
Madhav Chopra
- Assistant Professor, Medicine - (Clinical Scholar Track)
Contact
- (520) 626-6114
- AHSC, Rm. 2301
- chopramv@arizona.edu
Degrees
- M.D.
- University of Cincinnati, Cincinnati, Ohio, United States
Licensure & Certification
- Internal Medicine, ABIM (2018)
Interests
Teaching
Procedural Education
Research
Interventional PulmonaryThoracic OncologyBronchoscopy
Courses
No activities entered.
Scholarly Contributions
Journals/Publications
- Bixby, B., Vrba, L., Lenka, J., Oshiro, M., Watts, G., Hughes, T., Erickson, H., Chopra, M., Knepler, J., Knox, K., Jarnagin, L., Alalawi, R., Kala, M., Bernert, R., Routh, J., Roe, D., Garland, L., Futscher, B., & Nelson, M. (2024). Cell-free DNA methylation analysis as a marker of malignancy in pleural fluid. Scientific Reports, 14(1). doi:10.1038/s41598-024-53132-xMore infoDiagnosis of malignant pleural effusion (MPE) is made by cytological examination of pleural fluid or histological examination of pleural tissue from biopsy. Unfortunately, detection of malignancy using cytology has an overall sensitivity of 50%, and is dependent upon tumor load, volume of fluid assessed, and cytopathologist experience. The diagnostic yield of pleural fluid cytology is also compromised by low abundance of tumor cells or when morphology is obscured by inflammation or reactive mesothelial cells. A reliable molecular marker that may complement fluid cytology for the diagnosis of malignant pleural effusion is needed. The purpose of this study was to establish a molecular diagnostic approach based on pleural effusion cell-free DNA methylation analysis for the differential diagnosis of malignant pleural effusion and benign pleural effusion. This was a blind, prospective case–control biomarker study. We recruited 104 patients with pleural effusion for the study. We collected pleural fluid from patients with: MPE (n = 48), indeterminate pleural effusion in subjects with known malignancy or IPE (n = 28), and benign PE (n = 28), and performed the Sentinel-MPE liquid biopsy assay. The methylation level of Sentinel-MPE was markedly higher in the MPE samples compared to BPE control samples (p < 0.0001) and the same tendency was observed relative to IPE (p = 0.004). We also noted that the methylation signal was significantly higher in IPE relative to BPE (p < 0.001). We also assessed the diagnostic efficiency of the Sentinel-MPE test by performing receiver operating characteristic analysis (ROC). For the ROC analysis we combined the malignant and indeterminate pleural effusion groups (n = 76) and compared against the benign group (n = 28). The detection sensitivity and specificity of the Sentinel-MPE test was high (AUC = 0.912). The Sentinel-MPE appears to have better performance characteristics than cytology analysis. However, combining Sentinel-MPE with cytology analysis could be an even more effective approach for the diagnosis of MPE. The Sentinel-MPE test can discriminate between BPE and MPE. The Sentinel-MPE liquid biopsy test can detect aberrant DNA in several different tumor types. The Sentinel-MPE test can be a complementary tool to cytology in the diagnosis of MPE.
- Corcoran, A., Shore, D., Boesch, R. P., Chopra, M., Das, S., DiBardino, D., Goldfarb, S., Haas, A., Hysinger, E., Phinizy, P., Vicencio, A., Toth, J., & Piccione, J. (2024). Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States. Pediatric Pulmonology. doi:10.1002/ppul.26977
- Corcoran, A., Shore, D., Boesch, R., Chopra, M., Das, S., DiBardino, D., Goldfarb, S., Haas, A., Hysinger, E., Phinizy, P., Vicencio, A., Toth, J., & Piccione, J. (2024). Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States. Pediatric Pulmonology, 59(6). doi:10.1002/ppul.26977More infoIntroduction: Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9]. Methods: We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States. Results: We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows. Discussion: This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.
