Respiratory Pathology Practice Questions

Q: Lung biopsy of an urban city dweller shows presence of: (Recent NEET Pattern 2016-17)

Anthracosis. ***Anthracosis*** - Anthracosis is the accumulation of **carbon pigment** in the lungs, commonly seen in urban dwellers due to exposure to **air pollution** and smoke [1]. - It is generally considered a benign condition and is a common finding in lung biopsies of individuals living in polluted environments. *Simple coal worker pneumoconiosis* - This condition is caused by the inhalation of **coal dust** and is primarily seen in **coal miners**, not typically in urban city dwellers without occupational exposure [1]. - It is characterized by the presence of **coal macules** and **nodules** in the lungs, which are distinct from the diffuse carbon deposition of anthracosis. *Progressive massive fibrosis* - This is a severe complication of **coal worker pneumoconiosis** or **silicosis**, characterized by large fibrotic masses in the lungs [1]. - It implies significant occupational exposure to dust and is not a typical finding in an urban city dweller without such a history. *Silicosis* - Silicosis results from the inhalation of **silica dust**, commonly found in occupations like **mining, quarrying, and sandblasting** [1]. - It is characterized by specific **silicotic nodules** and is an occupational lung disease, not generally associated with typical urban living. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, p. 695.

Q: A 35-year-old female presents with difficulty in breathing at rest. On examination stridor is noted. The lung histopathological specimen shows presence of: (Recent NEET Pattern 2016-17)

Wegener's granulomatosis. ***Wegener's granulomatosis*** - **Stridor** indicates upper airway obstruction, which can be caused by **granulomatous inflammation** in the trachea or larynx, a feature of Wegener's. - Histopathology would show **necrotizing granulomatous inflammation** and **vasculitis**, consistent with this diagnosis [1]. *Tuberculosis* - While tuberculosis can cause respiratory symptoms, **stridor** is an uncommon presentation unless there is significant **lymph node enlargement** compressing the airway. - Histopathology typically shows **caseating granulomas** with Langhans giant cells, which is different from necrotizing vasculitis. *Sarcoidosis* - Sarcoidosis can cause **dyspnea** and **lung involvement**, but **stridor** is rare unless there is significant laryngeal or tracheal involvement, which is not typical. - Histopathology reveals **non-caseating granulomas** without vasculitis [2]. *Hypersensitivity pneumonitis* - This condition primarily affects the **alveoli and bronchioles**, leading to **dyspnea** and cough, but **stridor** is not a characteristic feature. - Histopathology shows **non-caseating granulomas**, **interstitial inflammation**, and **bronchiolitis**, but not necrotizing vasculitis [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 519-520. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 700-701. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 701-702.

Q: The following image of lung washing in AIDS positive patient is stained with:

Grocott's methenamine silver stain. ***Grocott's methanamine silver stain*** - This stain is specifically used to visualize fungal organisms, particularly **Pneumocystis jirovecii** (formerly P. carinii), which is a common opportunistic infection in AIDS patients [1,5]. - It stains the **fungal cell walls black**, making them easily identifiable in lung washings or biopsies [1]. *Ziehl-Neelsen stain* - This stain is primarily used for identifying **acid-fast bacilli**, such as **Mycobacterium tuberculosis**. - While tuberculosis can occur in AIDS patients, the image (not provided but implied to show fungi) would not be characteristic of ZN staining. *Auramine Rhodamine* - This is a **fluorescent stain** used for the rapid screening of **acid-fast bacilli** like Mycobacterium tuberculosis. - It is a screening test that requires a fluorescence microscope and is not typically used for fungal identification. *Giemsa stain* - Giemsa stain is commonly used for staining **blood smears** to identify parasites like malaria, and for staining **bone marrow** and **lymph nodes** [2]. - It can also be used to stain some bacteria and fungi, but it is **not the primary or most effective stain** for Pneumocystis jirovecii in lung washings [2]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 318-319. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, p. 362.

Q: A 25-year-old woman with ocular myasthenia Gravis on prednisolone for last 5 years is having cough with night sweats and significant weight loss. The lung histopathological specimen shows:

Pneumocystis jirovecii. ***Pneumocystis carinii*** - The patient is on chronic **prednisolone** (a corticosteroid), which causes **immunosuppression**, making her susceptible to opportunistic infections like *Pneumocystis jirovecii* pneumonia (PJP), formerly known as *Pneumocystis carinii* [1]. - Symptoms like **cough, night sweats, and significant weight loss** are consistent with a chronic opportunistic infection in an immunocompromised host [1]. *TB* - While **TB** can cause cough, night sweats, and weight loss, it is less likely to be the primary diagnosis in a patient on chronic corticosteroids without other specific risk factors for TB exposure. - Histopathology for TB would typically show **granulomas with caseous necrosis**, which is not the most common opportunistic infection in this scenario. *Aspergillosis* - **Aspergillosis** can occur in immunocompromised patients [1], but it often presents with specific features like **hemoptysis** or **fungal balls** (aspergilloma) in the lungs. - Histopathology would show **septate hyphae with acute angle branching**, which is distinct from *Pneumocystis*. *Mucormycosis* - **Mucormycosis** is a severe fungal infection typically seen in patients with **diabetes mellitus** or profound immunosuppression, often affecting the sinuses and brain. - Lung involvement is possible but less common than PJP in this clinical context, and histopathology would show **broad, non-septate hyphae with right-angle branching**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 318-319.

Q: An 8-year-old boy with acute lymphoblastic leukemia on chemotherapy develops fever with nonproductive cough and respiratory distress. The lung specimen shows:

Aspergillosis. ***Aspergillosis*** - In an immunocompromised patient, such as a child on **chemotherapy** for **acute lymphoblastic leukemia**, **Aspergillus** is a common cause of invasive fungal infections, including **pulmonary aspergillosis** [1][2]. - The symptoms of fever, nonproductive cough, and respiratory distress are consistent with **invasive pulmonary aspergillosis**, which can be confirmed by lung biopsy showing **septate hyphae** with acute angle branching [1]. *Mucormycosis* - While also an opportunistic fungal infection in immunocompromised patients, **Mucormycosis** typically presents with **broad, non-septate hyphae** with right-angle branching on histology. - It often involves the **paranasal sinuses** and **brain** in addition to the lungs, and is more common in patients with **diabetes mellitus** or **neutropenia**. *Desquamative interstitial pneumonitis* - This is a form of **idiopathic interstitial pneumonia** characterized by accumulation of **macrophages** in the alveolar spaces [3]. - It is typically seen in **smokers** and is not an acute infectious process, nor is it directly linked to chemotherapy-induced immunosuppression in this context [3]. *Nonspecific interstitial pneumonitis* - This is another form of **idiopathic interstitial pneumonia** with a more uniform pattern of inflammation and fibrosis. - It is a chronic condition and does not present as an acute febrile illness with respiratory distress in an immunocompromised patient due to an opportunistic infection. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, pp. 396-397. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 318-319. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 702-703.

Q: A 32-year-old chain-smoker presented with persistent productive cough, fever and recurrent pulmonary infections. After his death, lung specimen was extracted. Which of the components are destroyed?

All of the above. ***All of the above*** - Chronic inflammation and recurrent infections in a chain-smoker, as seen in conditions like **bronchiectasis** or severe **COPD**, can lead to widespread destruction of lung architecture [1]. - This destruction can involve **cartilage** in the bronchi, **smooth muscle** in the airways, and the crucial **elastic tissue** of the alveoli and small airways, leading to irreversible damage and loss of lung function [1]. *Cartilage* - While **cartilage** in the larger airways (bronchi) can be damaged by chronic inflammation and infection, it is not the primary or sole component destroyed in the context of widespread pulmonary disease from smoking and recurrent infections. - Its destruction alone would not account for the full clinical picture of a chain-smoker with recurrent infections. *Muscle* - **Smooth muscle** in the bronchial walls can undergo hypertrophy and spasm in chronic lung diseases, but in severe, long-standing inflammatory conditions, it can also be damaged or replaced by fibrous tissue [1]. - However, muscle destruction is typically part of a broader pattern of tissue damage, not an isolated finding. *Elastic tissue* - **Elastic tissue** is critically important for maintaining the structural integrity and recoil of the alveoli and small airways, and its destruction is a hallmark of **emphysema**, a common consequence of chronic smoking [1]. - While its destruction is significant, the overall pathology in a case with recurrent infections and widespread damage often involves more than just elastic tissue. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 683-686.

Q: A 55-year-old male patient presented with a 4 month history of cough and hemoptysis. Bronchoscopy revealed an intrabronchial polyp. Biopsy from the polyp showed small cells with salt and pepper chromatin, with microscopic necrosis and 5 mitotic figures per 10 high power fields as shown below. Chromogranin staining was positive. What is the diagnosis and grade of the lesion?

