Pulmonology Practice Questions

Q: Which interstitial lung disease is characterized by granulomas on lung biopsy?

Sarcoidosis. **Explanation:** **Sarcoidosis** is the correct answer because it is a multisystem inflammatory disease defined histologically by the presence of **non-caseating granulomas**. These granulomas are organized collections of epithelioid histiocytes, multinucleated giant cells (often containing **Schumann bodies** or **Asteroid bodies**), and a rim of lymphocytes. In the lungs, these typically follow a lymphangitic distribution along the pleura and bronchovascular bundles. **Analysis of Incorrect Options:** * **Usual Interstitial Pneumonitis (UIP):** This is the hallmark pattern of Idiopathic Pulmonary Fibrosis (IPF). It is characterized by **spatial and temporal heterogeneity**, fibroblastic foci, and "honeycombing," but lacks granulomas. * **Diffuse Alveolar Damage (DAD):** This is the histological correlate of **ARDS**. It is characterized by the formation of **hyaline membranes** lining the alveolar spaces, not granulomatous inflammation. * **Desquamative Interstitial Pneumonia (DIP):** This is a smoking-related ILD characterized by the diffuse accumulation of **intra-alveolar macrophages** (pigmented "smoker's macrophages") rather than organized granulomas. **High-Yield NEET-PG Pearls:** * **Differential for Lung Granulomas:** Always distinguish between **Non-caseating** (Sarcoidosis, Hypersensitivity Pneumonitis, Berylliosis) and **Caseating** (Tuberculosis, Fungal infections). * **Kveim-Siltzbach Test:** A historical skin test for Sarcoidosis (rarely used now). * **Radiology:** Look for bilateral hilar lymphadenopathy (Stage I) and the "Galaxy Sign" on HRCT. * **Lab Marker:** Elevated Serum **ACE (Angiotensin-Converting Enzyme)** levels and hypercalciuria/hypercalcemia due to 1-alpha hydroxylase activity in macrophages.

Q: Which of the following is NOT true about Kartagener's syndrome?

Mental retardation. Explanation: **Kartagener’s Syndrome** is a subset of **Primary Ciliary Dyskinesia (PCD)**, an autosomal recessive disorder characterized by the structural and functional impairment of cilia. The syndrome is classically defined by a clinical triad: **Situs Inversus (including Dextrocardia), Chronic Sinusitis, and Bronchiectasis.** [1] **Why Mental Retardation is the Correct Answer:** Mental retardation is **not** a feature of Kartagener’s syndrome. The pathology is strictly related to the dysfunction of dynein arms in cilia (most commonly a defect in the DNAH5 or DNAH11 genes). Since cognitive development does not rely on ciliary motility, intelligence and neurological functions remain normal. **Analysis of Incorrect Options:** * **A. Dextrocardia:** In PCD, the lack of ciliary motion during embryonic development leads to the random rotation of internal organs. In 50% of cases, this results in *Situs Inversus Totalis*, where the heart is on the right side (Dextrocardia). * **B. Infertility:** Ciliary action is essential for the motility of sperm tails (flagella) and the movement of ova through the fallopian tubes. Therefore, both males and females with this syndrome often face infertility. * **C. Bronchiectasis:** Impaired mucociliary clearance leads to recurrent pulmonary infections, chronic inflammation, and permanent dilation of the bronchi (bronchiectasis), typically involving the lower lobes. [1] **High-Yield Clinical Pearls for NEET-PG:** * **The Triad:** Bronchiectasis + Sinusitis + Situs Inversus. [1] * **Diagnosis:** The screening test of choice is **Nasal Nitric Oxide (nNO)** levels (which are low). The gold standard for diagnosis is **Electron Microscopy** (showing absent dynein arms) or genetic testing. * **Associated Condition:** Young’s Syndrome (Bronchiectasis + Obstructive Azoospermia) is a common differential but lacks the ciliary structural defects seen in Kartagener’s. [1]

Q: In the management of pulmonary emboli, what is the recommended infusion time for alteplase?

