April 2014 Arizona Thoracic Society Notes

The April 2014 Arizona Thoracic Society meeting was held on Wednesday, 4/23/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 15 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

It was announced that there will be a wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting. The tasting will be led by Peter Wagner and is scheduled for the Cobalt Room in the Hilton San Diego Bayfront on Tuesday, May 20, from 4-8 PM.

Guideline development was again discussed. The consensus was to await publication of the IDSA Cocci Guidelines and respond appropriately.

George Parides, Arizona Chapter Representative, gave a presentation on Hill Day. Representatives of the Arizona, New Mexico and Washington Thoracic Societies met with their Congressional delegations, including Rep. David Schweikert, to discuss the Cigar Bill, NIH funding, and the Medicare Sustainable Growth Rate Factor (SGR). Dr. Parides also spoke about the need for increased funding for Graduate Medical Education.

Four cases were presented:

1. Jud Tillinghast presented a case of a middle aged man who suffered a cervical cord injury 6-7 years ago resulting in paraplegia. The patient had just moved from California and was referred because of an abnormal chest x-ray. After his injury the patient had a great deal of pain and repeated episodes of aspiration. The patient was asymptomatic. The chest x-ray showed haziness surrounding the right hilum. A CT scan showed RLL, LLL, and RML consolidation which was essentially unchanged from a thoracic CT performed 6 months earlier. A biopsy was performed and consistent with lipoid pneumonia. On further questioning the patient recalled taking mineral oil for the first 2-3 years after his injury to relieve constipation induced by narcotics for pain.
2. Gerald Schwartzberg presented a 79 year old man with very severe COPD who presented with hemoptysis. Chest x-ray showed bilateral lower lobe consolidation with an air-fluid level in the right chest. Bronchoalveolar lavage revealed only Aspergillus. A discussion ensued and many were unconvinced that the consolidations resulted from Aspergillus. Since the patient was relatively asymptomatic except from the dyspnea from his COPD, the consensus was to perform a repeat thoracic CT scan.
3. Lewis Wesselius presented a 71 year old woman with dyspnea since late 2013. She had a cardiac pacemaker placed in 2008. Her physical exam was unremarkable. Her SpO2 was 96% on room air but decreased to 84% with exercise. Chest x-ray and pulmonary function testing were unremarkable (a DLco was unable to be performed. Echocardiogram revealed a large patent foramen ovale (PFO).
4. Allen Thomas presented a 65 year old with dyspnea. The patient had a history of cardiomegaly with diastolic dysfunction and a bipolar disorder treated with lithium, lamotrigine, gabapentin. Chest x-ray showed bilateral interstitial infiltrates. CT scan showed sub-pleural patchy ground-glass opacities combined with irregular reticular opacities reminiscent of nonspecific interstitial pneumonia (NSIP). Collage vascular work up was negative. Review of the website Pneumotox (http://www.pneumotox.com) showed reports of interstitial disease with lamotrigine. The medication was stopped an follow-up CT scan showed near resolution of the abnormalities.

There being no further business the meeting was adjourned about 8:15 PM. The next meeting is scheduled to be a case presentation conference for May 28, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

Reference as: Robbins RA. April 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(4):236-7. doi: http://dx.doi.org/10.13175/swjpcc054-14 PDF

March 2014 Arizona Thoracic Society Notes

The March 2014 Arizona Thoracic Society meeting was a special meeting. In conjunction with the Valley Fever Center for Excellence and the Arizona Respiratory Center the Eighteenth Annual Farness Lecture was held in the Sonntag Pavilion at St. Joseph's Hospital at 6 PM on Friday, April 4, 2014. The guest speaker was Antonio "Tony" Catanzaro, MD from the University of California San Diego and current president of the Cocci Study Group. There were 57 in attendance representing the pulmonary, critical care, sleep, and infectious disease communities.

