Respiratory Diseases Practice Questions

Q: A month old HIV positive child following an upper respiratory infection developed sudden onset of breathlessness. The chest x-ray shows hyperinflation. The O2 saturation was greater than 90%. What is the most appropriate antiviral therapy among the given options?

Ribavirin. **Ribavirin** - The clinical presentation of a 1-month-old HIV-positive infant with sudden breathlessness, hyperinflation on chest X-ray, and oxygen saturation >90%, following an URI, is highly suggestive of **Respiratory Syncytial Virus (RSV) bronchiolitis**. - **Ribavirin** is an antiviral drug that was historically used for severe RSV infection, especially in high-risk infants like those who are immunocompromised. - **Note:** Current guidelines emphasize supportive care as primary treatment; ribavirin use is now controversial due to limited efficacy and toxicity concerns. *IV Ganciclovir* - **Ganciclovir** is primarily used for the treatment of **Cytomegalovirus (CMV)** infections, which typically present differently than the acute bronchiolitis described. - CMV pneumonitis often manifests with diffuse interstitial infiltrates and may be accompanied by other systemic CMV manifestations. *Cotrimoxazole* - **Cotrimoxazole (trimethoprim-sulfamethoxazole)** is the drug of choice for prophylaxis and treatment of **Pneumocystis jirovecii pneumonia (PJP)**. - While PJP is common in HIV-positive infants, the acute onset, hyperinflation, and O2 saturation >90% are less typical for severe PJP, and cotrimoxazole is an antibiotic, not an antiviral. *Nebulized Acyclovir* - **Acyclovir** is an antiviral agent used to treat **herpes simplex virus (HSV)** and **varicella-zoster virus (VZV)** infections. - Respiratory involvement with HSV or VZV in an infant would present with different clinical features and radiological findings than those described.

Q: A 3 month old infant presents with a 3 day history of fever, cough, and poor feeding. On examination, the baby appears ill and has a temperature of 102 F and a respiratory rate of 32. A chest x-ray film showed bilateral patchy infiltrates in the lungs. Which of the following is the most likely etiologic agent?

Respiratory syncytial virus. ***Respiratory syncytial virus*** - **Respiratory syncytial virus (RSV)** is the most common cause of **bronchiolitis** and **pneumonia** in infants, particularly those under 6 months. - The presentation of fever, cough, poor feeding, respiratory distress (high respiratory rate), and bilateral patchy infiltrates on chest X-ray are highly characteristic of severe RSV infection in a **3-month-old infant**. *Parainfluenza type 1* - **Parainfluenza type 1 (PIV-1)** is primarily associated with **croup** (laryngotracheobronchitis) in infants and young children, characterized by a **barking cough** and stridor. - While it can cause lower respiratory tract infections, severe pneumonia with bilateral patchy infiltrates and prominent respiratory distress is less typical than with RSV. *Influenza type A* - **Influenza type A** can cause severe respiratory illness in infants, but it is typically more common in older children and adults. - While it can present with fever, cough, and pneumonia, RSV is a more frequent cause of severe lower respiratory tract disease in this specific age group (**3-month-old infant**). *Coronavirus* - While some coronaviruses (e.g., **SARS-CoV-2**) can cause severe respiratory illness in infants, they are generally less common causes of typical infant bronchiolitis or pneumonia compared to RSV. - The pattern of a 3-month-old with fever, cough, respiratory distress, and patchy infiltrates is most strongly associated with RSV in the absence of specific epidemiological factors pointing to another coronavirus.

Q: A 14-year-old boy presents with headache, fever, and cough for 2 days. Sputum is scant and non-purulent and gram stain reveals many white cells but no organisms. The treatment should be initiated with :