1-3 hours. **Explanation:** In the management of hemodynamically unstable (massive) pulmonary embolism (PE), thrombolytic therapy is indicated to rapidly dissolve the clot and reduce right ventricular strain [1]. **Alteplase (rt-PA)** is the preferred thrombolytic agent [2]. **1. Why Option A is Correct:** The standard FDA-approved regimen for alteplase in acute PE is **100 mg administered as a continuous intravenous infusion over 2 hours**. This rapid infusion (1-3 hour window) is preferred over older, prolonged regimens because it achieves faster clot lysis and hemodynamic improvement without a significant increase in major bleeding complications. In extreme cases of cardiac arrest, a "bolus" dose may be considered, but the 2-hour infusion remains the gold standard for massive PE. **2. Why Other Options are Incorrect:** * **Options B, C, and D:** These timeframes (4-12 hours) represent outdated protocols. Historically, first-generation thrombolytics like Streptokinase were administered over 12–24 hours [2]. However, for Alteplase, prolonged infusions do not offer additional efficacy and significantly increase the risk of bleeding, particularly intracranial hemorrhage [1]. **3. Clinical Pearls for NEET-PG:** * **Indication:** Thrombolysis is reserved for **Massive PE** (defined by hypotension: SBP <90 mmHg) or select cases of Submassive PE with evidence of severe RV dysfunction [1]. * **Drug of Choice:** Alteplase (100 mg over 2 hours). * **Alternative:** Tenecteplase (TNK-tPA) is often used in MI but is currently being studied for PE (not yet the primary standard over Alteplase in all guidelines). * **Contraindication:** Always screen for absolute contraindications like recent intracranial hemorrhage, active internal bleeding, or recent ischemic stroke (within 3 months) [1]. * **Post-Thrombolysis:** Heparin therapy should be initiated/resumed once the aPTT falls below twice the upper limit of normal.

Q: Thermoplasty is used in which condition?

Asthma. **Explanation:** **Bronchial Thermoplasty (BT)** is an innovative, FDA-approved bronchoscopic procedure specifically designed for the management of **severe, persistent asthma** that remains uncontrolled despite optimal medical therapy (high-dose inhaled corticosteroids and long-acting beta-agonists) [1]. **Why Asthma is the Correct Answer:** The pathophysiology of asthma involves hypertrophy and hyperplasia of the **bronchial smooth muscle (BSM)**, leading to airway hyperresponsiveness and narrowing. Bronchial thermoplasty uses controlled **radiofrequency energy** (thermal energy) delivered via a catheter to the airways. This heat selectively reduces the mass of the smooth muscle, thereby decreasing the lung's ability to constrict during an asthma attack. It typically involves three separate sessions targeting different lobes of the lungs. **Why Other Options are Incorrect:** * **COPD:** While COPD involves airway obstruction, the primary pathology is alveolar destruction (emphysema) and chronic inflammation/mucus production (bronchitis), rather than reversible smooth muscle constriction. * **Bronchiectasis:** This is characterized by permanent, abnormal dilation of the bronchi due to chronic infection and inflammation. Treatment focuses on airway clearance and antibiotics, not smooth muscle reduction. * **Carcinoma Lung:** Treatment modalities for lung cancer include surgery, chemotherapy, radiotherapy, or endobronchial interventions like stenting or laser ablation, but not thermoplasty. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Severe persistent asthma in patients ≥18 years old [1]. * **Mechanism:** Reduction of airway smooth muscle (ASM) mass. * **Contraindication:** Patients with pacemakers, internal defibrillators, or those experiencing an active asthma exacerbation. * **Common Side Effect:** Transient worsening of respiratory symptoms (cough, wheeze) immediately following the procedure.

Q: A patient presented with bilateral hilar lymphadenopathy and a negative Mantoux test. What is the most likely diagnosis?