- Agarwal, M., Cummings, K., Larsen, B., Chopra, M., & Rodriguez-Pla, A. (2023). Late Onset of Rivaroxaban-Associated Anti-Neutrophil Cytoplasmic Antibody–Associated Vasculitis. Journal of Investigative Medicine High Impact Case Reports, 11. doi:10.1177/23247096231207689More infoAlthough anti-thyroid drugs (ATDs) are the most common cause of drug-associated anti-neutrophil cytoplasmic antibody (ANCA) vasculitis (AAV), many other classes of drugs can lead to drug-associated AAV. We present a unique case of rivaroxaban-associated AAV. A 76-year-old female with a past medical history of atrial fibrillation on rivaroxaban presented with fatigue, bilateral lower extremity purpura, and hemoptysis to an outside hospital. Investigations revealed a positive cytoplasmic-ANCA (c-ANCA) titer of 1:320 and a positive anti-myeloperoxidase (anti-MPO), and negative perinuclear-ANCA (p-ANCA) and anti-proteinase 3 (anti-PR3). In addition, chest imaging demonstrated bilateral ground-glass opacities which raised suspicion for diffuse alveolar hemorrhage (DAH). A lung biopsy revealed acute and ongoing DAH with focally active capillaritis and characteristic pathological findings, which strongly suggested that was likely secondary to rivaroxaban. Rivaroxaban was discontinued, and the patient received pulses of intravenous glucocorticosteroids and rituximab. Her symptoms improved. She continued immunosuppressive therapy with rituximab for 2 years. She presented to our hospital for a second opinion regarding the discontinuation of rituximab, and we decided to discontinue rituximab. After discontinuation, the patient remained stable after 1.5 years of follow-up and did not have any relapses. This is a unique case of rivaroxaban-associated AAV. Clinicians should consider drug-associated AAV in all patients who present with an atypical clinical presentation and/or pathological findings of AAV. Given the broad and rapidly increasing use of novel anticoagulants, it is important to raise awareness of this potential complication. Prompt discontinuation of the drug and initiation of immunosuppressant treatment in severe cases may be lifesaving.
- Chopra, M., Patel, B., Puthalapattu, S., & Nguyen, T. (2021). An Unusual Case of Chronic Hemoptysis. Chest, 159(5). doi:10.1016/j.chest.2020.12.031More infoCase Presentation: A 62-year-old African American man was admitted to the hospital with hemoptysis. He had a complicated medical history significant for active tobacco use (>50 pack-year history), coronary artery disease, and heart failure with reduced ejection fraction. He reported intermittent episodes of coughing up streaks of blood in the sputum for the past 3 years. For the past few days before this presentation, he had multiple episodes of coughing up over a tablespoon of only blood. He was not on any anticoagulant agents. There were no risk factors for TB, nor was there a history of fevers, chills, shortness of breath, leg swelling, changes in his urine color and frequency or urgency, or unintended weight loss. On admission, he was noted to be breathing comfortably. Vital signs revealed a temperature of 36.6ºC, BP of 138/70 mm Hg, heart rate of 66 beats/min, respiratory of rate of 18 breaths/min, and a blood oxygen saturation level of 98% on room air. Physical examination was significant for decreased bilateral breath sounds with no wheezing, crackles, or rhonchi. Cardiovascular examination revealed normal cardiac rhythm without murmur, rubs, or gallops. There was no clubbing or edema on his extremities.
- Harris, D., Badowski, M., Jernigan, B., Sprissler, R., Edwards, T., Cohen, R., Paul, S., Merchant, N., Weinkauf, C., Bime, C., Erickson, H., Bixby, B., Parthasarathy, S., Chaudhary, S., Natt, B., Cristan, E., El Aini, T., Rischard, F., Campion, J., , Chopra, M., et al. (2021). SARS-CoV-2 rapid antigen testing of symptomatic and asymptomatic individuals on the University of Arizona campus. Biomedicines, 9(5). doi:10.3390/biomedicines9050539More infoSARS-CoV-2, the cause of COVID19, has caused a pandemic that has infected more than 80 M and killed more than 1.6 M persons worldwide. In the US as of December 2020, it has infected more than 32 M people while causing more than 570,000 deaths. As the pandemic persists, there has been a public demand to reopen schools and university campuses. To consider these demands, it is necessary to rapidly identify those individuals infected with the virus and isolate them so that disease transmission can be stopped. In the present study, we examined the sensitivity of the Quidel Rapid Antigen test for use in screening both symptomatic and asymptomatic individuals at the University of Arizona from June to August 2020. A total of 885 symptomatic and 1551 asymptomatic subjects were assessed by antigen testing and real-time PCR testing. The sensitivity of the test for both symptomatic and asymptomatic persons was between 82 and 90%, with some caveats.