Azithromycin. ***Azithromycin*** - The clinical picture of **headache, fever, cough, scant non-purulent sputum**, and Gram stain showing white cells but no organisms is highly suggestive of **atypical pneumonia**, likely caused by *Mycoplasma pneumoniae* in this age group. - **Macrolides** like azithromycin are the **first-line treatment** for atypical pneumonia as they are effective against organisms like *Mycoplasma* and *Chlamydia* which lack cell walls and are therefore resistant to beta-lactam antibiotics. *Levofloxacin* - **Levofloxacin** is a **fluoroquinolone**, which is effective against atypical pathogens but is generally reserved for **older patients** or those with **allergies** to macrolides due to concerns about potential side effects like cartilage damage in children. - Using fluoroquinolones as a first-line treatment in adolescents for suspected atypical pneumonia is **not recommended** due to these potential side effects and the availability of safer alternatives. *Amikacin* - **Amikacin** is an **aminoglycoside antibiotic** primarily used for severe infections caused by **Gram-negative bacteria**. - It is **ineffective against atypical bacteria** like *Mycoplasma* or *Chlamydia* which are the likely causative agents in this scenario. *Cefazolin* - **Cefazolin** is a **first-generation cephalosporin**, which is a **beta-lactam antibiotic** effective mostly against Gram-positive cocci and some Gram-negative bacteria. - It is **ineffective against atypical pathogens** because these organisms **lack a cell wall** (like *Mycoplasma*) or have cell walls that are not targeted by beta-lactam antibiotics.

Q: A 2-year-old child presented with the following x-ray finding. What is the most likely diagnosis?

Acute laryngotracheobronchitis. ***Acute laryngotracheobronchitis*** - The x-ray finding of a **steeple sign** (subglottic narrowing) is a classic radiographic feature of **croup**, also known as acute laryngotracheobronchitis. - Croup is characterized by a **barking cough**, hoarseness, and inspiratory stridor, primarily affecting the **larynx** and **trachea**. *Acute pharyngitis* - Acute pharyngitis is an **inflammation of the pharynx** and does not typically involve the subglottic region or cause the characteristic steeple sign on radiographs. - It presents with symptoms like **sore throat**, fever, and difficulty swallowing, without the prominent stridor or barking cough of croup. *Acute epiglottitis* - Acute epiglottitis, though a serious airway emergency, typically shows a **thumb sign** on a lateral neck x-ray due to a swollen epiglottis, not a steeple sign. - It presents with rapid onset of **high fever**, **dysphagia**, drooling, and muffled voice, often without a cough. *Parapharyngeal abscess* - A parapharyngeal abscess is a deep neck infection that would likely present with a **mass effect**, **displacement of airway structures**, and **soft tissue swelling** on imaging, not subglottic narrowing. - Symptoms include severe **sore throat**, **fever**, **trismus**, and neck swelling, with potential airway compromise from external compression.

Q: A 24 month child, with a weight of 11 kg, has RR of 38 / min, chest indrawing, cough and fever. Management according to IMNCI?

Give antibiotics. ***Give antibiotics*** - The child presents with **chest indrawing** along with cough and fever, which according to **IMNCI guidelines** classifies as **pneumonia**. - Note: RR of 38/min is **within normal limits** for a 24-month-old child (fast breathing threshold is ≥40/min for 12-59 months age group). - The diagnosis of pneumonia is based on the presence of **chest indrawing**, not fast breathing in this case. - According to **IMNCI**, pneumonia (without danger signs) should be treated with **oral antibiotics** (amoxicillin 250 mg twice daily for 5 days) at the primary care level. - The child should be followed up in 2 days and the mother advised on when to return immediately. *Refer to a higher-level health facility for further management.* - Referral is indicated for **severe pneumonia**, which requires presence of any **general danger sign** (inability to drink/breastfeed, persistent vomiting, convulsions, lethargy/unconsciousness, or stridor in calm child). - This child has **pneumonia** (not severe), so outpatient treatment with oral antibiotics is appropriate. *Monitor at home without medical treatment.* - This would be inappropriate as the child has **pneumonia** requiring antibiotic treatment. - Untreated pneumonia can rapidly progress to severe disease and is a **leading cause of child mortality** in developing countries. *Provide symptomatic treatment with antipyretics only.* - While antipyretics (paracetamol) can be given for fever, they do not treat the underlying **bacterial infection**. - Antibiotics are essential to treat pneumonia and prevent complications and mortality.

Q: A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?