Dr. Antonio Catanzaro

After opening remarks by Arizona Thoracic Society president, Lewis Wesselius (a former fellow under Dr. Catanzaro at UCSD), John Galgiani, director of the Valley Fever Center for Excellence, gave a brief history of the Farness lecture before introducing Dr. Catanzaro. The lecture is named for Orin J. Farness, a Tucson physician, who was the first to report culture positive coccidioidomycosis (cocci or Valley Fever). The title of Dr. Catanzaro's talk was "Coccidioidomycosis, Why I Have Found It So Interesting". Dr. Catanzaro came to San Diego from Georgetown to study the immunology of sarcoidosis. Much to his surprise, he found little sarcoidosis in San Diego and was looking for a new direction. While attending the California Thoracic Society meeting, Tony met Dr. Hans Einstein from Bakersfield, California, the leading authority on Valley Fever. He persuaded Tony to attend the Cocci Study Group meeting, held in conjunction with the California Thoracic Society meeting. Dr. Catanzaro reviewed his investigations of Valley Fever including transfer factor, hypercalcemia associated with Valley Fever and treatment with ketoconoazole, fluconazole, itraconazole, and posaconazole (1-4). Prominently mentioned Hans Einstein from Bakersfield, John Galgiani from Tucson, Bernie Levine from Phoenix and J. Burr Ross also from Phoenix.

The Cocci Study Group meeting was held the following day, Saturday, April 5th at the University of Arizona College of Medicine, Phoenix. The next meeting of the Arizona Thoracic Society is on Wednesday, April 23, 2014, 6:30 PM at Shea Hospital.

Richard A. Robbins, M.D.

References

1. Catanzaro A, Einstein H, Levine B, Ross JB, Schillaci R, Fierer J, Friedman PJ. Ketoconazole for treatment of disseminated coccidioidomycosis. Ann Intern Med. 1982 Apr;96(4):436-40. [CrossRef] [PubMed]
2. Catanzaro A, Galgiani JN, Levine BE, Sharkey-Mathis PK, Fierer J, Stevens DA, Chapman SW, Cloud G. Fluconazole in the treatment of chronic pulmonary and nonmeningeal disseminated coccidioidomycosis. NIAID Mycoses Study Group. Am J Med. 1995;98(3):249-56. [CrossRef]  [PubMed]
3. Galgiani JN, Catanzaro A, Cloud GA, Johnson RH, Williams PL, Mirels LF, Nassar F, Lutz JE, Stevens DA, Sharkey PK, Singh VR, Larsen RA, Delgado KL, Flanigan C, Rinaldi MG. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med. 2000;133(9):676-86. [CrossRef] [PubMed]
4. Catanzaro A, Cloud GA, Stevens DA, Levine BE, Williams PL, Johnson RH, Rendon A, Mirels LF, Lutz JE, Holloway M, Galgiani JN. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clin Infect Dis. 2007;45(5):562-8. [CrossRef] [PubMed]

Reference as: Robbins RA. March 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(4):223-4. doi: http://dx.doi.org/10.13175/swjpcc038-14 PDF

February 2014 Arizona Thoracic Society Notes

The February 2014 Arizona Thoracic Society was a dinner meeting sponsored by Select Specialty Hospital and held on Wednesday, 2/26/2014 at Shea Hospital beginning at 6:30 PM. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Gerald Swartzberg was presented a plaque as the Arizona Thoracic Society clinician of the year by George Parides (Figure 1).

Figure 1. George Parides (left), Arizona Representative to the ATS Council of Chapter Representatives, presenting a plaque to Gerald Swartzberg (right), Arizona Thoracic Society Clinician of the Year.

A discussion was held about having a wine tasting in San Diego at the ATS International Conference. Peter Wagner (Slurping Around with PDW) has agreed to lead the conference. It was decided to extend invitations to the New Mexico, Colorado and California Thoracic Societies along with the Mayo Clinic.

A question was raised about guideline development. It was felt that we should review the Infectious Disease Society of America Valley Fever guidelines and determine if the Arizona Thoracic Society might have something to contribute.