- Puthalapattu, S., Chopra, M., & Rao, S. (2021). “Did You Leave the Wire in?” A Striking Case of Linear Pulmonary Cement Embolism. American Journal of Respiratory and Critical Care Medicine, 204(10), e110-e112. doi:10.1164/rccm.202010-3985im
- Ripperger, T., Uhrlaub, J., Watanabe, M., Wong, R., Castaneda, Y., Pizzato, H., Thompson, M., Bradshaw, C., Weinkauf, C., Bime, C., Erickson, H., Knox, K., Bixby, B., Parthasarathy, S., Chaudhary, S., Natt, B., Cristan, E., El Aini, T., Rischard, F., , Campion, J., et al. (2020). Orthogonal SARS-CoV-2 Serological Assays Enable Surveillance of Low-Prevalence Communities and Reveal Durable Humoral Immunity. Immunity, 53(5). doi:10.1016/j.immuni.2020.10.004More infoWe conducted a serological study to define correlates of immunity against SARS-CoV-2. Compared to those with mild coronavirus disease 2019 (COVID-19) cases, individuals with severe disease exhibited elevated virus-neutralizing titers and antibodies against the nucleocapsid (N) and the receptor binding domain (RBD) of the spike protein. Age and sex played lesser roles. All cases, including asymptomatic individuals, seroconverted by 2 weeks after PCR confirmation. Spike RBD and S2 and neutralizing antibodies remained detectable through 5–7 months after onset, whereas α-N titers diminished. Testing 5,882 members of the local community revealed only 1 sample with seroreactivity to both RBD and S2 that lacked neutralizing antibodies. This fidelity could not be achieved with either RBD or S2 alone. Thus, inclusion of multiple independent assays improved the accuracy of antibody tests in low-seroprevalence communities and revealed differences in antibody kinetics depending on the antigen. We conclude that neutralizing antibodies are stably produced for at least 5–7 months after SARS-CoV-2 infection. Serological assays for SARS-CoV-2 exposures are challenging due to poor positive predictive values. Ripperger et al. show that the combinatorial use of spike receptor binding domain and S2 eliminates almost all false positives. This serological assay is used to show durable antibody production for at least 5–7 months after infection.
- Power, E. P., Chopra, M., Kumar, S., Ojo, T., & Knepler, J. (2018). Ultrasound for critical care physicians: characteristic findings in a complicated effusion. Southwest Journal of Pulmonary and Critical Care. doi:10.13175/swjpcc122-18
Proceedings Publications
- Anderson, A., Patel, P. P., & Chopra, M. (2023). What Is Blocking the Bronchus? A Case of Pulmonary Extramedullary Plasmacytoma Presenting as Right Mainstem Bronchial Obstruction. In ATS.
- Bixby, B., Vrba, L., Lenka, J., Oshiro, M., Watts, G. S., Hughes, T., Erickson, H., Chopra, M., Knepler, J. L., Knox, K. S., Jarnagin, L., Alalawi, R., Kala, M., Bernert, R., Routh, J., Roe, D. J., Garland, L. L., Futscher, B. W., & Nelson, M. A. (2023). Cell-Free DNA Methylation Analysis as a Marker of Malignancy in Pleural Fluid. In ATS 2023.
- Johnson, A., Collura, B., Kumar, S., Chopra, M., & Bime, C. (2023). A Confusing Case of Bloody Cough: Not Everything is TB. In American Thoracic Society 2023.