Atypical carcinoid grade 2. ***Atypical carcinoid grade 2*** - The presence of **salt and pepper chromatin**, **microscopic necrosis**, and **5 mitotic figures per 10 high power fields** are characteristic features of an **atypical carcinoid tumor** [1]. - **Positive chromogranin staining** confirms neuroendocrine differentiation, and the mitotic rate coupled with necrosis indicates a Grade 2 (atypical) carcinoid based on WHO classification [1]. *Carcinoid grade 1* - A typical carcinoid (Grade 1) would show **no necrosis** and a mitotic count of **less than 2 mitoses per 10 high power fields**, which contradicts the findings [1]. - While it features **salt and pepper chromatin** and positive neuroendocrine markers, the higher mitotic activity and necrosis exclude a typical carcinoid. *Small cell carcinoma grade IV* - **Small cell carcinoma** typically presents with extensive necrosis, very high mitotic activity (often >10 mitoses/10 HPF), and a more **scanty cytoplasm** than seen here, and often **crush artifact** [2]. - Although it is a high-grade neuroendocrine tumor, the described features (only 5 mitoses/10HPF, "salt and pepper chromatin" is less typical for SCLC which has more uniform nuclei, and distinct necrosis without widespread crush artifact) are more consistent with an atypical carcinoid [1], [2]. *Large cell neuroendocrine carcinoma grade IV* - **Large cell neuroendocrine carcinoma** (LCNEC) is characterized by **large cells** with prominent nucleoli, high mitotic counts (often >10-11 mitoses/10HPF), and extensive necrosis [2]. - The "small cells" and **salt and pepper chromatin** described in the biopsy are inconsistent with the large cell morphology of LCNEC. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 725-727. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 337-338.

Q: A patient with a depressive illness is brought to casualty with acute breathlessness. X-ray shows diffuse infiltrates in right middle lobe and right lower lobe. The patient expired. The lung specimen on biopsy shows:

Aspiration pneumonitis. ***Aspiration pneumonitis*** - The lung biopsy shows **alveolar necrosis** and intra-alveolar edema with **foreign body giant cells** formed in response to aspirated material—these are the characteristic histologic features of aspiration pneumonitis. - The clinical context strongly supports this diagnosis: the patient's **depressive illness** predisposes to impaired consciousness or reflexes, increasing aspiration risk. The X-ray findings of diffuse infiltrates in the **right middle and lower lobes** are classic sites for aspirated contents due to anatomical positioning (right main bronchus is more vertical and wider). - Aspiration pneumonitis results from chemical injury to lung tissue from acidic gastric contents, causing acute inflammation, necrosis, and foreign body reaction. *Pulmonary alveolar proteinosis* - Characterized by accumulation of **lipid-rich proteinaceous material (surfactant)** in the alveoli, appearing as granular, eosinophilic debris on histology with PAS-positive staining—not alveolar necrosis with foreign body giant cells. - While it can cause diffuse infiltrates on X-ray and breathlessness, the histologic pattern is distinct, and there is no predisposing clinical context for aspiration. *Tuberculosis* - Typically shows **caseating granulomas** with epithelioid macrophages and Langhans giant cells on biopsy—these features are absent here. - TB usually has a more chronic presentation and different radiological pattern (upper lobe predominance, cavitation), not the acute presentation with aspiration risk factors seen in this case. *Fat embolism syndrome* - Would show **fat globules within pulmonary capillaries** and arterioles on histology (visible with Oil Red O or Sudan stains), along with pulmonary edema and hemorrhage—not foreign body giant cells and alveolar necrosis. - Typically occurs after long bone fractures or orthopedic trauma, which is not mentioned in this clinical scenario.

Q: A 40-year-old man underwent lung transplantation. The resected lung specimen is shown below. Comment on the diagnosis.

Miliary TB. ***Miliary TB*** - The image likely shows numerous small, uniform granulomas scattered throughout the lung parenchyma, characteristic of **miliary tuberculosis** [1]. - This widespread dissemination occurs when **Mycobacterium tuberculosis** spreads hematogenously, leading to a "millet seed" appearance on gross and microscopic examination [1]. *Bronchiectasis* - Bronchiectasis is characterized by **permanent dilation of bronchi** and bronchioles due to destruction of the muscle and elastic tissue [1]. - Grossly, it would show dilated, thickened airways often filled with mucus or pus, not diffuse small nodules. *Lung abscess* - A lung abscess is a **localized collection of pus** within the lung parenchyma, typically appearing as a single or a few large cavitary lesions [2]. - It would present as a well-defined cavity with necrotic debris, not numerous small, widely distributed lesions [2]. *Carcinoma lung* - Carcinoma of the lung typically presents as a **mass lesion**, nodule, or infiltrative growth, often with irregular borders [3]. - While multiple metastases can occur, the uniform, small, and widely distributed pattern seen in miliary TB is not typical for primary lung carcinoma [4]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 320-321. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 715-716. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 336-337. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 723-724.

Q: 'Masson Bodies' formed due to proliferation of immature collagen are a characteristic histopathological finding seen in which of the following conditions?