Three cases were presented:

Lewis Wesselius from the Mayo Clinic Arizona presented a 19 year old man with shortness of breath and fever. He was seen in the Emergency Department and had a normal chest x-ray but returned 6 days later with a diffuse nodular pneumonia. Bronchoscopy with bronchoalveolar lavage revealed blood but all cultures with negative. He underwent video-assisted thorascopic lung (VATS) biopsy. Histologically the biopsy showed massive neutrophilic infiltration, hemorrhage, and small, angiocentric abscess formation. This was considered compatible with pyoderma gangrenosum of the lung (1). He had dramatic improvement with corticosteroids.

Elijah Poulos, a second year fellow at the Good Samaritan/VA program, presented a case of a non-resolving lung infiltrate in the left lower lobe after 6 weeks. CT scan showed a patchy, nodular consolidation with hazy borders. The patient was asymptomatic. Lung biopsy showed adenocarcinoma. He was referred to thoracic surgery for possible resection.  A discussion ensued reminding everyone that carcinoma is a consideration in non-resolving lung lesions and that adenocarcinoma is becoming more common (2).

Dr. Poulos also presented a 66 year old who is retired but a semi-retired handyman/farmer who had a persistent nonproductive cough. CT scan showed a diffuse increase in interstitial markings. Pulmonary function testing revealed restrictive lung disease. Bronchoscopy with bronchoalveolar lavage was unremarkable. He was treated with fluticasone nasal spray and improved. Most advised a VATS biopsy to establish a diagnosis.

Richard A. Robbins, M.D.

References

1. Kanoh S, Kobayashi H, Sato K, Motoyoshi K, Aida S. Tracheobronchial pulmonary disease associated with pyoderma gangrenosum. Mayo Clin Proc. 2009;84(6):555-7. [CrossRef] [PubMed] 
2. Lortet-Tieulent J, Soerjomataram I, Ferlay J, Rutherford M, Weiderpass E, Bray F. International trends in lung cancer incidence by histological subtype: Adenocarcinoma stabilizing in men but still increasing in women. Lung Cancer. 2014 Jan 25. pii: S0169-5002(14)00044-0. [PubMed]

Reference as: Robbins RA. February 2014 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2014;8(2):138-9. doi: http://dx.doi.org/10.13175/swjpcc026-14 PDF

January 2014 Arizona Thoracic Society Notes

The January Arizona Thoracic Society meeting was held on Wednesday, 1/22/2014 at Shea Hospital beginning at 6:30 PM. There were 11 in attendance representing the pulmonary, critical care, sleep, pathology and radiology communities.

A discussion was held how to encourage attendance of young physicians to the Arizona Thoracic Society. A short presentation was made by Rick Robbins on the SWJPCC reiterating the material published in the yearly report from the editor (1).

Three cases were presented:

Dr. Tom Colby from the Pathology at the Mayo Clinic Arizona presented the first case. The patient was a 62 year old with polycythemia vera and shortness of breath. CT scan showed diffuse ground glass densities. The right ventricle and the pulmonary artery were slightly enlarged. A VATS lung biopsy was performed. The biopsy showed an increase in megakarocytes, immature red blood cells and immature white cell precursors consistent with extramedullary hematopoiesis. There was no fibrosis. There was a marked increase in CD34 staining consistent with alveolar septal capillary proliferation. Review of three other similar cases revealed similar findings. Dr. Colby questioned whether the endothelial proliferation could contribute to the clinical and radiologic findings. Suggestions were made to obtain pulmonary function testing, echocardiography and arterial blood gases. Depending on results it was felt that pulmonary hypertension needed to be excluded and he might require a right heart catherization.

