103707230-Respiratory-Medicine-101-150

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Respiratory medicine

101. A 35-year-old woman who has been treated for asthma presents for review. She helpswith mucking out at a horse-riding stable over the weekends. She had been well until the

past year or so, bit has since suffered recurrent chest infections, a dry cough and shortnessof breath. There is no haemoptysis. Full blood count reveals a raised eosinophil count.

Chest X-ray reveals evidence of pulmonary infiltration and some lobar consolidation andcavitation.

What is the diagnosis that fits best with this clinical picture?

Aspergilloma

Allergic bronchopulmonary aspergillosis (ABPA) Your answer

Asthma

Tuberculosis

Bronchiectasis

This woman helps out at a stables and is likely to have been exposed toAspergillus

fumigatus. Diffuse X-ray changes, an asthmatic-type presentation originally, now borderingon bronchiectasis with frequent infections and peripheral blood eosinophilia point towards

ABPA. Aspergilloma tends to become invasive, beginning in an old cavity, such as one left

by TB infection, and you would not expect such severe X-ray changes in someone withasthma. Management involves oral prednisolone initially, and then later bronchodilators.

The X-ray changes that appear long-term are in response to a type-2 hypersensitivity

reaction.

102. A 16-year-old boy is brought to casualty after a fire in his parents' house. Heinhaled a lot of smoke and has a hoarse voice, stridor and burned nasal hairs.Due to deterioration in his peak flow rate and arterial blood gases, he has beenintubated, ventilated and transferred to the intensive care unit where hiscondition is now stable.

In terms of investigation, what is the most important next step in assessing thisboys condition?

CT thorax

Chest X-ray

Bronchoscopy Your answer


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Ventilationperfusion scan

Echocardiography

Inhalation of hot smoke can burn the upper airways and contributes significantlyto deaths due to fires. Upper airway obstruction due to heat injury and mucosalswelling usually develops within 24 h of exposure, but stenosis due to scarringcan develop later. A hoarse voice, stridor, severe conjunctivitis, burnt nasal hairsand falling peak flow all suggest significant upper airway damage. Bronchoscopyis then the best tool to establish whether there is significant oedema or mucosalulceration obstructing the airways.

103. People with coal-workers pneumoconiosis are predisposed to developingwhich disease?

Tuberculosis

Carcinoma of the lung

Progressive massive fibrosis

Your answer

Silicosis

Heart failure

Simple coal-workers pneumoconiosis causes no symptoms or physical signs, norany important physiological abnormality. The danger associated with simplepneumoconiosis is that it is a predisposition to progressive massive fibrosis, a riskdirectly related to the profusion of simple pneumoconiosis on the X-ray.

Progressive massive fibrosis may occur during working life or appear for the firsttime after (sometimes many years after) dust exposure ceases, even when there


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is no apparent simple pneumoconiosis on the X-ray. Progressive massive fibrosisusually causes a mixture of restriction of lung volumes and, owing to associatedemphysema, airflow obstruction. Ultimately, it may lead to cor pulmonale anddeath. However, the rate of progression is variable. In general, the earlier thatprogressive massive fibrosis develops in a persons life, the more rapidly it is

progressive and thus the greater is the threat to health.A patient with progressive massive fibrosis may complain of shortness of breathand symptoms of cor pulmonale. An unusual, but pathognomonic symptom ismelanoptysis the expectoration of the black contents of a cavitated lesion.Haemoptysis and finger clubbing suggest lung cancer and should not beattributed to pneumoconiosis. Abnormal signs in the chest, if present, relate tothe presence of bullae, although sometimes lobar collapse can occur.

Coal-workers pneumoconiosis is not associated with an increased risk oftuberculosis or lung cancer, although obviously these diseases can be seen in coalminers and should be suspected if an unusual progression of radiological changes

occurs. The association between pneumoconiosis and emphysema has beencontroversial, but there is now clear evidence of a parallel association betweendust exposure and two effects pneumoconiosis and airflow obstruction. Themore dust that a miner has been exposed to, the greater are his risks ofpneumoconiosis on the one hand, and productive cough, reduction in forcedexpiratory volume in 1 s (FEV1), and the presence of centriacinar emphysema onthe other. Of course, the latter risks are also related to cigarette smoking, andthe effect of dust exposure is additive.

104. You review a 72-year-old man with severe chronic obstructive pulmonary disease(COPD), who asks about the provision of oxygen therapy at home. In which of the

following have randomised controlled trials shown that long-term oxygen therapy (LTOT)

reduces mortality?

Asthma

Cor pulmonale caused by chronic airflow obstruction Your answer

Cryptogenic fibrosing alveolitisCystic fibrosis

Pulmonary sarcoidosis

Two controlled studies (in a mostly male population) indicated that life can be prolongedby the continuous delivery of 2 litres per minute of oxygen via nasal prongs to achieve

saturations of greater than 90% for a large proportion of the day and night. Improvements

in pulmonary artery hypertension were obtained in patients who wore oxygen for more


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than 15 hours per day, but mortality was only improved in patients who wore oxygen for

more than 19 hours per day. Long-term oxygen therapy (LTOT) should therefore be

considered in patients with chronic obstructive pulmonary disease (COPD) and a forcedexpiratory volume 1 (FEV1) of less than 1.5 litres, an arterial partial pressure of oxygen

(PaO2) of less than 7.3 kPa, and carboxyhaemoglobin of less than 3%. Although oxygen

cylinders may be provided for intermittent use by patients for the relief of symptoms ofbreathlessness, they have no effect on prognosis.

105. A patient with tuberculosis was initially treated with streptomycin, later this was

changed to a combination of isoniazid, rifampicin, pyrazinamide and ethambutol. He now

complains of impaired visual acuity and loss of red/green colour discrimination. Which

drug is responsible?

