Pulmonary Practice Questions

Q: A 32-year-old man comes to the physician for a 1-month history of fever, chest pain with deep breathing, and a 4-kg (9 lb) weight loss. His temperature is 38°C (100.4°F). An x-ray of the chest shows a subpleural nodule in the right lower lobe with right hilar lymphadenopathy. Histological examination of a right hilar lymph node biopsy specimen shows several granulomas with acellular cores. Which of the following is the most likely diagnosis?

Primary tuberculosis. ***Primary tuberculosis*** - The combination of **fever**, **chest pain with deep breathing**, **weight loss**, a **subpleural nodule**, **right hilar lymphadenopathy**, and **granulomas with acellular cores** on biopsy strongly points to primary tuberculosis. - Granulomas in tuberculosis are typically **caseating** (acellular cores often imply caseating necrosis in this context), and the presence of hilar lymphadenopathy with a peripheral nodule (Ghon complex) is classic for primary infection. *Hodgkin lymphoma* - While Hodgkin lymphoma can cause fever, weight loss (B symptoms), and lymphadenopathy, the presence of a **subpleural nodule** and **granulomas with acellular cores** is not typical. - Histology would show **Reed-Sternberg cells** amidst a mixed inflammatory infiltrate, not granulomas with acellular cores. *Chronic berylliosis* - This condition is caused by **beryllium exposure** and typically presents with a history of occupational exposure and **non-caseating granulomas**. - No history of beryllium exposure is provided, and the granulomas described are consistent with **caseating necrosis** (acellular cores). *Miliary tuberculosis* - Miliary tuberculosis involves widespread dissemination, often presenting with **diffuse, small nodules** (millet seed-sized) across both lungs on X-ray, rather than a single subpleural nodule and hilar lymphadenopathy. - While it features granulomas, the **radiological pattern** is distinct. *Pulmonary sarcoidosis* - Sarcoidosis is characterized by **non-caseating granulomas** in multiple organs, often presenting with bilateral hilar lymphadenopathy and pulmonary involvement. - The description of **acellular cores** suggests **caseating granulomas**, which are not typical of sarcoidosis.

Q: An investigator is studying the effects of influenza virus on human lung tissue. Biopsy specimens of lung parenchyma are obtained from patients recovering from influenza pneumonia and healthy control subjects. Compared to the lung tissue from the healthy control subjects, the lung tissue from the affected patients is most likely to show which of the following findings on histopathologic examination?

Increased type II pneumocytes. ***Increased type II pneumocytes*** - **Type II pneumocytes** are responsible for producing **surfactant** and act as **progenitor cells** for **type I pneumocytes**. - In response to injury, like that caused by **influenza pneumonia**, type II pneumocytes proliferate to replace damaged type I pneumocytes and repair the alveolar epithelium. *Decreased alveolar macrophages* - **Alveolar macrophages** are immune cells that **phagocytose** pathogens and cellular debris in the alveoli. - In an active infection like **influenza pneumonia**, their numbers would likely be **increased** due to their role in immune response, not decreased. *Increased goblet cells* - **Goblet cells** are found in the larger airways and are responsible for **mucus production**. - While respiratory infections can increase mucus production, the question specifies **lung parenchyma** (alveoli) where goblet cells are not typically found. *Decreased interstitial fibroblasts* - **Interstitial fibroblasts** contribute to the structural integrity of the lung and can differentiate into **myofibroblasts** during repair and fibrosis. - In the context of pneumonia and potential repair processes, fibroblast activity might be altered, but a decrease is unlikely given their role in tissue remodeling, and an increase might be seen in the context of **fibrosis**. *Increased alveolar squamous epithelial cells* - **Alveolar squamous epithelial cells** are **type I pneumocytes**, which form the primary gas-exchange surface. - **Influenza pneumonia** causes damage and destruction of type I pneumocytes, meaning their numbers would be **decreased**, not increased.

Q: A lung mass of a 50 pack-year smoker is biopsied. If ADH levels were grossly increased, what would most likely be the histologic appearance of this mass?

