June 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 6/26/2013 at Scottsdale Shea beginning at 6:30 PM. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, announced that the journal had begun using digital object identifiers (DOI) through the CrossRef service. In addition, the content of the journal will be stored in the CLOCKSS Archive.

The Mayo Clinic in Rochester has asked to partner with the Southwest Journal of Pulmonary and Critical Care. The Arizona Thoracic Society endorsed this association.

Rick Robbins is stepping down as the Arizona representative to the Council of Chapter (CCR) Representatives. Dr. George Parides was unanimously elected CCR representative.

Dr. Lewis Wesselius presented the case of an 80 year old Asian man with a history of the recent onset of cough, weight loss, headache and an abnormal chest x-ray. He was a nonsmoker. Physical exam revealed a thin man but was otherwise unremarkable.  Laboratory showed only an elevated erythrocyte sedimentation rate. CBC was normal. Chest x-ray showed increased right perihilar densities and a small right pleural effusion. CT scan showed areas of dense consolidation in the right upper and middle lobes. Bronchoscopy was performed. No bronchial abnormality was noted. However, the cultures grew Crytococcus. Lumbar puncture showed elevated protein, slightly low glucose and slightly increased lymphocytes. A CD4 count was performed and was low at 150 cells/mm3. HIV was negative.

It was felt he had idiopathic CD4 lymphocytopenia which is a severe CD4 T-cell depletion resulting in a predisposition to opportunistic infections (1). The epidemiologic data do not suggest that the condition is caused by a transmissible agent. Unlike HIV infection, the decrease in the CD4 cell counts is often slow. The clinical spectrum ranges from an asymptomatic laboratory abnormality to life-threatening opportunistic infections. There cause is unknown and there is no proven treatment.

There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, July 24, 6:30 PM in Tucson at the Kiewit Auditorium on the University of Arizona campus.  

Richard A. Robbins, M.D.

Reference

1. Luo L, Li T. Idiopathic CD4 lymphocytopenia and opportunistic infection--an update. FEMS Immunol Med Microbiol. 2008;54(3):283-9. [CrossRef] [PubMed]  

Reference as: Robbins RA. June 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;6(6):306-7. doi: http://dx.doi.org/10.13175/swjpcc085-13 PDF

May 2013 Council of Chapter Representatives Notes

The Council of Chapter Representatives met in conjunction with the ATS meeting in Philadelphia on May 18, 2012.

Roll Call. The meeting was called to order at 11 AM. Representatives from Arizona, California, DC Metro, Louisiana, Michigan, New Mexico, New York, Oregon, and Rhode Island were in attendance, and by telephone from Washington.

Chapter Updates. Information on chapter activities and a chapter brochure. There are currently 19 active chapters. Most are having annual meetings.

Advocacy. Gary Ewart from ATS Government Relations gave a presentation on Washington activities. Highlights included activities on the SGR, a number of air pollution regulations and a letter campaign advocating regulation of cigars.

ATS President 2013-14-vision for the coming year. Patrician Finn gave a summary of what she hopes to accomplish over the next year. The theme of her presidency will be health equality.

ATS Executive Director-update. Steve Crane gave a positive presentation on the financial status. Although not as well attended as last year’s ATS in San Francisco, this year’s Philadelphia meeting has better attendance than expected. The reserve has increased to nearly 75% of the yearly budget. The ATS is offering free maintenance of certification modules.

2013 Outstanding Clinician Award. The finalists for the ATS 2013 Outstanding Clinician Award; Allen Thomas (Arizona), Amine Temmar (New Mexico) and Steve Kirtland (Washington) will be recognized at the Clinician’s Center, Monday, 3:30-4:30 PM, Pennsylvania Convention Center, Hall C, 200 level.

Presentation of CCR Officers 2013-4

• Linda Nici-Immediate Past Chair
• Samya Nasr-Chair
• Robin Gross-Chair-elect
• Steve Kirtland-Secretary

ATS Foundation. Jim Donahue, Foundation president, gave a presentation of the activities of the ATS Foundation. Currently, all monies designated for research are used to support research. The ATS is also holding a meeting with the ALA to discuss joint grants.

Great Cases Symposium. The Great Cases Symposium organized by CCR will be held on Sunday, May 19, 2:00-4:30 PM.

A Look at the Coming Year. Samya Nasr, incoming CCR Chair, reviewed plans for the upcoming year.