Streptomycin

Ethambutol Your answer

Rifampicin

Pyrazinamide

Isoniazid

The side-effects of ethambutol are largely confined to visual disturbances in the form of

loss of acuity, colour blindness or restriction of visual fields. These toxic effects are morecommon where an excessive dosage is used or if the patients renal function is impaired.

The earliest features of ocular toxicity are subjective and patients should be advised todiscontinue therapy immediately if they develop deterioration in vision and to seek further

advice promptly. Early discontinuation of the drug is almost always followed by recoveryof eyesight. Patients who cannot understand warnings about visual side-effects should, if

possible, be given an alternative drug. In particular, ethambutol should be used with

caution in children until they are at least 5 years old and capable of reporting symptomaticvisual changes accurately.

106. Leukotriene-receptor antagonists (LTRAs) may be used as add-on therapy in the

treatment of asthma. Which of the following statements best describes how and when theyshould be used?

LTRAs should be used as initial therapy in adults

They are an ideal add-in for those patients using excessive prn salbutamol


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LTRAs are usually not of therapeutic value in patients with aspirin-

intolerant asthma and should be avoided in this group

LTRAs should be add-in therapy when patients are poorly controlled on

dual therapy with high-dose inhaled corticosteroids and a long-acting 2-agonist

Your

answer

LTRAs may elicit a delayed response in terms of symptom improvement,and it is necessary to continue treatment for at least 6 months

LTRAs such as montelukast are given orally and are effective in a subpopulation of asthma

patients. A 4-week treatment trial to determine symptomatic response to the therapeutic

class is normally recommended. Patients who are aspirin-intolerant appear to deriveparticular benefit from this therapy. LTRAs act by inhibiting the cysteinyl leukotriene

receptor and partially inhibiting the inflammatory cascade associated with asthma. They

should be considered as add-in therapy for those patients who are poorly controlled on

high-dose inhaled steroid and inhaled long-acting 2-agonists.

107. A 43-year-old woman is referred by her general practitioner with a productive coughand inspiratory crackles at the left base.

Which of the following is considered to be a core adverse prognostic factor?

Respiratory rate of 28/minute

Blood pressure of 98/65 mmHg

Serum urea concentration of 7.1 mmol/l Your answer

Oxygen saturation of 92% on room air

Bilateral changes on chest radiograph

Core clinical adverse prognostic factors are given by the abbreviation CURB: Confusion

(new onset) with a Mini-Mental Test score < 8; Urea > 7.0 mmol/l; Respiratory rate >30/minute; Blood pressure systolic < 90 mmHg or diastolic < 60 mmHg. If any core

clinical factors are present then the patient is at increased risk of death and should not be

sent home (British Thoracic Society Guidelines, December 2001).

108. A 64-year-old man is brought to the Accident and Emergency Department by his wifewith drowsiness and confusion. He has a history of COPD and attends the chest clinic. He

had been commenced on antibiotics by his general practitioner 2 days earlier for an

exacerbation of his COPD. Which of the following blood gases (on 2 litres O2/min) fit bestwith this mans condition?

pH 7.14pa(CO2) 7.3pa(O2) 9.1 bicarbonate 14

pH 7.24pa(CO2) 9.3pa(O2) 8.1 bicarbonate 34 Your answer


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pH 7.38pa(CO2)5.3pa(O2) 8.1 bicarbonate 30


This patient has acute on chronic respiratory acidosis. Respiratory acidosis will have a

raisedpa(CO2) and H+ concentration. The elevation of the bicarbonate reflects renalbuffering from his chronic respiratory failure. In acute respiratory acidosis every 1 kPa rise

in CO2 produces 6 nmol/l of hydrogen ion and a 1 mmol/l increase in bicarbonate, whereaswhen chronic, the increase in hydrogen ions per kPa rise in carbon dioxide falls to about

2.5 nmol/l. In this question B is the best response as it best encapsulates the clinical data

provided.

109. A 50-year-old woman is admitted with a dry cough, shortness of breath and

a 2-week history of intermittent fevers. She had had flu-like symptoms at thebeginning of her illness. On examination she has right-sided crepitations and achest X-ray shows patchy shadowing at her right lower lobe, with an airbronchogram. Her white cell count and CRP are raised. She is started onantibiotics for community-acquired pneumonia and after 2 days of clinicallyimproving, she is discharged. You see her in clinic 3 months later, when she tellsyou she is no better. Her chest X-ray shows left upper lobe consolidation. What isthe most likely cause of this?

Recurrent bacterial pneumonia

Eosinophilic pneumonia

Cryptogenic organising pneumonia

Your answer

Lymphangioleiomyomatosis

Pulmonary alveolar proteinosis

Cryptogenic organising pneumonia is a non-specific inflammatory pulmonaryprocess, with buds of granulation tissue forming in the distal air spaces.Organising pneumonia may result from a number of causes, includingconnective tissue disease, infection and drugs, but if there is no obvious causeit is called cryptogenic. It causes non-specific symptoms of fever, dry cough,


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malaise, anorexia and weight loss. It is associated with raised a WCC and C-reactive protein (CRP) levels. The chest X-ray can show consolidation, nodulesor thickened septal lines. The consolidation typically occurs in differentplaces at different times. CT findings are characteristic with multiple patchyalveolar opacities, which often spontaneously migrate. The diagnosis may be

made from CT alone, or from transbronchial or open lung biopsy. Treatment iswith steroids. Relapse is common with further consolidation and may needtreatment with increased steroid doses.

Recurrent lobar bacterial infection is unusual in an immunocompetentadult, and eosinophilic pneumonia gives flitting peripheral chest X-rayshadows. Lymphangioleiomyomatosis is a rare disease affecting women ofchild-bearing age, who have abnormal proliferation of atypical smooth musclecells throughout their lungs and airways. CT shows multiple small cysts.Pulmonary alveolar proteinosis is a rare defect where the alveoli becomefilled with proteinaceous material that cannot be cleared. CT shows airspaceshadowing.