Cryptogenic Organizing Pneumonia. ***Cryptogenic Organizing Pneumonia*** - **Masson bodies**, which are intraluminal plugs of organizing connective tissue composed of fibroblasts, myofibroblasts, and immature collagen, are the **hallmark histopathological feature** of cryptogenic organizing pneumonia (COP) [1]. - These plugs are found predominantly in the **alveolar ducts** and **bronchioles**, leading to a characteristic pattern of organizing pneumonia [1]. *Lymphocytic Interstitial Pneumonia* - Characterized by a **dense interstitial infiltrate** dominated by **lymphocytes**, plasma cells, and histiocytes, often forming germinal centers. - It is frequently associated with **immunodeficiency states** such as HIV infection or autoimmune diseases like Sjögren's syndrome. *Desquamative Interstitial Pneumonia* - Marked by the accumulation of a large number of **macrophages** within the alveolar spaces, with minimal interstitial inflammation or fibrosis. - Primarily seen in **smokers** and is thought to be a reaction to inhaled particulate matter. *Respiratory Bronchiolitis* - Characterized by **peribronchiolar inflammation** and fibrosis, with pigment-laden macrophages accumulating within the respiratory bronchioles. - This condition is also strongly associated with **cigarette smoking** and is considered a milder variant of interstitial lung disease. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 330-331.

Question 1

Lung biopsy of an urban city dweller shows presence of: (Recent NEET Pattern 2016-17)

Accepted Answer

Anthracosis

Answer

Simple coal worker pneumoconiosis

Answer

Progressive massive fibrosis

Answer

Silicosis

Question 2

A 35-year-old female presents with difficulty in breathing at rest. On examination stridor is noted. The lung histopathological specimen shows presence of: (Recent NEET Pattern 2016-17)

Accepted Answer

Wegener's granulomatosis

Answer

Tuberculosis

Answer

Sarcoidosis

Answer

Hypersensitivity pneumonitis

Question 3

The following image of lung washing in AIDS positive patient is stained with:

Accepted Answer

Grocott's methenamine silver stain

Answer

Ziehl-Neelsen stain

Answer

Auramine Rhodamine

Answer

Giemsa stain

Question 4

A 25-year-old woman with ocular myasthenia Gravis on prednisolone for last 5 years is having cough with night sweats and significant weight loss. The lung histopathological specimen shows:

Accepted Answer

Pneumocystis jirovecii

Answer

TB

Answer

Aspergillosis

Answer

Mucormycosis

Question 5

An 8-year-old boy with acute lymphoblastic leukemia on chemotherapy develops fever with nonproductive cough and respiratory distress. The lung specimen shows:

Accepted Answer

Aspergillosis

Answer

Mucormycosis

Answer

Desquamative interstitial pneumonitis

Answer

Nonspecific interstitial pneumonitis

Question 6

A 32-year-old chain-smoker presented with persistent productive cough, fever and recurrent pulmonary infections. After his death, lung specimen was extracted. Which of the components are destroyed?

Accepted Answer

All of the above

Answer

Cartilage

Answer

Muscle

Answer

Elastic tissue

Question 7

A 55-year-old male patient presented with a 4 month history of cough and hemoptysis. Bronchoscopy revealed an intrabronchial polyp. Biopsy from the polyp showed small cells with salt and pepper chromatin, with microscopic necrosis and 5 mitotic figures per 10 high power fields as shown below. Chromogranin staining was positive. What is the diagnosis and grade of the lesion?

Accepted Answer

Atypical carcinoid grade 2

Answer

Carcinoid grade 1

Answer

Small cell carcinoma grade IV

Answer

Large cell neuroendocrine carcinoma grade IV

Question 8

A patient with a depressive illness is brought to casualty with acute breathlessness. X-ray shows diffuse infiltrates in right middle lobe and right lower lobe. The patient expired. The lung specimen on biopsy shows:

Accepted Answer

Aspiration pneumonitis

Answer

Pulmonary alveolar proteinosis

Answer

Tuberculosis

Answer

Fat embolism syndrome

Question 9

A 40-year-old man underwent lung transplantation. The resected lung specimen is shown below. Comment on the diagnosis.

Accepted Answer

Miliary TB

Answer

Bronchiectasis

Answer

Lung abscess

Answer

Carcinoma lung

Question 10

'Masson Bodies' formed due to proliferation of immature collagen are a characteristic histopathological finding seen in which of the following conditions?

Accepted Answer

Cryptogenic Organizing Pneumonia

Answer

Lymphocytic Interstitial Pneumonia

Answer

Desquamative Interstitial Pneumonia

Answer

Respiratory Bronchiolitis

Respiratory Pathology — MCQs

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