- Kumar, S., Kumar, S., Rathbun, J., Rathbun, J., Chopra, M., & Chopra, M. (2023). BRAIN DRAIN: A CASE OF VENTRICULOPLEURAL SHUNT WITH OVERDRAINAGE CAUSING SYMPTOMATIC PLEURAL EFFUSION. In American Thoracic Society.More infoSESSION TITLE: Many Roads Lead to the Pleural Space SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 09:40 am - 10:25 am INTRODUCTION: The pleural space is a less common but known location for placement of shunts to divert CSF, used when the typical first choice(peritoneal) location is not suitable due to adhesions, infection, thrombosis, or obliteration. Such drainage devices are called ventriculopleural shunts (VPLS). Flow into the distal(draining) catheter of a VPLS is typically regulated by a one-way valve which often contain magnets that enable transcutaneous valve pressure adjustments. CASE PRESENTATION: A 41 year old woman with a past medical history of asthma, gastrocystoplasty and spina bifida complicated by hydrocephalus with ventriculoperitoneal (VP) shunt placement at birth presented to the hospital with complaints of headache and abdominal pain. Of note, her VP shunt had been replaced and revised one month and two weeks prior to acute presentation, respectively. The patient was found to have a peritoneal CSF pseudocyst (10.5 x 9.1x 12.4cm). The patient was taken to the OR for VP shunt exchange to Ventriculo-pleural shunt (VPLS), with distal end in the right pleural space. She was discharged two days later with resolution of symptoms. Two weeks later, the patient represented with complaints of shortness of breath. Radiograph displayed a moderate right pleural effusion (Figure 1). Initially the effusion was thought to be typical asymptomatic association seen in VPLS and further interventions were deferred by Neurosurgery. Pulmonary was subsequently consulted for pleural effusion management. After failed attempts at bedside ultrasound guided thoracentesis, a CT guided right 8F pigtail chest tube was placed. Pleural fluid analysis confirmed CSF origins(Figure 2). She later developed a headache and a CT head showed evidence of over-shunting (Figure 3). After readjustment of her VPLS to the highest resistance pressure sensing drainage by neurosurgery, her effusion resolved with minimal drainage from the chest tube. The patient's chest tube was later removed. The patient was discharged home with improved symptoms. Plan for outpatient follow up include discussions around shunt revision to a higher resistance valve if symptoms reoccur. DISCUSSION: The overall complication rate of VPLS is about 24%. Small asymptomatic pleural effusions are common in patients with a VPLS. Symptomatic pleural effusions are rare. Possible mechanisms include impaired drainage from the pleural space(From infection/inflammation), excessive CSF drainage into the pleural space. Pleural fluid analysis consistent with CSF typically shows transudative, beta 2 transferrin positivity as seen in our patient. It is postulated that the negative pressure generated by the pleural space increases the risk of over drainage. Evidence of CSF over drainage can be seen on imaging as slit like ventricles. This can cause symptomatic pleural effusion and headaches. Addition of an antisiphon valve has shown to reduce the incidence of overdrainage. Treatment is typically through adjustment of ventricular drainage valve to higher resistances/shunt revision/alternate locations for CSF drainage. CONCLUSIONS: The pleural space is a suitable alternative for drainage of CSF when peritoneal locations are not ideal. Asymptomatic pleural effusions do not typically require drainage. Symptomatic pleural effusions in VPLS require further interrogation and intervention.Complications to be aware of with VPLS shunt include infection, adhesions, and shunt malfunction including overdrainage. REFERENCE #1: Küpeli, Elif et al. "Pleural effusion following ventriculopleural shunt: Case reports and review of the literature." Annals of thoracic medicine vol. 5,3 (2010): 166-70. doi:10.4103/1817-1737.65048 REFERENCE #2: Adam N. Wallace, Jonathan McConathy, Christine O. Menias, Sanjeev Bhalla, and Franz J. Wippold IIAmerican Journal of Roentgenology 2014 202:1, 38-53 REFERENCE #3: https://doi.org/10.1016/j.chest.2020.08.1126 DISCLOSURES: No disclosure on file for Madhav Chopra No relevant relationships by Sooraj Kumar No relevant relationships by John Rathbun
