with a  step up in the oxygen saturation at the right atrium. Transesophageal echocardiogram (TEE) showed a patent foramen ovale (PFO).  Insertion of a balloon stopped the right to left shunting but resulted in a significant increase in the pulmonary artery pressure. He was referred for percutaneous closure of the PFO along with treatment of his pulmonary artery hypertension.

There being no further business the meeting was adjourned about 8:15 PM. The June meeting is scheduled for Tucson. There will be no meeting in July. The next meeting in Phoenix will be a case presentation conference on August 27, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

Reference

1. King TE Jr, Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med 2014;370:2083-92. [CrossRef] [PubMed] 

Reference as: Robbins RA. May 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(6): 297-8. doi: http://dx.doi.org/10.13175/swjpcc072-14 PDF