Pulmonary - Part 1

(D) CORRECT. AAT deficiency leads to lack of an anti-protease, which leads to development of emphysema, typically a panlobular type affecting lower lobes more severely.
(A) Incorrect. Wilson disease affects the liver and the CNS.
(B) Incorrect. Though cystic fibrosis commonly affects the lungs, it leads to the obstructive lung disease known as bronchiectasis.
(C) Incorrect. Alcoholism does not lead to emphysema (but many alcoholics also smoke).
(E) Incorrect. Intravenous drug users are at greater risk for infections and abscesses. The injected talc may form small foreign body granulomas in lung.
(F) Incorrect. A positive ANA can be associated with autoimmune diseases such as SLE. There is often type III hypersensitivity with deposition of antigen-antibody complexes at basement membranes, producing serositis and effusions, such as pleural effusions.

(B) CORRECT. A Lung abscesses can result from aspiration of oropharyngeal or nasopharyageal contents, where bacterial organisms as part of normal flora can be picked up and transported to the lungs. The straighter bronchus to the right lung is more likely to conduct aspirated material. With septicemia, multiple abscesses are more likely to be present.
(D) Incorrect. Bronchiectasis can occur from chronic bronchial inflammation and destruction following obstruction and/or infection; cystic fibrosis is the best known disease to produce a widespread pattern of bronchiectasis. With obstruction, it depends upon the cause for the obstruction where the focus of bronchiectasis will be.
(E) Incorrect. Sequestrations are masses of lung tissue without a normal connection to the airways. They act as space occupying lesions and can cause obstruction.

(B) CORRECT. The chronic lung disease of cystic fibrosis often includes bronchiectasis, a disease characterized by inflammation with obstruction and dilation and destruction of bronchi. This process is diffuse throughout the lungs. The loss of pulmonary vascular bed with progressive bronchiectasis can lead to pulmonary hypertension and cor pulmonale.
(A) Incorrect. The incidence of lung cancer is not increased with cystic fibrosis.
(C) Incorrect. Dilation of lymphatics is an infrequent occurrence with mediastinal masses such as lymphomas.
(D) Incorrect. Pleural plaques are most frequently seen with pneumoconioses.
(E) Incorrect. Patients with cystic fibrosis usually have lung infections with bacteria such
as Pseudomonas.
(F) Incorrect. Pneumonias with cystic fibrosis are unlikely to produce pneumothorax. No bullae form.

(D) CORRECT. The activity of ambulation resulted in sudden movement of a thrombus that formed during his period of immobilization in the leg or pelvic veins. The thrombus became an embolus and traveled to the lungs.
(B) Incorrect. An effusion would take days to weeks to form. There could be dyspnea.
(C) Incorrect. Post-operative changes should have resolved after a week or so and would have a course of gradual improvement.

(C) CORRECT. Sarcoidosis is typified by non-caseating granulomas. However, culture of the tissue and a careful search histologically should be made for organisms.
(A) Incorrect. Histoplasmosis is most common in the Mississippi and Ohio river valleys in the US. The dimorphic fungi tend to mimic tuberculosis and can have granulomas with central caseation.
(B) Incorrect. Adenocarcinoma should yield malignant cells, not granulomas, on biopsy.
(D) Incorrect. UIP is the end result of a diffuse fibrosing alveolitis. Many cases are idiopathic. The end stage is a honeycomb lung. No granulomas are seen.
(E) Incorrect. Though berylliosis can produce sarcoid-like granulomas, it is very uncommon. An environmental history would be helpful.

(G) CORRECT. She has a lobar pneumonia, which is most often a community aquired pneumonia (the nursing home counts as a community venue), following a debilitating course of Alzheimer disease. The most common organism is Streptococcus pneumoniae (pneumococcus).
(B) Incorrect. Listeriosis is infrequent. Some cases occur in immune compromised persons. It can be a congenital infection.
(F) Incorrect. S. aureus is more likely to be a nosocomial infection and more likely to produce a bronchopneumonia with patchy infiltrates.

(D) CORRECT. The large central mass is consistent with a squamous cell carcinoma, which is seen mainly in smokers.
(E) Incorrect. Cytomegalovirus infections occur in immunocompromised patients. No mass is present.
(B) Incorrect. Mesothelioma is rare; it is characterized by a bulky pleural mass in a person with prior asbestos exposure.
(C) Incorrect. Granulomatous inflammation is typical for mycobacterial and fungal infections; though a solitary granuloma may be present, it is usually not larger than 2 to 3 cm in size.

(C) CORRECT. The typical appearance of a viral lung infection is chronic interstitial inflammation.
(A) Incorrect. TB most often produces a granulomatous pattern of inflammation with reticulonodular densities, particularly in the upper lobes.
(B) Incorrect. Pneumococcus leads to alveolar filling with neutrophils.
(D) Incorrect. Cryptococcus leads to granulomatous disease.
(E) Incorrect. MAI may produce poorly-formed granulomas.

(A) CORRECT. Both squamous cell and oat cell carcinomas tend to be central in location. Squamous cell carcinomas of the lung are associated with hypercalcemia, though overall the oat cell carcinomas are best known for paraneoplastic syndromes.
(B) Incorrect. This is more typical of a bronchioloalveolar carcinoma.
(C) Incorrect. Such a peripheral mass would more likely be a granuloma, an adenocarcinoma or a hamartoma.
(D) Incorrect. The carina is an unusual site for a primary tumor.
(E) Incorrect. The findings do not suggest a mesothelioma.