110. A patient with cystic fibrosis presents with a severe bronchopneumonia.What is the most likely pathogen?

Streptococcus pyogenes

Streptococcus pneumoniae

Pseudomonas aeruginosa

Your answer

Klebsiella pneumoniae

An atypical Mycobacteria sp

Pseudomonas aeruginosa is the commonest colonising organism in patients withcystic fibrosis after the age of 10 years, with a reported prevalence varyingbetween 40 and 80%. Enhanced adherence to the airways of patients with cysticfibrosis promotes colonisation, but prior antibiotic treatment may play a part. Noparticular phage type predominates, but siblings with cystic fibrosis often carry


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the same type, and environmental sources have been identified in cystic fibrosiscentres, dentistry equipment, hydrotherapy pools and nebulisers. After somemonths or years of colonisation, pseudomonas produces mucoid alginate as aprotective biofilm and the organisms live in mucoid microcolonies. This mucoidvariant is associated with a worse prognosis and greater antibiotic resistance.

Most colonising types ofPseudomonas aeruginosa are sensitive to antibiotics atfirst, but over the years and in association with antibiotic treatment, multipleresistance to most antibiotics (except colistin (eg Colomycin)) develops.

111. What is the most common cause of haemoptysis?

Infective exacerbation of COPD Your answer

Pulmonary infarction

TuberculosisGoodpastures syndrome

Bronchial carcinoma

The most common cause of haemoptysis is acute infection, in exacerbation of COPD in

particular. But other causes should be excluded while investigating. Bronchial carcinoma,

pulmonary infarction and tuberculosis are common causes. Massive haemoptysis of morethan 200 ml of blood is present in cases of bronchiectasis and tuberculosis. Pulmonary

haemosiderosis, Goodpastures syndrome, microscopic polyangiitis, and trauma are some

of the rarer causes worth remembering.

112. A 28-year-old black nurse develops painful nodules on the shin of both legs. She has

low grade fever and has lost 5 kg in the two months prior to her presentation. Her chest X-ray shows bilateral hilar lymphadenopathy. The MOST likely outcome of this patients

illness is?

Complete remission after appropriate course of steroid and cytotoxic

drugs

Complete remission without any specific treatmentYour

answer

Complete initial remission soon interrupted by increasing relapses

Diffuse reticulo-nodular changes in the lung and progressive shortnessof breath

Generalised lymphadenopathy and progressive wasting in 510 years


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Acute sarcoidosis includes the complex of erythema nodosum and X-ray findings of

bilateral hilar adenopathy, often accompanied by joint symptoms, including arthritis at the

ankles, knees, wrists, or elbows. Spontaneous remission occurs in nearly two-thirds ofpatients with acute sarcoidosis, while 1030% develop a chronic course. Remissions often

occur within the first six months after diagnosis. NSAIDs are very useful for

musculoskeletal symptom control.

113. The parents (both cystic fibrosis gene carriers) of a child with cystic fibrosis (CF)

come to see you for advice after reading about CF on the Internet. Which of the followingbits of information from their Internet printout is correct?

The gene defect is a mutation on chromosome 6

There is evidence of pulmonary disease at birth


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increasing, particularly during the second decade of life, where it may affect up to 1015%

of the population.

115. A 68-year-old man who has a long history of smoking presents to the EmergencyDepartment with worsening shortness of breath. His general health has deteriorated over

the past few months and recently he has been prescribed a salbutamol inhaler by his GP for

cough and wheezing, particularly on exercise and at night. On examination in theEmergency Department he is lip pursing and has considerable wheeze on auscultation of

the chest. He is pyrexial at 37.8C and has purulent sputum. He can only manage a peak

flow of 150 l/min. Arterial blood gas sampling reveals apa(O2) of 7.2 kPa. Which of thefollowing would be the most appropriate choice for antibiotic therapy in this man?

Clarithromycin 500 mg po bd Your answer

Penicillin V 500 mg po qds

Metronidazole 500 mg po tdsCefotaxime 1 g iv tds

Ciprofloxacin 500 mg po bd

This man has an exacerbation of chronic pulmonary disease (COPD). The most common

causative pathogens areHaemophilus influenzae andMoraxella catarrhalis. The most

appropriate antibiotic therefore would be a macrolide such as clarithromycin. It should benoted however that in patients taking theophyllines, concomitant use of macrolides might

increase serum aminophylline levels. Other important acute treatment in this case would be

repeated nebulisation with salbutamol and ipratropium 46 hourly, oxygen therapy, andoral steroids. Non-invasive ventilation may be considered where the pH is 7.3 or less and

the patient is not improving after 4 h of medical therapy.

116. A 60-year-old patient was referred with a 1-year history of persistent coughproductive of mucopurulent sputum throughout the year. He has been treated by his GP for

recurrent chest infections. What is the most likely diagnosis?

Fibrosing alveolitis

Carcinoma of the lung

Sarcoidosis

Bronchiectasis Your answer

Allergic asthma

Bronchiectasis should be suspected when there is a history of persistent cough productiveof mucopurulent or purulent sputum throughout the year. Patients have frequently been

treated for recurrent chest infections and labelled as bronchitic, often despite the absence


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of a history of smoking. Patients may produce mucoid sputum early in their disease,

developing purulent sputum when they suffer an exacerbation associated with a viral upper

respiratory tract infection. Such exacerbations may be associated with pleuritic chest pain,haemoptysis, fever and sometimes wheeze. Those presenting as adults often recall a chesty

cough or wheezy bronchitis associated with upper respiratory tract infections in

childhood, followed by complete resolution of symptoms in their teens and early adult lifebefore the symptoms return after a viral trigger. Upper respiratory tract symptoms such as

postnasal drip are common, and in about 30% of cases there is a history of chronic

sinusitis. Patients with bronchiectasis also suffer from undue tiredness, which many findmore troublesome than the productive cough.