Acute Laryngotracheobronchitis. ***Acute Laryngotracheobronchitis*** - The combination of **low-grade fever** and **stridor** in a 2-year-old child strongly suggests **croup**, which is medically known as acute laryngotracheobronchitis. - Croup is characterized by **inflammation** of the larynx, trachea, and bronchi, often presenting with a **barking cough** and inspiratory stridor. The X-ray image would show the characteristic **steeple sign**. *Acute Bacterial Tracheitis* - This is a more severe bacterial infection that can present with stridor but typically shows **higher fever**, **toxic appearance**, and rapid clinical deterioration. - Unlike croup, bacterial tracheitis patients appear **more ill** and may have **purulent secretions** requiring more aggressive management. *Acute Epiglottitis* - A serious condition characterized by **rapid onset of high fever**, **dysphagia**, drooling, and a **"tripod" position**, which are not indicated by the given symptoms. - The stridor in epiglottitis is typically quieter and may indicate more severe airway obstruction compared to the characteristic stridor of croup. *Foreign Body aspiration* - While foreign body aspiration can cause stridor, it is typically an **acute event** with a sudden onset of choking, coughing, and respiratory distress. - There is no mention of a choking episode or sudden onset, and a low-grade fever is less typical for an uncomplicated foreign body aspiration.

Q: Fast breathing in a 6-month-old infant is taken as:

>50 breaths/min. ***>50 breaths/min*** - For infants aged 2 to 12 months, a respiratory rate of **greater than 50 breaths per minute** is considered consistent with **tachypnea** or fast breathing. - This is an important indicator of respiratory distress, often used in clinical assessment frameworks like the **Integrated Management of Childhood Illness (IMCI)**. *>30 breaths/min* - A respiratory rate of **>30 breaths/min** would be considered fast breathing for an older child or adult, but it is within the normal range for an infant. - Normal respiratory rates are **higher in infants** and gradually decrease with age. *>60 breaths/min* - While a respiratory rate of **>60 breaths/min** is indeed fast and indicates severe respiratory distress, it is not the initial threshold for defining fast breathing in a 6-month-old infant. - This rate would suggest a more **severe clinical presentation** than simply "fast breathing." *>40 breaths/min* - A respiratory rate **>40 breaths/min** is typically considered fast breathing for children aged 1 to 5 years, but not for infants under 12 months. - For a 6-month-old, this rate is still within the **normal or upper-normal range**, depending on activity and state.

Q: Which of the following conditions is most associated with digital clubbing in children?

Cystic fibrosis. ***Cystic fibrosis*** - **Cystic fibrosis** is a common cause of **digital clubbing** in children due to chronic hypoxemia and lung disease, leading to abnormal growth of connective tissue at the nail beds. - The chronic lung infections, bronchiectasis, and airway obstruction characteristic of cystic fibrosis contribute to persistent **tissue hypoxia**, which is a primary driver of clubbing. *Croup* - Croup is an acute viral infection of the upper airway, primarily characterized by a **barking cough** and **stridor**, and generally resolves within a week without chronic complications like clubbing. - It does not cause chronic hypoxemia necessary for the development of digital clubbing. *Bronchiolitis* - **Bronchiolitis** is an acute viral infection of the lower respiratory tract, most common in infants, causing wheezing and respiratory distress, but it is typically a **short-lived illness** without chronic sequelae leading to clubbing. - This condition does not cause prolonged enough or severe enough **hypoxia** to result in clubbing. *Asthma* - While severe, uncontrolled **asthma** can cause intermittent hypoxia, it is typically not associated with chronic digital clubbing, especially in children, unless there are other coincident chronic lung conditions. - Digital clubbing is rare in asthma and often suggests an alternate or co-existing pathology, such as **bronchiectasis** or **cystic fibrosis**.

Q: Which antibiotic is best suited for Pseudomonas aeruginosa in a CF patient?