Lewis Wesselius also from the Mayo Clinic Arizona presented a 53 year old woman from Indiana with a history of chronic cough and progressive shortness of breath since May 2013. Echocardiography showed 16% left ventricular ejection fraction. She had a biventricular pacemaker placed. A clinical diagnosis of sarcoidosis with a dilated cardiomyopathy was made but the patient did no improve on corticosteroids and methotrexate.  CT scan of the chest showed some mosaic attenuation.  There were no perilymphatic abnormalities as often seen in sarcoidosis. A VATS biopsy was performed. Histology revealed a proliferation of neuroendocrine cells within the airways forming tumorlets. A diagnosis of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) or a diffuse carcinoid tumor was made. Previously, 24 cases of DIPNECH were reported in the American Journal of Respiratory and Critical Care by Nassar et al. (2) but none had cardiomyopathy. It was questioned whether her cardiomyopathy could be secondary to DIPNECH.

Jessica Hurley from Bethesda North Hospital presented a 27 year old man with asthma, recurrent pneumonia, dyspnea and progressive hypoxia. He had an elevated IgE but less than 1000. Thoracic CT scan showed diffuse consolidation. Cultures were negative. He was placed on high dose corticosteroids but his hypoxia progressively worsened. A lung biopsy was performed and revealed broncholitis. No definitive diagnosis was apparent and it was felt there was more going than asthma but there were differing opinions on how to proceed. The biopsy will be reviewed by the lung pathologists at Mayo Clinic Arizona.

There being no further business the meeting was adjourned at about 8:30 PM. The next meeting is scheduled for Wednesday, February 26, 6:30 PM at Scottsdale Shea hospital.

Richard A. Robbins, M.D.

References

1. Robbins RA. The tremedous threes! annual report from the editor. Southwest J Pulm Crit Care. 2014:8(1):1-3. [CrossRef]
2. Nassar AA, Jaroszewski DE, Helmers RA, Colby TV, Patel BM, Mookadam F. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: a systematic overview. Am J Respir Crit Care Med. 2011;184(1):8-16. [CrossRef] [PubMed] 

Reference as: Robbins RA. January 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014:8(1):66-7. doi: http://dx.doi.org/10.13175/swjpcc006-14 PDF

December 2013 Arizona Thoracic Society Notes

A breakfast meeting of the Arizona Thoracic Society and the Tucson winter lung series was held on Saturday, 12/14/2013 at Kiewit Auditorium on the University of Arizona Medical Center Campus beginning at 8:30 AM. There were 31 in attendance.

A lecture was presented by Joe G. N. "Skip" Garcia, MD, the senior vice president for health sciences at the University of Arizona (Figure 1).

Figure 1. Joe G. N. “Skip” Garcia, MD

The title of Garcia’s talk was “Personalizing Medicine in Cardiopulmonary Disorders: The Post ACA Landscape”.

Garcia began with reiterating that the Affordable Care Act (ACA, Obamacare) is fact and could pose a threat to academic medical centers. However, he views the ACA as an opportunity to develop personalized medicine which grew from the human genome project. Examples cited included the genetic variability among patients in determining the dose of warfarin and bronchodilator response to beta agonists in asthma (1,2).

Garcia’s laboratory has studied predominately 6 diseases including the adult respiratory distress syndrome (ARDS), idiopathic pulmonary fibrosis (IPF), sarcoidosis, asthma, pulmonary artery hypertension and sickle cell disease. Each has in common that there has been minimal progress made in the past generation and each has been shown to have racial or ethnic disparities in outcomes. He cited examples of how molecular testing could improve care.

Black and Hispanic patients with ARDS have a significantly higher risk of death compared with white patients (3). Garcia noted that the ventilator is not necessarily a friend and use of higher tidal volumes has been associated with increased mortality (4). He reasoned that the variation in susceptibility to ventilator induced lung injury could potentially explain the racial differences in mortality. Beginning with a dog model of ARDS, highly significant regional differences in gene expression were observed between lung apex/base regions. One of these potential targets was pre-B-cell colony enhancing factor (PBEF), a gene not previously associated with lung pathophysiology (5). Further work showed PBEF could induce changes seen in ARDS including a neutrophil alveolitis and increases in nuclear factor-κβ (NFKB) expression (6).