117. A 56-year-old man with confirmed squamous cell carcinoma of the right upper lobe of

the lung has a normal FEV1 and normal serum biochemistry. Which one of the following

investigations is most appropriate to assess operability?

Bone scan

Chest CT scan Your answer

Differential perfusion lung scan

Measurement of total lung capacity

Sputum cytology

A chest CT scan is the best method for staging squamous cell carcinoma of the lung. This

would indicate the extent of involvement and surgical approach. Five-year survival ratesare > 75% in stage I disease (nodes 0, tumour confined within visceral pleura) and 55% in

stage II disease, which includes resection in patients with ipsilateral peribronchial or hilarnode involvement. Sputum cytology is irrelevant, as the diagnosis has already been

established. Measurement of total lung capacity and differential perfusion lung scans is nothelpful in staging. A bone scan is not required as there is no clinical, haematological or

biochemical evidence of tumour spread to bony sites.

118. A 49-year-old woman with ulcerative colitis becomes breathless anddevelops a dry cough. Her pulmonary function tests reveal mild gas trapping and

reduced expiratory flow rates at low lung volumes. Which of the followingpulmonary complications of ulcerative colitis is the most likely explanation?

Bronchiolitis

Your answer

Interstitial lung disease


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120. A 43-year-old woman has a pleural effusion and evidence of fibrosis on CXR. She has

noticed a facial rash on sun exposure that has worsened over the past few months. Which is

the most likely diagnosis?

Systemic lupus erythematosus Your answer

Adenocarcinoma lungWegener's granulomatosis

Progressive massive fibrosis

Actinomycosis

Direct pulmonary involvement in systemic lupus erythematosus (SLE) occurs in 30%

(pleuropericarditis, atelectasis, pneumonitis, raised hemidiaphragms and pulmonary

fibrosis). Autoimmune screen with antinuclear antibody (ANA) and anti-dsDNA antibodiesmay be useful in confirmation of the diagnosis. The other stems are all associated with

cavitating lung lesions. Wegener's granulomatosis is a necrotising vasculitis characterised

by granulomas in the upper and lower respiratory tracts and a focal glomerulonephritis.

Progressive massive fibrosis is a complicated coal workers pneumoconiosis wherepulmonary nodules coalesce and cavitate. Actinomycosis is a chronic granulomatous

disorder produced by a Gram-positive anaerobe. Any lung cancer may cavitate if it

outgrows its blood supply but it is typically squamous cell carcinoma, which cavitates.

121. A 40-year-old man presents to the emergency department with difficultybreathing and swallowing. Examination is normal. Chest X-ray shows an enlargedupper mediastinum, so you arrange a CT scan, which is performed the next day.

This shows an enlarged thymus gland. What would you do next?

Arrange a fine-needle aspirate of the thymus

Arrange a biopsy of the thymus

Refer to the surgeons for thymus excision

Your answer

Refer to the oncologists for radiotherapy

Await the results of antibody testing prior to making a decision

This man has a thymoma, which is a tumour of epithelial origin arising in thethymus. Between 30 and 40% of patients with a thymoma have myasthenia


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gravis, and will have positive antiacetylcholine-receptor antibodies. Themyasthenia often does not improve after the thymus is removed. Awaiting theresults of antibody testing does not alter the management, which is thymectomy(20% of patients with myasthenia gravis have a thymoma). Thymomas containedwithin the thymic capsule tend to be benign, but those that have extended

beyond it are generally malignant. Biopsy or FNA can breech the capsule andhence increase the risk of thymoma tumour seeding and should be avoided.Postoperative radiotherapy is indicated for those malignant or incompletelyexcised thymomas.

122. A 48-year-old man with hepatitis B is admitted via his GP with a history ofbreathlessness. He has signs of chronic liver disease and does not want to stay inhospital. His INR is 2.8 and his chest radiograph appears normal. The nursescomment that his oxygen saturation drops from 98% to 91% on room air every

time he gets up to leave. What is the most likely diagnosis?

Small pneumothorax

Aspiration pneumonia

Pulmonary embolus

Hepatopulmonary syndrome

Your answer

Viral pneumonitis

Hepatic disease can result in right-to-left shunting, secondary to intrapulmonaryvasodilatation mainly in the lower lobes. This is similar to pulmonaryarteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia,where the PAVMs are located mostly in the lower lobes. As a result, there isincreased blood flow through the lower lobes when the patient moves from the

supine to the erect posture. The end result of this is that deoxygenated bloodenters the left side without going through the lungs, with consequentdesaturation in the erect posture. This phenomenon is called orthodeoxia.


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123. A 30-year-old asthmatic patient has the following drug regimen: regular

inhaled corticosteroids, regular inhaled long-acting 2-agonists (salmeterol), oral

leukotriene-receptor antagonists and inhaled short-acting 2-agonists whenrequired. Although her compliance is good, her symptoms are still notsatisfactorily controlled. What is the next step in her therapy?

Oral steroids

Antibiotics

Switch to nebuliser

Oral cromoglycate

Oral theophylline

Your answer

Theophylline is indicated in step 4 in the treatment of chronic asthma whensymptoms are still not controlled. Theophylline improves lung function andsymptoms; however, side-effects can occur more commonly.

124. You are asked to see a newly diagnosed asthmatic woman who is eightweeks pregnant. She is not on any treatment at the moment. Her PEFR diaryshows wide diurnal variations and she also gives a past history of eczema. Whichof the following is true?

Short-acting 2-agonists are contraindicated during the firsttrimester

Inhaled steroids are associated with major congenitaldeformities

A leukotriene-receptor antagonist is the first-line treatment


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Theophyllines are safe during pregnancy

Youranswer

Steroid tablets are teratogenic

In general, the medicines used for asthma are safe during pregnancy.