Important Dates

• May 16-21, 2014-ATS International Conference, San Diego
• July 1, 2013-Call for input for 2014 International Conference
• November 6, 2013-Abstract deadline for the 2014 International Conference

CCR Committee Representatives 2013-4

• Clinicians Advisory: Robin Gross
• Education: Carol Welsh
• Ethics and Conflicts of Interest: Samya Nasr
• Health Policy: Dona Upson
• Planning and Evaluation: Linda Nici
• Quality Improvement: Rick Robbins
• Research Advocacy: Linda Nici
• Training: Samya Nasr

Adjournment. The meeting was adjourned at 1:00 PM.

Richard A. Robbins

Arizona Chapter Representative

Reference as: Robbins RA. May 2013 council of chapter representatives notes. Southwest J Pulm Crit Care. 2013:6(5):239-40. PDF

May 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 5/15/2013 at Scottsdale Shea beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep, thoracic surgery, and radiology communities.

Dr. George Parides will have served his 2 year tenure as Arizona Thoracic Society President by July, 2013. However, he will be unable to attend the June meeting and for this reason Presidential elections were held. Dr. Lewis Wesselius was nominated and unanimously elected as President.

Three cases were presented:

1. Dr. Gerald Schwartzberg presented the case of a 49 year old woman with a history of Valley Fever in 2009. She was a nonsmoker and had no other known medical diseases.  However, she developed shortness of breath beginning earlier this year along with a cough productive of clear, jelly-like sputum. Her physical was normal. Pulmonary function testing revealed restrictive disease with significant improvements in the FEV1 and FVC after bronchodilators.  Eosinophils were increased in her CBC at 12%. IgE was moderately increased at 286 IU/ml.  Chest x-ray was normal. A high resolution thoracic CT scan revealed scattered bronchiectasis and mucoid impaction.  Some speculated that this could be a case of allergic bronchopulmonary aspergillosis (ABPA) although all agreed that the level of IgE was lower than commonly occurs with ABPA. It was felt that an Aspergillus specific IgE might be useful. It was also suggested that the coccidiomycosis might have caused the bronchiectasis, noting that mycosis other than Aspergillus sp. may cause the syndrome similar to ABPA which has been termed allergic bronchopulmonary mycosis.
2. Dr. Jud Tillinghast presented a case of 45 year old woman who worked as a nurse practioner. She had developed rheumatoid arthritis a few years earlier and was being treated with plaquenil and steroids. Recently she had developed shortness of breath. A few squeaks were normal on auscultation of the lungs. Pulmonary function testing was normal. However, a thoracic CT scan revealed a mosaic pattern consistent with air trapping. An open lung biopsy was performed and was consistent with constrictive bronchiolitis. The biopsy did not show inflammation but obliteration of the small bronchioles. Considerable discussion centered on treatment with most agreeing that there were no known efficacious treatments. 
3. Dr. Allen Thomas presented a case of a 72 year old man with 2 small pulmonary nodules discovered incidentally in Northern California. However, at the time of discovery he was in the process of moving to Arizona and presented a year later. Follow up thoracic CT scan revealed multiple small nodules and mediastinal nodes. Mediastinoscopy revealed noncaseating granulomas. A repeat CT showed that the mediastinal nodes have resolved but the nodules persisted. A PET scan showed markedly enhanced uptake by the nodules and in the mediastinum raising a question of carcinoma. Most felt that this was likely a manifestation of sarcoidosis and not necessarily an indication of cancer.

There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, June 26. The July meeting will be in Tucson on July 24^th at 6:30 PM. Location to be determined.  

Rick Robbins

Arizona CCR Representative

Reference as: Robbins RA. May 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2013;6(5):237-8. PDF

April 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 4/24/2013 at Scottsdale Shea beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep, infectious disease, and radiology communities. Drs. Gotway and August, thoracic radiologists, were both unable to attend. Dr. Tilman Kolesch from Maricopa more than capably filled in as our radiologist.

The meeting was preceded by a discussion on Pharma and the availability of physicians who accept money, including dinners, from pharmaceutical companies. The Arizona Thoracic Society is sponsored by pharmaceutical companies.

Ken Knox asked if Arizona Thoracic Society meetings could be held in Tucson during July and December, the two months meetings have not been scheduled. The attendees enthusiastically endorsed this expansion of the Arizona Thoracic Society meetings.

In addition, Dr. Knox wishes to sponsor a winter symposium in Tucson in collaboration with the Arizona Thoracic Society. The attendees also enthusiastically endorsed this meeting. 