Sarcoidosis. ### Explanation **Correct Answer: B. Sarcoidosis** **Reasoning:** The combination of **bilateral hilar lymphadenopathy (BHL)** and a **negative Mantoux test** is a classic presentation of Sarcoidosis. 1. **Bilateral Hilar Lymphadenopathy:** This is the hallmark radiological finding in Stage I and II Sarcoidosis [1]. 2. **Negative Mantoux (Anergy):** Sarcoidosis is characterized by a paradox: there is systemic T-cell energy (suppression of delayed-type hypersensitivity) despite intense local inflammation in the lungs. Approximately 30–70% of sarcoidosis patients will have a negative tuberculin skin test, even if previously exposed to TB. **Analysis of Incorrect Options:** * **D. Tuberculosis:** While TB is a common cause of lymphadenopathy in India, it typically presents with **unilateral** hilar lymphadenopathy and a **positive** Mantoux test [2]. * **A. Erythema Nodosum:** This is a clinical *sign* (painful shins) often associated with Sarcoidosis (as part of Löfgren syndrome), but it is not a diagnosis for the systemic findings described [1]. * **C. Hepatitis:** This is an inflammatory condition of the liver and does not typically present with hilar lymphadenopathy or specific Mantoux findings. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren Syndrome:** A triad of BHL, Erythema Nodosum, and Migratory Polyarthritis [1]. It has a highly favorable prognosis. * **Heerfordt Syndrome (Uveoparotid Fever):** Parotid enlargement, Uveitis, and Facial nerve palsy. * **Biopsy Finding:** Non-caseating granulomas (unlike the caseating granulomas of TB) [2]. * **Biomarkers:** Elevated Serum ACE levels and hypercalciuria/hypercalcemia (due to 1-alpha hydroxylase activity in macrophages) [1]. * **Kveim-Siltzbach Test:** Historically used for diagnosis but now largely replaced by biopsy and imaging.

Question 1

A 30-year-old paraplegic male with a history of recurrent UTIs secondary to an indwelling Foley catheter presents with fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves initially, but over one week, he develops increasing shortness of breath and tachypnea. He has frothy sputum and diffuse alveolar infiltrates. There is no fever, jugular venous distension, S3 gallop, or peripheral or sacral edema. What is the best prognostic indicator?

Accepted Answer

Pulmonary capillary wedge pressure

Answer

Blood cultures

Answer

CT scan of the chest

Answer

Ventilation-perfusion scan

Question 2

Which interstitial lung disease is characterized by granulomas on lung biopsy?

Accepted Answer

Sarcoidosis

Answer

Usual interstitial pneumonitis

Answer

Diffuse alveolar damage

Answer

Desquamative interstitial pneumonia

Question 3

Which of the following is NOT true about Kartagener's syndrome?

Accepted Answer

Mental retardation

Answer

Dextrocardia

Answer

Infertility

Answer

Bronchiectasis

Question 4

In the management of pulmonary emboli, what is the recommended infusion time for alteplase?

Accepted Answer

1-3 hours

Answer

4-6 hours

Answer

7-9 hours

Answer

10-12 hours

Question 5

A 30-year-old man presents with coughing up blood and sputum. There is no associated dyspnea, fever, or pleuritic chest pain. His past medical history is significant for recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is usually worse when lying down and in the morning. He quit smoking 5 years ago and started when he was 18 years old. On physical examination, he appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. Chest imaging reveals scarring in the right lower lobe, identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is the most likely diagnosis?

Accepted Answer

Bronchiectasis

Answer

Chronic bronchitis

Answer

Disseminated pulmonary tuberculosis

Answer

Pulmonary neoplasm

Question 6

Thermoplasty is used in which condition?

Accepted Answer

Asthma

Answer

COPD

Answer

Bronchiectasis

Answer

Carcinoma lung

Question 7

A 80-year-old male presented with a lung abscess in the left upper zone. What is the best initial treatment modality?

Accepted Answer

Antibiotics guided by identified organisms

Answer

Surgical drainage

Answer

Tube thoracostomy

Answer

Observation (wait and watch)

Question 8

Clinical manifestations of bronchogenic carcinoma include the following except?

Accepted Answer

Gastroparesis due to vagal involvement

Answer

Hoarseness of voice due to involvement of left recurrent laryngeal nerve

Answer

Horner's syndrome

Answer

Diaphragmatic palsy due to infiltration of phrenic nerve

Question 9

A patient presents with non-productive cough, hemoptysis, and grade III clubbing. Chest X-ray reveals an upper left zone lesion. What is the likely cause?

Accepted Answer

Non-small cell carcinoma of the lung

Answer

Small cell carcinoma of the lung

Answer

Tuberculosis

Answer

Fungal infection of the lung

Question 10

A patient presented with bilateral hilar lymphadenopathy and a negative Mantoux test. What is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Erythema nodosum

Answer

Hepatitis

Answer

Tuberculosis

Pulmonology — MCQs

Pulmonology — MCQs

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