Sheets of small round cells with hyperchromatic nuclei. ***Sheets of small round cells with hyperchromatic nuclei*** - Grossly increased **ADH levels** in a smoker suggest **syndrome of inappropriate antidiuretic hormone (SIADH)**, which is commonly associated with **small cell lung carcinoma (SCLC)**. - SCLC is characterized histologically by sheets of **small (lymphocyte-like) cells** with scant cytoplasm and **hyperchromatic nuclei**. *Layered squamous cells with keratin pearls* - This description corresponds to **squamous cell carcinoma**, which is associated with smoking but typically causes **hypercalcemia** due to parathyroid hormone-related peptide (PTHrP) production, not elevated ADH. - Key histological features are **keratin pearls** and **intercellular bridges**. *Pleomorphic giant cells with leukocyte fragments in cytoplasm* - This describes **large cell carcinoma**, which is a diagnosis of exclusion and does not typically manifest with paraneoplastic SIADH. - **Large cell carcinoma** is characterized by large, anaplastic cells without differentiation towards squamous, glandular, or small cell features. *Hyperplasia of mucin producing glandular tissue* - This appearance is characteristic of **adenocarcinoma**, which often arises in non-smokers and is not typically associated with SIADH. - **Adenocarcinoma** exhibits glandular differentiation and often produces mucin. *Tall columnar cells bordering the alveolar septum* - This refers to **lepidic growth pattern** often seen in some subtypes of **adenocarcinoma (e.g., adenocarcinoma in situ or minimally invasive adenocarcinoma)**. - While it is a type of lung cancer, it is not primarily associated with SIADH as a paraneoplastic syndrome.

Q: A 73-year-old man is brought to the emergency department because of fever, malaise, dyspnea, and a productive cough with purulent sputum for the past day. His temperature is 39.2°C (102.6°F). Pulmonary examination shows crackles over the right upper lung field. Sputum Gram stain shows gram-positive cocci. Despite the appropriate treatment, the patient dies 5 days later. At autopsy, gross examination shows that the right lung has a pale, grayish-brown appearance and a firm consistency. Microscopic examination of the tissue is most likely to show which of the following?

Fibrinopurulent leukocytic exudate with lysed erythrocytes. **Fibrinopurulent leukocytic exudate with lysed erythrocytes** - This description aligns with the **gray hepatization** stage of lobar pneumonia, characterized by the accumulation of **fibrin**, **neutrophils**, and **lysed red blood cells** in the alveolar spaces, giving the lung a firm, grayish-brown appearance. - The patient's presentation of **fever, dyspnea, productive cough with purulent sputum**, and Gram-positive cocci points to bacterial pneumonia, and the severe outcome suggests a progression to this advanced stage. *Dilation of alveolar capillaries and serous exudate with abundant bacteria* - This describes the stage of **congestion**, which is the initial phase of pneumonia. - While it includes bacterial presence, it does not account for the **firm, grayish-brown appearance** of the lung found at autopsy. *Fibrinous exudate with erythrocytes, leukocytes, and bacteria* - This describes the stage of **red hepatization**, which follows congestion. - In red hepatization, the lung appears red and firm due to engorged capillaries and intra-alveolar hemorrhage, which is distinct from the **pale, grayish-brown appearance** mentioned in the autopsy findings. *Resorbed exudate with aerated alveoli* - This describes the stage of **resolution**, where the inflammatory exudate is cleared, and the lung tissue returns to normal. - Given the patient's death and autopsy findings of a firm, discolored lung, resolution had **not occurred**. *Neutrophilic infiltrate in the bronchiolar walls and adjacent alveoli* - This pattern is more characteristic of **bronchopneumonia**, which presents as patchy consolidation centered around bronchioles. - The description of a **pale, grayish-brown, firm lung** suggests a more widespread lobar involvement rather than a patchy bronchopneumonia.

Q: A 53-year-old man is admitted to the intensive care unit from the emergency department with severe pancreatitis. Overnight, he starts to develop severe hypoxemia, and he is evaluated by a rapid response team. On exam the patient is breathing very quickly and has rales and decreased breath sounds bilaterally. He is placed on 50% FiO2, and an arterial blood gas is collected with the following results: pH: 7.43 pCO2: 32 mmHg pO2: 78 mmHg The oxygen status of the patient continues to deteriorate, and he is placed on ventilator support. Which of the following would most likely be seen in this patient?