Four cases were presented:

1. Tim Kuberski, infectious disease from Maricopa, presented a case of a 27 year old woman who was in her 38th week of pregnancy who was referred for an abnormal chest x-ray. She has a positive history of tuberculosis which was treated with only 2 weeks of isoniazid, rifampin and ethambutol. Her chest x-ray showed volume loss and left upper lobe cavitary disease. This had progressed from an old chest x-ray taken several years previously.  Sputum was positive for acid-fast bacilli. Previously the patient had grown Mycobacterium kansasii. Given that she was in her 38^th week of pregnancy, the patient was asymptomatic and the tempo of her disease appeared slow, most suggested waiting until after her delivery to start therapy.
2. Tom Colby, pulmonary pathologist from the Mayo Clinic presented a case of a 5 year old with enlarging nodules in both lungs. The child had a history of cystic pulmonary adenomatoid malformation or congenital cystic adenomatoid malformation (CPAM/CCAM) at 8 days. Biopsy of the lesions revealed histology consistent with mucinous adenocarcinoma. This has been previously reported (Am J Surg Pathol. 2003;27:1139-46).  
3. Dr. Colby also presented a case of a 38 year old with a history of sarcoidosis that had developed cystic changes in the left upper lobe. Biopsy was consistent with mucinous adenocarcinoma. Dr. Colby discussed the potential association of these lymphocytic predominant lesions with mucinous adenocarcinoma.
4. Lewis Wesselius, pulmonologist from the Mayo Clinic, presented a 65 year old from Colorado with lung masses. The patient had a history of dermatomyositis and was being with intravenous immunoglobulin (IVIG), prednisone and methotrexate for his dermatomyositis and warfarin for his pulmonary embolism. A thoracic CT scan showed multiple nodules which were new compared to an old chest x-ray. A PET scan was positive. A CT guided biopsy was nondiagnostic.  Video-assisted thorascopic surgery (VATS) biopsy showed an Epstein Barr Virus-positive immunodeficiency-associated lymphoproliferative disorder with Hodgkin lymphoma-like features. Dr Wesselius reviewed immunodeficiency-associated lymphoproliferative diseases. If was thought that the patient’s case was most consistent with a methotrexate-induced lymphoma which have been reported to spontaneously improve with discontinuation of methotrexate. Methotrexate was discontinued and the lesions are shrinking.

There being no further business the meeting was adjourned at about 8 PM. The next meeting is scheduled for Wednesday, May 15 prior to the American Thoracic Society meeting in Philadelphia.

Rick Robbins

Arizona CCR Representative

Reference as: Robbins RA. April 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;6(4):189-190. PDF

March 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 3/20/2013 at Scottsdale Shea beginning at 6:30 PM. There were 14 in attendance representing the pulmonary, critical care, sleep, infectious disease, nursing, and radiology communities.

Copies of the book “Breathing in America: Diseases, Progress, and Hope” were distributed.

Three cases were presented:

1. Tim Kuberski, infectious diseases from Maricopa, presented a 49 year old woman with a history of alcoholism who presented with RML pneumonia. Despite azithromycin and cephtriaxone she developed progressive respiratory failure and a right pleural effusion. A right chest tube was placed. Cultures of blood and the pleural fluid were negative. She was suspected of having an anaerobic infection. Follow-up CT scan showed abscess formation in her RML with areas of dense consolidation on the left and a left pleural effusion. Discussion focused on whether RML resection should be performed. Most favored a surgical approach.
2. Andrew Goldstein, thoracic surgery, presented a 48 year old man with a large extrathoracic chest mass who presented with hematuria. The hematuria eventually proved to be secondary to bladder cancer. On CT the approximate 7 cm mass appears to be growing from the manubrium. Biopsy of the mass revealed transitional cell carcinoma. There are clinically no other metastasis. The sternal tumor was resected and the patient has done well and has returned to work.
3. Tom Ardiles, pulmonary from Maricopa, presented 21 yo woman who presented with pneumonia after a cardiac arrest. She has a history of alcohol and dextroamphetamine abuse. Her procalcitonin levels were elevated. She developed right lower lung consolidation and a right pneumothorax. Sputum grew Pseudomonas. CT shows diffuse grown glass opacities and pneumomediastinum and intertidal emphysema. She has had progressive consolidation on chest x-ray and persistent respiratory failure. A right pleural effusion developed and was drained which also cultured Pseudomonas. She is gradually improving on oscillatory ventilation and antibiotics.

There being no further business, the meeting was adjourned at about 8 PM. The next meeting is Wednesday, April 24, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. March 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;6(3):148. PDF