Few would question that there is a need for validated biomarkers in idiopathic pulmonary fibrosis. Using a similar approach to the investigation of PBEF in ARDS, peripheral blood mononuclear cell (PBMC) gene expression profiles predictive of poor outcomes in idiopathic pulmonary fibrosis (IPF) were examined by microarray. Microarray analyses suggest that 4 genes (CD28, ICOS, LCK, and ITK) are potential outcome biomarkers in IPF and should be further evaluated for patient prioritization for lung transplantation and stratification in drug studies (7). PBMC gene expression profiles were also examined in sarcoidosis.  There was a significant association of single nucleotide polymorphisms (SNPs) in signature genes with sarcoidosis susceptibility and severity (8). Further examples were presented on sickle cell disease.

Garcia concluded that molecular techniques represent powerful tools to investigate potential therapeutic approaches in respiratory diseases where little progress has been made.

Richard A. Robbins, MD

References

1. International Warfarin Pharmacogenetics Consortium, Klein TE, Altman RB, Eriksson N, Gage BF, Kimmel SE, Lee MT, Limdi NA, Page D, Roden DM, Wagner MJ, Caldwell MD, Johnson JA. Estimation of the warfarin dose with clinical and pharmacogenetic data. N Engl J Med. 2009;360(8):753-64. [CrossRef] [PubMed]
2. Duan QL, Lasky-Su J, Himes BE, Qiu W, Litonjua AA, Damask A, Lazarus R, Klanderman B, Irvin CG, Peters SP, Hanrahan JP, Lima JJ, Martinez FD, Mauger D, Chinchilli VM, Soto-Quiros M, Avila L, Celedón JC, Lange C, Weiss ST, Tantisira KG. A genome-wide association study of bronchodilator response in asthmatics. Pharmacogenomics J. 2013 Mar 19. [Epub ahead of print] [CrossRef] [PubMed]
3. Erickson SE, Shlipak MG, Martin GS, Wheeler AP, Ancukiewicz M, Matthay MA, Eisner MD; National Institutes of Health National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. Racial and ethnic disparities in mortality from acute lung injury. Crit Care Med. 2009 Jan;37(1):1-6. [CrossRef] [PubMed]
4. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8. [CrossRef] [PubMed]
5. Simon BA, Easley RB, Grigoryev DN, Ma SF, Ye SQ, Lavoie T, Tuder RM, Garcia JG. Microarray analysis of regional cellular responses to local mechanical stress in acute lung injury. Am J Physiol Lung Cell Mol Physiol. 2006;291(5):L851-61. Herazo-Maya JD, Noth I, Duncan SR, Kim S, Ma SF, Tseng GC, Feingold E, Juan-Guardela BM, Richards TJ, Lussier Y, Huang Y, Vij R, Lindell KO, Xue J, Gibson KF, Shapiro SD, Garcia JG, Kaminski N. Peripheral blood mononuclear cell gene expression profiles predict poor outcome in idiopathic pulmonary fibrosis. Sci Transl Med. 2013 Oct 2;5(205):205ra136.
6. Hong SB, Huang Y, Moreno-Vinasco L, Sammani S, Moitra J, Barnard JW, Ma SF, Mirzapoiazova T, Evenoski C, Reeves RR, Chiang ET, Lang GD, Husain AN, Dudek SM, Jacobson JR, Ye SQ, Lussier YA, Garcia JG. Essential role of pre-B-cell colony enhancing factor in ventilator-induced lung injury. Am J Respir Crit Care Med. 2008;178(6):605-17. [CrossRef] [PubMed]  
7. Zhou T, Zhang W, Sweiss NJ, Chen ES, Moller DR, Knox KS, Ma SF, Wade MS, Noth I, Machado RF, Garcia JG. Peripheral blood gene expression as a novel genomic biomarker in complicated sarcoidosis. PLoS One. 2012;7(9):e44818. [CrossRef] [PubMed] 

Reference as: Robbins RA. December 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(6):360-2. doi: http://dx.doi.org/10.13175/swjpcc175-13 PDF