Intra-alveolar hyaline membrane formation. ***Intra-alveolar hyaline membrane formation*** - The patient's presentation with **severe hypoxemia**, **rales**, decreased breath sounds, and rapid deterioration despite oxygen supplementation is highly suggestive of **Acute Respiratory Distress Syndrome (ARDS)**. - **Hyaline membranes** form in ARDS due to damage to the alveolar-capillary barrier, leading to fluid and protein exudation into the alveoli, which combines with necrotic epithelial cells. *Diffuse lipid droplets and globules* - This finding is characteristic of **fat embolism syndrome**, which typically occurs after long bone fractures or orthopedic procedures. - While fat embolism can cause respiratory distress, the clinical context of **severe pancreatitis** points away from it. *Large clot in pulmonary artery* - A large clot in the pulmonary artery would indicate a **pulmonary embolism**, which can cause sudden onset dyspnea and hypoxemia. - However, the gradual deterioration, generalized rales, and bilateral decreased breath sounds are more consistent with a diffuse parenchymal lung process like ARDS rather than a localized vascular obstruction. *Hemosiderin-laden alveolar macrophages* - Also known as **heart failure cells**, these are seen in conditions involving chronic extravasation of red blood cells into the alveoli, such as **congestive heart failure** or **pulmonary hemorrhage**. - This patient's acute presentation and primary diagnosis of pancreatitis do not align with chronic conditions causing hemosiderin deposition. *Decreased lecithin to sphingomyelin ratio* - A decreased **lecithin to sphingomyelin ratio** is a marker of **fetal lung immaturity** and is seen in **Neonatal Respiratory Distress Syndrome (NRDS)**. - It is not relevant in an adult patient developing acute respiratory failure due to pancreatitis-induced ARDS.

Q: A 73-year-old female with no past medical history is hospitalized after she develops a fever associated with increasing shortness of breath. She states that 1 week prior, she had a cold which seemed to be resolving. Yesterday, however, she noticed that she started to feel feverish, measured her temperature to be 101.5°F (38.6°C), and also developed an unproductive dry cough and difficulty breathing. On exam, her temperature is 100.8°F (38.2°C), blood pressure is 110/72 mmHg, pulse is 96/min, and respirations are 16/min. Her exam demonstrates decreased breath sounds at the right lung base. The chest radiograph shows a right-sided pleural effusion with an opacity in the right lower lobe that is thought to be a bacterial pneumonia. Which of the following can be expected on a sample of the effusion fluid?

Protein-rich fluid. ***Protein-rich fluid*** - This patient presents with symptoms and radiographic findings consistent with **bacterial pneumonia** and an associated **pleural effusion**. - Pleural effusions associated with pneumonia are typically **exudative**, meaning they are rich in **protein** and cells due to inflammation and increased capillary permeability. *Malignant cells* - While malignancy can cause pleural effusions, the clinical picture here points strongly to an **infectious etiology** (pneumonia) rather than cancer. - The presence of **fever** and recent cold-like symptoms transitioning to bacterial pneumonia makes malignancy less likely as the primary cause of the effusion. *Specific gravity of 1.010* - A specific gravity of 1.010 or less is characteristic of a **transudative effusion**, which is typically seen in conditions like **heart failure** or **cirrhosis**. - **Exudative effusions**, like the one expected with bacterial pneumonia, generally have a **higher specific gravity (>1.020)** due to their high protein content. *Hypocellular fluid* - An effusion associated with **bacterial pneumonia** is typically **inflammatory** and contains numerous cells, including **neutrophils**, bacteria, and dead cells. - Hypocellular fluid would be more characteristic of a **transudative effusion**, resulting from hydrostatic pressure imbalances rather than inflammation. *Clear fluid* - Pleural effusions from **bacterial pneumonia** are often **turbid** or **cloudy** due to the high concentration of inflammatory cells, proteins, and possibly bacteria. - **Clear fluid** is more commonly associated with **transudative effusions** or certain non-purulent exudative conditions.