Leukotriene-receptor antagonists are not the first-line treatment duringpregnancy. However, they may be continued in women who havedemonstrated significant improvement in asthma control with these agentsprior to pregnancy.

125. Which one of the following conditions is rarely associated with pulmonary infiltrates

and peripheral eosinophilia?

Allergic bronchopulmonary aspergillosis

Lefflers syndrome

Churg-Strauss syndrome

Sulphonamide therapy

Fibrosing alveolitis Your answer

Eosinophilic lung diseases are a heterogeneous group of disorders which are characterisedby the presence of pulmonary symptoms or an abnormal chest X-ray accompanied by

inflammatory cell infiltrate in the airways and/or lung parenchyma which contain a large

number of eosinophils. Many of these disorders are associated with peripheral eosinophilia.

The following list is just an example:

Drugs and toxins (nitrofurantoin, L-tryptophan, sulphonamides)

Helminthic infection (Lefflers syndrome, larva migran)

Acute and chronic eosinophilic pneumonia (primary)

Churg-Strauss syndrome

Allergic bronchopulmonary aspergillosis

Hypereosinophilic syndrome

126. Which one of the following features is MOST characteristic of small cell bronchial

carcinoma?

History of prior asbestos exposure is usually obtained

Hyponatraemia Your


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answer

Known as small cell because the cancer cell origin is from small

lymphocytes

It has a relatively better prognosis when compared with other bronchial

cancers

Surgery is often the only defined treatment

Small cell (oat cell) bronchial carcinoma is frequently associated with ectopic hormoneproduction. The syndrome of inappropriate anti-diuretic hormone secretion (SIADH)

causes hyponatraemia. By the time the diagnosis has been made the tumour is usually

disseminated, so that surgery is seldom considered. Unlike mesothelioma a history of

asbestos exposure is seldom obtained. The prognosis is very poor and survival beyond twoyears is exceptional.

127. A 70-year-old man with chronic obstructive pulmonary disease andbronchiectasis had a sputum sample sent from clinic because he had been morebreathless for 6 months and was coughing purulent sputum. The result has shownthe presence ofMycobacterium malmoense. What does this mean?

He should have further sputum samples sent for culture

Youranswer

He needs admitting to hospital and isolating in a side room

Public health authorities should be informed to begin contacttracing

He should be started on triple-drug antituberculous therapy

He should be started on quadruple-drug antituberculous therapy

Mycobacterium malmoense is a non-tuberculous mycobacterium and anenvironmental low-grade pathogen in humans. This organism most commonlycauses pulmonary infection in middle-aged and older adults with pre-existinglung disease or immunodeficiency. M. malmoense can also cause local invasionfrom a skin lesion. It causes non-specific symptoms, such as malaise and weightloss, or chest disease not progressing as expected. Chest X-ray appearances canbe indistinguishable from those seen in patients with Mycobacterium


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tuberculosis infection, with upper zone fibrosis and cavitation. A single isolatefrom a non-sterile site may not be significant and may represent contamination.More than two isolates from a non-sterile site are required to establish disease.There is a low-risk of cross-infection, so there is no need to isolate patients ornotify public health authorities. There are BTS guidelines on the treatment of

each of the different non-tuberculous mycobacteria, but this is with either twoor three antituberculous drugs (see Subcommittee of the Joint TuberculosisCommittee of the British Thoracic Society 2000. Management of opportunisticmycobacterial infections. Thorax,55(3),21018).

128. A 48-year-old mechanic presented to the clinic complaining of increasing shortness ofbreath over the last 3 months, but with no symptoms of cough. There was no recent history

of chest trauma. He smokes 2025 cigarettes per day and two cans of beer every day. His

brother recently died of stomach cancer and he was quite concerned about his problem.

Clinically, he had a large pleural effusion on his left side, which was confirmed on X-ray.On aspiration, a white fluid came out and there was no clear supernatant after

centrifugation. Co-cholesterol crystals were detected. What is the probable cause of theeffusion?

Lymphoma Your answer

Tuberculosis

Metastatic stomach carcinoma

Lymphangioleomyomatosis

Yellow-nail syndrome

This effusion is chylous fluid, classically described as a milky, opalescent fluid that

contains fat globules. It is differentiated from empyema because the latter yields a clear

supernatant on centrifugation. Pseudochyle is a fluid that has a high lipid content, ascholesterol, and is typically seen in patients with tuberculosis. The commonest cause of a

chylothorax is trauma or a malignancy. The malignancy is usually a lymphoma. Although

metastatic lung deposits may cause chylothorax, it is not so common. Other causes ofchylothorax are a congenital absence of thoracic ducts, filariasis, tuberculous mediastinal

lymphadenitis, lymphangioleiomyomatosis, yellow-nail syndrome and left subclavian

venous thrombosis.

129.A 26-year-old patient admitted with suspected pneumonia and an abnormal chest X-

ray mentions to the attending physician that he has an azygous lobe. Where would you

visualize the azygous lobe on an anterior-posterior chest X-ray?

Right upper zone Your answer


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Right middle zone

Right lower zone

Left upper zone

Left lower zone

An azygous lobe is seen in about 0.5% of routine chest X-rays and is a normal variant. It isseen as a reverse comma sign behind the medial end of the right clavicle.

130. Which of the following statements applies to the peak expiratory flow rate?

It is a less sensitive parameter for assessing improvement to therapy in

patients with acute bronchial asthma

It measures small-airway resistance

Your

answer

It is more related to age than height

Less than 50% of normal is an indication for aminophylline therapy in

those with acute asthma

It is effort-dependent

PEFR is a sensitive measurement of small-airway obstruction, although the maximal mid-

expiratory flow rate is more changed in mild disease. The ease of performing the PEFR at

the bedside has made it more relevant in clinical practice. It is more related to height thanage, and is effort-independent if the proper technique is used.

