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

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

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

November 2013 Arizona Thoracic Society Notes

The November Arizona Thoracic Society meeting was held on Wednesday, 11/20/2013 at Shea Hospital beginning at 6:30 PM. There were 26 in attendance representing the pulmonary, critical care, sleep, nursing, radiology, and infectious disease communities.

As per the last meeting a separate area for upcoming meetings has been created in the upper left hand corner of the home page on the SWJPCC website.

A short presentation was made by Timothy Kuberski MD, Chief of Infectious Disease at Maricopa Medical Center, entitled “Clinical Evidence for Coccidioidomycosis as an Etiology for Sarcoidosis”. Isaac Yourison, a medical student at the University of Arizona, will be working with Dr. Kuberski on his scholarly project. Mr. Yourison hypothesizes that certain patients diagnosed with sarcoidosis in Arizona really have coccidioidomycosis. It would be predicted that because of the immunosuppression, usually due to steroids, the sarcoidosis patients would eventually express the Coccidioides infection. The investigators will be collaborating with the University of Washington to perform polymerase chain reaction (PCR) on tissue samples diagnosed with sarcoidosis for Coccidioides.

There were 4 cases presented:

1. The first case was presented by Lewis Wesselius from the Mayo Clinic Arizona. The patient was a 56 year old woman with rheumatoid arthritis and a prior history of bronchiectasis. In 2009 she was diagnosed with Mycobacterium avium-intracellulare (MAI) on bronchoscopy and started on azithromycin, ethambutol, and rifabutin. She had been on etanercept which was held after her diagnosis of MAI.  She had a negative sputum culture for MAI in September 2012 and her MAI medications were stopped. However, in May 2013 she had increasing symptoms and bronchoscopy demonstrated Pseudomonas and nontuberculous mycobacterium (NTB). She subsequently moved to Phoenix and a CT scan showed the size of her lung nodules to be increased. Bronchoscopic cultures showed Pseudomonas and Mycobacterium abscessus only sensitive to amikacin. She was treated with tigecycline and inhaled amikacin. A repeat CT scan indicated some decrease in size of lung nodules. Dr. Wesselius gave a short presentation on bronchiectasis associated with rheumatoid arthritis and NTB infection in these patients.
2. The second case was presented by Gerry Swartzberg. Dr. Schwartzberg showed a chest x-ray and asked the audience to guess the diagnosis. Jasminder Mand was the first to correctly guess allergic bronchopulmonary aspergillosis (ABPA) because of the finger in glove sign which best seen in the right upper lobe. The density forms from mucous impaction in a more central bronchus and has been referred to as a rabbit ear appearance, Mickey Mouse appearance, toothpaste shaped opacities, Y-shaped opacities, and V-shaped opacities. Dr. Mand also referred to this as the Churchill sign since it looks like the “V” gesture often associated with Churchill. The patient was begun on corticosteroids and a repeat chest x-ray taken about a month later showed near clearing of the opacities.
3. Dr. Schwartzberg presented a second case of an elderly woman in her 80’s with a history of bronchiectasis. Chest x-ray and CT scan showed several rapidly expanding lung masses. The radiographic appearance was not particularly suggestive of a diagnosis. There was a concern for malignancy and the majority thought bronchoscopy would be appropriate.
4. The last case was presented by Joshua  Jewell, a third year pulmonary fellow in the Good Samaritan/VA program. The patient was a middle-aged man who had a history of diffusely metastatic hepatocellular cancer including to his lung and mediastinal lymph nodes. He was also diagnosed with sleep apnea and begun on continuous positive airway pressure (CPAP). He had increasing size of his neck and presented to the pulmonary clinic. Palpation revealed crepitus and a chest x-ray and CT scan confirmed the presence of subcutaneous air and a pneumomediastinum. Dr. Jewell hypothesized that the air was introduced or at least was exacerbated by the CPAP possibly from a ball valve mechanism. Most in the audience agreed this was a reasonable explanation but none had observed this phenomenon previously.