Question 1

A 61-year-old male presents to your office with fever and dyspnea on exertion. He has been suffering from chronic, non-productive cough for 1 year. You note late inspiratory crackles on auscultation. Pulmonary function tests reveal an FEV1/FVC ratio of 90% and an FVC that is 50% of the predicted value. Which of the following would you most likely see on a biopsy of this patient's lung?

Accepted Answer

Subpleural cystic enlargement

Answer

Arteriovenous malformations

Answer

Hyaline membranes

Answer

Charcot-Leyden crystals

Answer

Linear immunofluorescence along alveolar basement membranes

Question 2

A 58-year-old woman presents to the physician with a cough that began 6 years ago, as well as intermittent difficulty in breathing for the last year. There is no significant sputum production. There is no history of rhinorrhea, sneezing or nose congestion. She has been a chronic smoker from early adulthood. Her temperature is 36.9°C (98.4°F), the heart rate is 80/min, the blood pressure is 128/84 mm Hg, and the respiratory rate is 22/min. A physical examination reveals diffuse end-expiratory wheezing with prolonged expiration on chest auscultation; breath sounds and heart sounds are diminished. There is no cyanosis, clubbing or lymphadenopathy. Her chest radiogram shows hyperinflated lungs bilaterally and a computed tomography scan of her chest is shown in the picture. Which of the following best describes the pathogenesis of the condition of this patient?

Accepted Answer

Increased release of matrix metalloproteinase 12 (MMP-12) by macrophages

Answer

Structural cell death mediated by Rtp801

Answer

Activation of histone deacetylase-2

Answer

Depletion of the periciliary fluid layer in airway cells

Answer

Infiltration of the lower airway mucosa by activated eosinophils and T lymphocytes

Question 3

A 32-year-old man comes to the physician for a 1-month history of fever, chest pain with deep breathing, and a 4-kg (9 lb) weight loss. His temperature is 38°C (100.4°F). An x-ray of the chest shows a subpleural nodule in the right lower lobe with right hilar lymphadenopathy. Histological examination of a right hilar lymph node biopsy specimen shows several granulomas with acellular cores. Which of the following is the most likely diagnosis?

Accepted Answer

Primary tuberculosis

Answer

Hodgkin lymphoma

Answer

Chronic berylliosis

Answer

Miliary tuberculosis

Answer

Pulmonary sarcoidosis

Question 4

An investigator is studying the effects of influenza virus on human lung tissue. Biopsy specimens of lung parenchyma are obtained from patients recovering from influenza pneumonia and healthy control subjects. Compared to the lung tissue from the healthy control subjects, the lung tissue from the affected patients is most likely to show which of the following findings on histopathologic examination?

Accepted Answer

Increased type II pneumocytes

Answer

Decreased alveolar macrophages

Answer

Increased goblet cells

Answer

Decreased interstitial fibroblasts

Answer

Increased alveolar squamous epithelial cells

Question 5

A lung mass of a 50 pack-year smoker is biopsied. If ADH levels were grossly increased, what would most likely be the histologic appearance of this mass?

Accepted Answer

Sheets of small round cells with hyperchromatic nuclei

Answer

Layered squamous cells with keratin pearls

Answer

Pleomorphic giant cells with leukocyte fragments in cytoplasm

Answer

Hyperplasia of mucin producing glandular tissue

Answer

Tall columnar cells bordering the alveolar septum

Question 6

A 73-year-old man is brought to the emergency department because of fever, malaise, dyspnea, and a productive cough with purulent sputum for the past day. His temperature is 39.2°C (102.6°F). Pulmonary examination shows crackles over the right upper lung field. Sputum Gram stain shows gram-positive cocci. Despite the appropriate treatment, the patient dies 5 days later. At autopsy, gross examination shows that the right lung has a pale, grayish-brown appearance and a firm consistency. Microscopic examination of the tissue is most likely to show which of the following?