131. A 64-year-old cigarette smoker presents with increasing breathlessness. Examination

confirms basal crackles in the absence of finger clubbing. His CXR shows widespreadpleural plaques with additional reticular shadowing at the bases. Lung function tests

confirm mild restriction with a low TLCO. Which of the following is likely to be true?

Inhaled steroids may prevent disease progression

Open lung biopsy is mandatory to establish a histological diagnosis

Oral corticosteroids should lead to a significant improvement in lungfunction

The condition is slowly progressiveYour

answer

The most likely diagnosis is extrinsic allergic alveolitis

Pulmonary asbestosis usually affects men with a history of heavy asbestos exposure. It

presents with progressive breathlessness and is resistant to treatment with


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immunosuppressive therapy. The changes typically affect the lower lobes and CT scanning

can be useful in detecting disease. Biopsy is not mandatory as the diagnosis can be made

on clinical and radiological grounds. The only advice is to avoid further exposure and to

stop smoking (>50 risk of lung cancer if a smoker and asbestos exposure compared toexposure to neither). Clubbing occurs in 43% cases of asbestosis.

132. A 23-year-old smoker of 30 cigarettes per day presents with rapidly increasing

shortness of breath, cough and haemoptysis over the past month following a chest

infection. His chest X-ray demonstrates diffuse alveolar infiltrates. Blood testing indicatesraised urea and creatinine levels, with positive anti-GBM antibodies. Urine analysis reveals

haematuria and proteinuria. Pulmonary transfer factor is elevated. What diagnosis best fits

this clinical picture?

Wegeners granulomatosisGoodpastures syndrome Your answer

Drug-induced renopulmonary disease

Systemic lupus erythematosus

Idiopathic glomerulonephritis

The picture of renal and pulmonary symptoms with evidence of glomerulonephritis andintrapulmonary haemorrhage is particularly suggestive of Goodpastures syndrome,

especially with the positive anti-GBM antibodies. The condition has a male:female ratio of

6:1, accounts for 5% of cases of rapidly progressive glomerulonephritis and 80% ofpatients are HLA-BR2 positive. Management is with prednisolone and cyclophosphamide,

dialysis support where necessary and plasma-exchange therapy in centres where it isoffered.

133. A 30-year-old asthmatic patient has the following drug regimen: regular inhaled

corticosteroids, regular inhaled long-acting 2-agonists (salmeterol) and inhaled short-

acting 2-agonists when required. Although her compliance is good, her symptoms are stillnot satisfactorily controlled. What is the next step in her therapy?

Antibiotics

Salbutamol nebuliser

Oral steroids

Oral cromoglycate

Oral leukotriene-receptor antagonists Your answer

Occasional-relief bronchodilators are indicated in step 1 in the treatment of chronic asthma,

if relief is only needed once daily and if there are no night-time symptoms or there is no


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impaired lung function. Regular inhaled corticosteroids are added in step 2. Regular

inhaled long-acting 2-agonists (salmeterol) are added in step 3. Oral leukotriene-receptorantagonists can also be added in step 3 if the asthma is still not controlled.

134. A 37-year-old man who speaks little English comes to the TB clinic. His notes are

missing but he is able to tell you that he has been on treatment for almost 1 year.

What is the most likely reason he has been treated for this length of time?

Pulmonary TB

Lymph-node TB

TB meningitis Your answer

Bony TB

Pleural TB

In the UK, all fully sensitive TB is treated for 6 months except for TB affecting the central

nervous system, which is treated for 12 months. Multi-drug resistant TB (MDRTB) will

require longer courses of treatment, usually with a combination of less commonly used

anti-TB drugs.

135. A 40-year-old AfroCaribbean woman presents to clinic following aninsurance medical examination, where she was found to have bilateral hilar

lymphadenopathy on her chest radiograph. Her CT scan confirms hilarlymphadenopathy and comments on nodularity in the lung fields. What wouldyou do next?

Arrange a trans-bronchial, lymph node needle aspiration

Arrange a lung biopsy

Commence oral prednisolone

Send sputum samples to microbiology

Observe and repeat her chest X-ray in 3 months Your answer


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Cryptogenic fibrosing alveolitis

Amiodarone may be related to diffuse lung fibrosis. NSAIDs may cause asthma or

pulmonary eosinophilia, phenytoin is also characteristically related to pulmonaryeosinophilia. Other drugs related to lung fibrosis include nitrofurantoin, hexamethonium

and a number of cytotoxic agents. Corticosteroids may be of value in some patients, butwithdrawal of the amiodarone, if possible, is advised. In this case, other therapies such as

an implantable defibrillator may be considered.

139. Which of the following statements applies to patients with cystic fibrosis (CF)?

Neonatal screening for CF results in a better survival rate and reduceddecline in lung function

Allergic bronchopulmonary aspergillosis is a recognised complication,found in 15% of adult CF patients

Youranswer

The controlled intake of high-calorie food is the first line of managementfor patients with CF-related diabetes

Reduced body mass index is an absolute contraindication for heartlung

transplantation

A correlation exists between genotype and the severity of the disease

The commonest mutation in patients with cystic fibrosis (CF) is the Delta-F508 mutation.There is no correlation between genotype, the range of manifestations, the age of

symptoms and the survival rate in CF. Neonatal screening allows the early implementation

of prophylactic therapeutic measures. Prospective and retrospective studies havedemonstrated that neonates detected by screening have a better nutritional status than those

who were discovered by symptoms. The age of acquisition ofPseudomonas aeruginosa

and the decline in lung function were found to be comparable in the two groups. Theincreased age of survival for CF patients is associated with increased complications, such

as diabetes mellitus, acquisition of multiple bacteria in their respiratory flora, osteoporosis

and liver disease. Diabetes is now seen in almost 10% of patients over the age of 20 years,

the main manifestations being weight loss, repeated respiratory infections and decline inlung function. The treatment of choice is subcutaneous insulin therapy. Calorie intake

should not be restricted in CF patients who are prone to malnutrition due to their pancreatic

insufficiency. The increasing incidence of allergic bronchopulmonary aspergillosis