- PATEL, B., Chopra, M., Bixby, B., & Knepler, J. (2023). EARLIER REFERRAL FOR BRONCHOSCOPY IN IMMUNOCOMPROMISED PATIENT. In CHEST.More infoSESSION TITLE: Proceduralist Round Table SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/10/2023 12:00 pm - 12:45 pm PURPOSE: There are many indications for bronchoscopy with alveolar lavage (BAL), especially in the immunocompromised patient with a new pulmonary infiltrate (1). At our hospital, these immunocompromised patients have empiric antibiotics started before pulmonology is consulted. When these patients undergo a BAL, there is always a chance the sample is sterilized and nondiagnostic. The purpose of this retrospective review was to answer if doing a BAL in immunocompromised patients in the inpatient setting with a new pulmonary infiltrate changed clinical management. METHODS: We collected data over one year from patients who had a bronchscopy while inpatient. We selected for patients that were immunocompromised, inpatient, and had a new pulmonary infiltrate. We defined immunocompromised per IDSA guidelines (2). 54 patients were selected. Each patient chart was analyzed for the type of immunocompromised status, when pulmonology was consulted, how many days of antibiotics the patient received before bronchoscopy, types of serum tests, sputum culture, an adequate BAL per ATS guidelines, results of tests from BAL, if a transbronchial biopsy (TBBx) was done, and if the data changed management. Descriptive statistics were performed for analysis. RESULTS: 54 patients met criteria for this review. There were 28 (52%) patients who had a BAL that provided data to change initial management. The average time from antibiotics to bronchoscopy for these patients was 6 days. 26 (48%) patients did not have a diagnostic BAL and their average time from antibiotics to bronchoscopy was 7 days. The consult to bronchoscopy time was 2 days. Only 25 patients had adequate BAL return per ATS. 4 patients had TBBx with BAL. 41 patients did not get sputum cultures prior to BAL. The BAL cultures from 45 patients did not grow any organisms. The most common diagnostic results from the BALs were infection, malignancy, and pulmonary toxicity. Finally, there were 9 patients (16%) that had a BAL result that was opposite of initial diagnosis, however, management of those patients did not change. CONCLUSIONS: This retrospective review shows that BAL appears to be an effective tool to guide treatment in patients who are immunocompromised with new pulmonary infiltrates. The data shows that molecular tests from the BAL were superior over sputum and BAL cultures. Additionally, those who underwent a TBBx with BAL, seemed to have increased diagnostic yield in comparison to just BAL. However, our data shows that those who did not get appropriate BAL return, usually did not yield diagnostic data. CLINICAL IMPLICATIONS: This research shows the importance of early BALin immunocompromised patients with new pulmonary infiltrates. Early bronchoscopy is helpful to avoid unnecessary antibiotics and likely leads to lower length of stay. It also shows us that adding on TBBx to the BAL can lead to increased diagnostic yield (3). Additionally, BAL should be considered as one of the first tests in these patient’s due to the increasing accuracy of molecular tests (4). Finally, it shows us that these group of patients should have earlier referral to pulmonology to increase diagnostic yield. DISCLOSURES: No relevant relationships by Billie Bixby No disclosure on file for Madhav Chopra No relevant relationships by James Knepler No relevant relationships by Bhargav Patel
- Cristan, E., & Chopra, M. (2020). Rivaroxaban Induced Anti-Neutrophil Cytoplasmic Antibody (ANCA) Associated Vasculitis. In ATS 2020.
- El Aini, T., Chopra, M., Chan, Y., & Nyquist, A. (2020). You're Hot Then You're Cold - Heat Stroke Complicated by Iatrogenic Hypothermia. In ATS 2020.
- Dicken, J., Chopra, M., Jaffer, F., & Snyder, L. A. (2018). Medical image of the week: Chylothorax. In Southwest Pulmonary and Critical Care Journal.