Accepted Answer

Fibrinopurulent leukocytic exudate with lysed erythrocytes

Answer

Dilation of alveolar capillaries and serous exudate with abundant bacteria

Answer

Fibrinous exudate with erythrocytes, leukocytes, and bacteria

Answer

Resorbed exudate with aerated alveoli

Answer

Neutrophilic infiltrate in the bronchiolar walls and adjacent alveoli

Question 7

A 38-year-old man comes to the physician because of fever, malaise, cough, and shortness of breath for 2 months. He has had a 4-kg (9-lb) weight loss during the same period. He works at a flour mill and does not smoke cigarettes. His temperature is 38.1°C (100.6°F) and pulse oximetry shows 95% on room air. Diffuse fine crackles are heard over both lung fields. A chest x-ray shows patchy reticulonodular infiltrates in the mid and apical lung fields bilaterally. A photomicrograph of a lung biopsy specimen is shown. Which of the following cytokines have the greatest involvement in the pathogenesis of the lesion indicated by the arrow?

Accepted Answer

Interferon gamma and interleukin-2

Answer

Tumor necrosis factor alpha and interleukin-4

Answer

Interferon alpha and interleukin-1

Answer

Interleukin-4 and interleukin-10

Answer

Transforming growth factor beta and interleukin-12

Question 8

A 61-year-old man presents with gradually increasing shortness of breath. For the last 2 years, he has had a productive cough on most days. Past medical history is significant for hypertension and a recent admission to the hospital for pneumonia. He uses a triamcinolone inhaler and uses an albuterol inhaler as a rescue inhaler. He also takes lisinopril and a multivitamin daily. He has smoked a pack a day for the last 32 years and has no intention to quit now. Today, his blood pressure is 142/97 mm Hg, heart rate is 97/min, respiratory rate is 22/min, and temperature is 37.4°C (99.3°F). On physical exam, he has tachypnea and has some difficulty finishing his sentences. His heart has a regular rate and rhythm. Auscultation of his lungs reveals wheezing and rhonchi that improves after a deep cough. Fremitus is absent. Pulmonary function tests show FEV1/FVC of 55% with no change in FEV1 after albuterol treatment. Which of the following is the most likely pathology associated with this patient's disease?

Accepted Answer

Inflamed bronchus with hypertrophy and hyperplasia of mucous glands

Answer

Airway hypersensitivity

Answer

Chronic granulomatous inflammation with bilateral hilar lymphadenopathy

Answer

Consolidation and red hepatization

Answer

Permanent bronchial dilation

Question 9

A 53-year-old man is admitted to the intensive care unit from the emergency department with severe pancreatitis. Overnight, he starts to develop severe hypoxemia, and he is evaluated by a rapid response team. On exam the patient is breathing very quickly and has rales and decreased breath sounds bilaterally. He is placed on 50% FiO2, and an arterial blood gas is collected with the following results:

pH: 7.43
pCO2: 32 mmHg
pO2: 78 mmHg

The oxygen status of the patient continues to deteriorate, and he is placed on ventilator support. Which of the following would most likely be seen in this patient?

Accepted Answer

Intra-alveolar hyaline membrane formation

Answer

Diffuse lipid droplets and globules

Answer

Large clot in pulmonary artery

Answer

Hemosiderin-laden alveolar macrophages

Answer

Decreased lecithin to sphingomyelin ratio

Question 10

A 73-year-old female with no past medical history is hospitalized after she develops a fever associated with increasing shortness of breath. She states that 1 week prior, she had a cold which seemed to be resolving. Yesterday, however, she noticed that she started to feel feverish, measured her temperature to be 101.5°F (38.6°C), and also developed an unproductive dry cough and difficulty breathing. On exam, her temperature is 100.8°F (38.2°C), blood pressure is 110/72 mmHg, pulse is 96/min, and respirations are 16/min. Her exam demonstrates decreased breath sounds at the right lung base. The chest radiograph shows a right-sided pleural effusion with an opacity in the right lower lobe that is thought to be a bacterial pneumonia. Which of the following can be expected on a sample of the effusion fluid?

Accepted Answer

Protein-rich fluid

Answer

Malignant cells

Answer

Specific gravity of 1.010

Answer

Hypocellular fluid

Answer

Clear fluid

Pulmonary — MCQs

Pulmonary — MCQs

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