(ABPA) is a recognised phenomenon. ABPA is encountered in 1 in 6 adult CF patients.Manifestations of ABPA include asthma symptoms, flitting opacities on the chest

radiograph, increased eosinophil count, and hyperreactivity to the skin-prick test andincreased specific plasma IgE. The main treatment is high-dose corticosteroids initially,

with a smaller maintenance dose. The duration of treatment ranges from few months to few

years. Anti-fungal agents are of no proven benefit. Heartlung transplantation is offered to

patients who exhibit a rapid decline in lung function despite optimal treatment, and topatients with respiratory failure. Moderately reduced body mass index (BMI) is an


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indication for transplantation. A severe reduction in BMI is a relative contraindication to

transplantation, this is because it is associated with a reduced survival but not an absolute

one.

140. Which of the following interventions is most likely to improve the FEV1 and

prognosis of a cigarette smoker with spirometric evidence of moderate COPD?

Tobacco-smoking cessationYour

answer

Frequent use of antibiotics for acute bacterial exacerbations of chronic

bronchitis

Daily use of salmeterol to improve FEV1

Long-term oxygen therapy at 2 l/min

Daily use of ipratropium bromide to improve FEV1

There is no treatment that has been shown to significantly slow or alter the progression of

COPD except smoking cessation. The single best thing patients with COPD can do forthemselves is to stop smoking. All other treatments are largely for symptom relief.

Chronic obstructive pulmonary disease is a common chronic respiratory illness. It is

steadily progressive and carries a large burden of mortality and morbidity. It causes about

30,500 deaths per year in the UK. The morbidity burden this raises for the NHS is huge. Ofall emergency medical admissions, 25% are due to acute respiratory infections and COPD

exacerbations comprise over half this total. The cost in hospital care for these patients is

about 500 million. Housing changes and alterations add to the social costs of this disease.COPD is caused by tobacco smoking, heavy exposure to occupational dusts and chemicals,

air pollution, cannabis smoking (which is now being recognised) and a 1-antitrypsin

deficiency.

141. A 29-year-old woman noticed shortness of breath and a dry cough whilejogging last winter. She now wakes up twice a week at 4 oclock in the morning

with a troublesome cough. What is the most likely cause?

Cardiac insufficiency

Mycoplasma pneumonia


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Asthma

Your answer

Bronchiectasis

Extrinsic allergic alveolitis

The symptoms of asthma are non-specific: shortness of breath, wheezing, chesttightness and cough. These are manifestations of airway narrowing (which isusually variable in severity over short periods, but can be persistent) and ofairway hyperresponsiveness. Asthma as the cause of these symptoms is suggestedby the variability in their severity and distinguished by their periodicity (such as

daily, weekly, monthly, or seasonal), their provocation by specific (such asallergen) and non-specific stimuli and their reversibility with bronchodilators orcorticosteroids. Patients with asthma can be categorised, at any one time, bywhether their symptoms are intermittent or persistent, and by the severity oftheir symptoms and underlying airway narrowing measured by lung function tests(even those with mild asthma can develop severe asthma):

Mild, intermittent asthma symptoms occur less than weekly, with normalor near-normal lung function between episodes.

Mild persistent asthma symptoms occur more than weekly but less thandaily, with normal or near-normal lung function between episodes.

Moderate persistent asthma symptoms occur daily, with mild tomoderate variable airflow limitation.

Severe persistent asthma symptoms occur daily and interfere withnormal activities. There is frequent nocturnal waking and moderate tosevere variable airflow limitation.

Severe asthma severe distressing symptoms prevent sleep. Severeairflow limitation responds poorly to inhaled bronchodilators and can belife-threatening.

142. A morbidly obese 36 year-old man presents for review. His main reason forattendance is that his wife is concerned about his loud snoring and the fact that he stops

breathing during the night for periods of up to 810 seconds, followed by coughing,

snoring and arousal. Recently he has become hypertensive and is also on treatment for

impotence. His 24-h urinary free cortisol level is normal. Which diagnosis best fits thispicture?


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Cushings disease

Obstructive sleep apnoea Your answer

Simple snoring

Simple obesity

Essential hypertension

Symptoms of sleep apnoea include memory impairment, daytime somnolence, grossly

disrupted sleep pattern, decreased libido and systemic hypertension. Further investigationshould involve thyroid function testing to rule out hypothyroidism, and assessment of the

uvula and tonsils to rule out mechanical obstruction that might be amenable to ENT

surgery. Diagnosis of sleep apnoea is made via overnight oximetry. The mainstay of

management is weight loss, with the addition of overnight CPAP (continuous positiveairway pressure).

143. A 30-year-old woman presents with shortness of breath. This began gradually, around2.5 years ago, but now she is breathless on climbing a flight of stairs. There is no past

history of note. On examination the JVP is raised, carotid pulse volume is reduced and

there is evidence of right ventricular hypertrophy. There are right-sided murmurs oncardiac auscultation. Her chest X-ray shows pulmonary artery enlargement, ECG shows

right axis deviation and right ventricular hypertrophy. Arterial blood gases reveal hypoxia

and hypercapnia, a lung perfusion scan is normal. Cardiac catheterisation reveals that right-

sided pressures are markedly raised.

Which diagnosis best fits with this clinical picture?