Ceftazidime. ***Ceftazidime*** - **Ceftazidime** is the **gold standard** first-line treatment for *Pseudomonas aeruginosa* in CF patients according to **CF Foundation guidelines**, often combined with an **aminoglycoside** like tobramycin. - It demonstrates **superior efficacy** against P. aeruginosa with lower propensity for **resistance development** compared to other antibiotics, making it the preferred choice for acute exacerbations. *Clindamycin* - **Clindamycin** is primarily effective against **gram-positive bacteria** and **anaerobes**; it has **no activity** against *Pseudomonas aeruginosa*. - It is commonly used for skin and soft tissue infections or anaerobic infections, but is not suitable for treating **gram-negative rods** like *P. aeruginosa*. *Amoxicillin* - **Amoxicillin** is a broad-spectrum penicillin effective against many **gram-positive** and some **gram-negative bacteria**, but it **completely lacks activity** against *Pseudomonas aeruginosa*. - Even with beta-lactamase inhibitors (amoxicillin-clavulanate), it has **no antipseudomonal coverage** and is not appropriate for CF-related Pseudomonas infections. *Ciprofloxacin* - While **ciprofloxacin** has good antipseudomonal activity and offers advantages like **oral bioavailability** and **lung penetration**, it is primarily used for **maintenance therapy** or mild outpatient cases. - It has concerns about **resistance development** when used as monotherapy and is not considered the **first-line choice** for acute P. aeruginosa infections in CF patients.

Question 1

A month old HIV positive child following an upper respiratory infection developed sudden onset of breathlessness. The chest x-ray shows hyperinflation. The O2 saturation was greater than 90%. What is the most appropriate antiviral therapy among the given options?

Accepted Answer

Ribavirin

Answer

IV Ganciclovir

Answer

Cotrimoxazole

Answer

Nebulized Acyclovir

Question 2

A 3 month old infant presents with a 3 day history of fever, cough, and poor feeding. On examination, the baby appears ill and has a temperature of 102 F and a respiratory rate of 32. A chest x-ray film showed bilateral patchy infiltrates in the lungs. Which of the following is the most likely etiologic agent?

Accepted Answer

Respiratory syncytial virus

Answer

Parainfluenza type 1

Answer

Influenza type A

Answer

Coronavirus

Question 3

A 14-year-old boy presents with headache, fever, and cough for 2 days. Sputum is scant and non-purulent and gram stain reveals many white cells but no organisms. The treatment should be initiated with :

Accepted Answer

Azithromycin

Answer

Levofloxacin

Answer

Amikacin

Answer

Cefazolin

Question 4

A 2-year-old child presented with the following x-ray finding. What is the most likely diagnosis?

Accepted Answer

Acute laryngotracheobronchitis

Answer

Acute pharyngitis

Answer

Acute epiglottitis

Answer

Parapharyngeal abscess

Question 5

A 24 month child, with a weight of 11 kg, has RR of 38 / min, chest indrawing, cough and fever. Management according to IMNCI?

Accepted Answer

Give antibiotics

Answer

Refer to a higher-level health facility for further management.

Answer

Monitor at home without medical treatment.

Answer

Provide symptomatic treatment with antipyretics only.

Question 6

A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?

Accepted Answer

Acute Laryngotracheobronchitis

Answer

Acute Bacterial Tracheitis

Answer

Acute Epiglottitis

Answer

Foreign Body aspiration

Question 7

A 2 years old child presents to PHC with fever and cough. He has chest in-drawing and respiratory rate of 38 per minute, weight 11 kg. The next step in management according to IMNCI is:

Accepted Answer

Give antibiotics and refer to tertiary centre

Answer

Give antibiotics and re-assess in 3 days

Answer

Refer to tertiary care

Answer

Only antipyretics are given

Question 8

Fast breathing in a 6-month-old infant is taken as:

Accepted Answer

>50 breaths/min

Answer

>30 breaths/min

Answer

>60 breaths/min

Answer

>40 breaths/min

Question 9

Which of the following conditions is most associated with digital clubbing in children?

Accepted Answer

Cystic fibrosis

Answer

Croup

Answer

Bronchiolitis

Answer

Asthma

Question 10

Which antibiotic is best suited for Pseudomonas aeruginosa in a CF patient?

Accepted Answer

Ceftazidime

Answer

Clindamycin

Answer

Amoxicillin

Answer

Ciprofloxacin

Respiratory Diseases — MCQs

Respiratory Diseases — MCQs

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