There being no further business the meeting was adjourned at about 8:30 PM. The next meeting is scheduled for Saturday, December 14, 8-12 AM in Tucson at the Kiewit Auditorium at the University of Arizona Medical Center.  The next meeting in Phoenix will be held on Wednesday, January 22, 2014, 6:30 PM at Scottsdale Shea hospital.

Richard A. Robbins, M.D.

Reference as: Robbins RA. November 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013:7(5):311-2. doi: http://dx.doi.org/10.13175/swjpcc167-13 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

October 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 10/24/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

An announcement was made that the Colorado Thoracic Society has accepted an invitation to partner with the Arizona and New Mexico Thoracic Societies in the Southwest Journal of Pulmonary and Critical Care Medicine.

Discussions continue to be held regarding a combined Arizona Thoracic Society meeting with Tucson either in Casa Grande or electronically.

Six cases were presented:

Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 48 year old female who had been ill for 2 weeks. A CT of the chest revealed a left lower lobe nodule and a CT of the abdomen showed hydronephrosis and a pelvic mass. Carcinoembryonic antigen (CEA) was elevated. All turned out to be coccidioidomycosis on biopsy.  CEA decreased after the pelvic mass was resected.

Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a 60 year old man with a past medical history of a transbronchial biopsy showing nonspecific interstitial lung disease. CT scan showed bilateral hilar lymphadenopathy and multifocal ground glass opacities. Multiple serologies were all negative. Biopsy revealed both hypersensitivity pneumonitis and sarcoidosis. It was pointed out by Drs. Michael Gotway and David August that the usual presentation of sarcoidosis in the lung is bilateral lymphadenopathy with multiple small nodules in a peribronchovascular distribution along with irregular thickening of the interstitium. Although multifocal ground glass opacities have been reported with sarcoidosis, it is unusual.

Dr. George Parides presented two cases of patients with rheumatoid arthritis receiving biologic therapy. One presented with a positive QuantiFERON test for tuberculosis and the other with a positive PPD. Management was discussed. None were aware of any data but the majority thought that stopping the biologics, if possible, and treating with INH for 9 months was probably appropriate.

Dr. Colby presented a second case of a 52 year old heavy smoker with shortness of breath while playing basketball. Chest CT showed ground glass opacities with minimal fibrosis. A lung biopsy showed various areas consistent with desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease or nonspecific interstitial pneumonitis with scarring.  Dr. Colby stated that smokers with interstitial disease can have different patterns on biopsy. Drs. Gotway and August pointed out that the lung CT pattern is also often heterogenous.

Dr. Lewis Wesselius presented a 49 year old female admitted for hypoxia, lethargy, and an abnormal chest x-ray. She had a prior diagnosis of systemic lupus erythematosis (SLE) with a reported diagnosis of lupus pneumonitis made 3-4 years ago. There was a history of multiple episodes of pneumonia (25 in 5 years), a prior stroke and mitral valve disease with valve replacement. Chest CT showed multiple areas of ground glass opacities and bronchoscopy with bronchoalveolar lavage resulted in a bloody return. Serologies were inconsistent with SLE but anti-phospolipid antibodies were present. Dr. Wesselius reviewed antiphospholipid antibody syndrome (APS) which can occur as a primary condition or in the setting of an underlying systemic autoimmune disease such as SLE. Manifestations include deep venous thrombosis (32%), thrombocytopenia (22%), livedo reticularis (20%), stroke (13%), pulmonary embolus (9%), fetal loss (8%), transient ischemic attack (7%), hemolytic anemia (7%), and rarely alveolar hemorrhage. Treatment includes high dose corticosteroids, cyclophosphamide, mycophenolate, IVIG, and plasmapharesis. A recent report (Lupus 2012, 21:438-40) advocated Rituximab, a chimeric monoclonal antibody against the protein CD20, which is primarily found on the surface of B cells, for recurrent diffuse alveolar hemorrhage in primary APS.

There being no further business, the meeting was adjourned. The next meeting is November 28 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. October 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:218-9. PDF