Chronic thromboembolic disease

Right ventricular failure

Primary pulmonary hypertension (PPH) Your answer

Cryptogenic fibrosing alveolitis

Asthma

The perfusion scan is not suggestive of chronic thromboembolic disease, which makes

primary pulmonary hypertension the most likely diagnosis. Plexogenic pulmonary

arteriopathy is found in 3060% of sufferers and characterised by medial hypertrophy and

concentric laminar intimal fibrosis. The gene for PPH has now been mapped tochromosome 2, and mutations in the bone morphogenic protein receptor have been

identified in some patients. Intravenous epoprostenol (prostacyclin) and oxygen therapyhas been shown to improve quality of life in sufferers. Recently, phosphodiesterase (PDE)-

5 inhibitors have also been shown to have some therapeutic advantage. Unfortunately,

several studies report a mean survival of only 2.5 years from diagnosis, with rightventricular failure and sudden death the main causes of mortality.


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Admit him to hospital, send a sputum sample and addpyrazinamide, amikacin and ethambutol

Your

answer

The concern with this man is one of multidrug-resistant tuberculosis. He is failing

on his current regime and has clinical features of active tuberculosis. Treatmentfailure is usually due to poor compliance, which can lead to the development ofdrug resistance. Other risk factors for resistant disease are: previous anti-TBtreatment, HIV infection and contact with drug-resistant TB. Although he mayhave a superimposed simple bacterial infection, this should not deter frominvestigating and treating him for TB, as most of the antibiotics used for TB willcover the usual bacterial chest pathogens. A single drug should never be addedto a failing TB regime. Add two or three, ideally ones to which the organism isknown to be sensitive and which the patient has not previously taken. Sendsputum for culture and polymerase chain reaction (PCR) testing before startingfurther treatment. If he has confirmed multidrug-resistant TB, ensure he is on

five or more drugs to which the organism is likely to be susceptible.

147. A 42-year-old patient was diagnosed with mediastinal tuberculosis 3 weeks ago and

commenced on treatment. He presents with worsening breathlessness and stridor. His chest

X-ray shows mediastinal lymph nodes compressing the carina area, whilst he is distressedhe is alert and orientated and maintaining his oxygenation.

What is the next step in the investigation and/or management?

Urgent computed tomography (CT) scan Your answer

Tracheostomy

Hydrocortisone

Ethambutol

Broad spectrum antibiotics

The CT scan is the most appropriate investigation. On enhanced CT scans, nodes larger

than 2 cm in diameter invariably show central areas of low attenuation and peripheral rimenhancement. Enhanced walls are usually irregular in thickness. CT scan is useful prior to

commencing steroid therapy, a) to confirm the degree of airway compression and b) to

assess the response to chemotherapy. A number of commentators recommend rapidinitiation of steroid therapy, but with the availability of CT scanning, this would seem a

sensible measure first.


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148. A 78-year-old White woman presents with left upper lobe cavitating consolidation and

sputum samples confirm the presence ofMycobacterium tuberculosis, which is fully

sensitive. There is no previous history of treatment for tuberculosis (TB). The mostappropriate antibiotic regimen is?

Bacillus CalmetteGuerin (BCG) vaccinationRifampicin/clarithromycin 12 months

Rifampicin/ethambutol 12 months

Rifampicin/isoniazid/pyrazinamide/ethambutol 2 months then

rifampicin/isoniazid 4 months

Your

answer

Rifampicin/isoniazid/pyrazinamide 4 months then rifampicin/isoniazid 8months

In a white patient with pulmonaryMycobacterium tuberculosis that is fully sensitive, and

not previously treated, the use of four drugs for 2 months

(rifampicin/isoniazid/pyrazinamide/ethambutol) and then two drugs (rifampicin/isoniazid)

for 4 months is perfectly acceptable. Indications for using a four-drug regimen includepreviously treated tuberculosis, HIV risk factor(s) or being non-White.

149. You are fast-bleeped to see a 50-year-old woman on the medical ward. Shewas admitted earlier that day with a swollen lower leg following her return froma holiday in Australia. Her D-dimers were raised and she was started onsubcutaneous unfractionated heparin. She is now short of breath, pale, clammy,tachycardic and hypotensive. Her ECG shows sinus tachycardia. The house officer

has given her iv fluids, but her blood pressure is continuing to fall.

What would you consider doing next?

Intravenous heparin

Further iv fluids

Thrombolysis

Your answer

Echocardiogram

V/Q scan


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This is a woman who has a high clinical probability of having had a massivepulmonary embolus (PE). She has respiratory and cardiovascular compromisefrom this PE and is likely to die without treatment. Investigation with eitherechocardiogram showing pulmonary hypertension or CT showing a clot(s), wouldbe reasonable to confirm the diagnosis, but this woman is rapidly deteriorating.

She is not well enough for a V/Q scan. She has had iv fluids and unfractionatedheparin already, with no effect. Thrombolysis can be used for acute pulmonaryemboli causing circulatory collapse and there is emerging evidence to supportthis treatment. The risk/benefit analysis must be considered, but in a patientwho is at imminent risk of arrest/death, give alteplase 100 mg over 1.5 hoursperipherally. (see BTS guidelines for the management of suspected acutepulmonary embolism. Thorax2003,58(6),470).

150. A 24-year-old man with HIV and a CD4+ lymphocyte count of 150/l hasbeen complaining of gradually worsening dyspnoea associated with a non-productive cough and fever for the last 2 weeks. A chest X-ray shows bilateraldiffuse ground-glass opacities.

What is the diagnosis?

Tuberculosis

Legionellosis

Pneumocystis jirovecipneumoniaYour answer

Infectious mononucleosis

Toxoplasmosis

Pneumocystisjiroveci pneumonia (previously known as Pneumocystis cariniipneumonia) typically presents with gradually increasing dyspnoea and cough overweeks, but sometimes it presents as an acute illness with rapid deteriorationover a few days. The chest X-ray usually shows diffuse ground-glass opacities,which strongly suggests the diagnosis; sometimes, however, it shows nodularopacities, lobar consolidation or a normal film. Cystic abnormalities andspontaneous pneumothoraces in patients with known or suspected HIV infectionare usually caused by Pneumocystis jiroveci pneumonia. Pneumocystis jiroveci


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