(C) CORRECT. Smoking remains the most frequent cause of lung cancer. Lung cancer does, however, occur in nonsmokers. A small cell anaplastic carcinoma, as in this patient, is virtually always seen in smokers.
(A) Incorrect. Silicosis increases the risk for lung cancer slightly by about 2 fold.
(B) Incorrect. Radon is probably the second leading cause of lung cancer. However, most cases of lung cancer in which exposure to radon gas has been identified also occur in smokers.
(D) Incorrect. However, asbestos exposure increases the risk for lung cancer in smokers even more.
(E) Incorrect. Passive smoking could probably be right behind radon exposure as the second leading cause for lung cancer.

(D) CORRECT. These findings are classic for exposure to asbestos. Pleural plaques are more frequent in this condition than in other pneumonconioses, particularly with calcification. Asbestosis is a form of pneumoconiosis that can lead to restrictive lung disease. In smokers, there is an increased risk for development of bronchogenic carcinomas.
(B) Incorrect. Silicosis more typically produces a pattern of silicotic nodules in lung. Inorganic dusts often produce interstitial fibrosis.

(E) CORRECT. Diffuse alveolar damage (or ARDS as it is known clinically) is the final event following lung injury from a variety of serious illnesses or accidents. In this case, it was probably initiated by the hypotension ('shock lung') and potentiated by the 100% oxygen.
(A) Incorrect. A bacterial pneumonia, as a nosocomial infection, is likely to be accompanied by signs of sepsis.
(B) Incorrect. Chronic bronchitis develops and continues over months to years, probably from environmental agents.
(C) Incorrect. This is a process that takes at least weeks to months and is due to obstruction of airways in one or more parts of lung.
(D) Incorrect. Viral pneumonias are not likely to be acquired in hospital. They are often complicated by bacterial pneumonia.

(B) CORRECT. This is a description of the typical 'Ghon complex' of an initial, or primary, TB infection. The peripheral granuloma does not produce symptoms, but the enlarged lymph nodes may impinge upon airways. Most persons with a primary infection, however, are asymptomatic and the infection goes unnoticed.
(C) Incorrect. A carcinoid tumor could produce focal obstruction with a pneumonia, but pulmonary neoplasms in children are rare. Most bronchial carcinoids act in a benign fashion without metastases.

(B) CORRECT. The differential diagnosis of a solitary coin lesion most often includes lung cancer (adenocarcinoma most likely), granuloma, or hamartoma.
(A) Incorrect. An 'oat cell' carcinoma tends to spread very quickly and not remain localized. Moreover, it virtually always appears in persons with a history of smoking.
(D) Incorrect. An exogenous lipid pneumonia from aspiration of a substance that is oily or contains much lipid is not typically localized.

(C) CORRECT. Chronic bronchitis is defined clinically as a person who has persistent cough with sputum production for at least 3 months in at least 2 consecutive years. Air pollution and smoking are key causes for chronic bronchitis.
(A) Incorrect. Though lung cancers are more common in persons who smoke, his findings are not explained by a mass lesion, and his symptoms have persisted for years.
(B) Incorrect. Congestive heart failure will produce pulmonary edema, if it is primarily left heart failure. If severe, there can be 'rusty' colored sputum.
(E) Incorrect. As a smoker, he is at risk for development of emphysema, but this does not explain his sputum production. Sometimes, smokers have elements of both emphysema and chronic bronchitis.
(G) Incorrect. Bronchiectasis is not a typically complication of smoking.

(B) CORRECT. This tumor can spread in a pneumonia-like pattern. The lack of a change over time and the absence of a response to antibiotics should suggest a non-infectious process.
(D) Incorrect. An infarct is unlikely to yield - ATYPICAL CELLS.
(A) Incorrect. An atypical pneumonia with Mycoplasma is unlikely to be confined to just the right lower lobe, and it would not yield - ATYPICAL CELLS.

C) CORRECT. CMV produces a cytopathic effect with enlarged cells having prominent intranuclear inclusions.
(A) Incorrect. Toxo is not common in lung. Toxo cysts contain bradyzoites, which are about 2 microns in size. There may be surrounding free tachyzoites of the same size as bradyzoites.
(B) Incorrect. Candida yields budding cells and pseudohyphae.
(D) Incorrect. PCP yields foamy material that appears acellular with H&E and Pap stains.
(E) Incorrect. TB produces a granulomatous reaction. There may be giant cells of the Langhans variety, but a BAL will probably not have much that is diagnostic without an AFB stain or culture.
(F) Incorrect. Influenza virus infections are not characteristic for immunocompromised patients. No characteristic inclusions can be seen in specimens.
(G) Incorrect. Respiratory syncytial virus infections are most common in young children and infants. They are not characteristic for immunocompromised patients. Inclusions are in the cytoplasm with this RNA virus.

B) CORRECT. Paraseptal emphysema is not common, but does account for a significant number of cases of spontaneous pneumothorax in young persons. It is not related to smoking. There are subpleural bullae that can burst, even with minimal trauma.
(A) Incorrect. A bronchopleural fistula typically occurs in the setting of a severe lung infection, not in a healthy person.
(E) Incorrect. Both chronic restrictive and obstructive lung diseases can reduce the pulmonary vascular bed to increase pulmonary arterial pressures that promote pulmonary atherosclerosis. The vessels do not rupture.

(E) CORRECT. The hemoptysis suggests that the granulomas have eroded enough parenchyma and involved a bronchus. A granulomatous reaction is typical for Mycobacterium tuberculosis.
(A) Incorrect. Aspergillus infection is not common. It is more likely to produce a fungus ball. Persons who are neutropenic are at greatest risk. The inflammatory reaction could vary from acute to mixed to granulomatous.
(B) Incorrect. A squamous cell carcinoma is usually a central mass lesion. It is unlikely that epithelioid cells would appear on biopsy
(C) Incorrect. PCP in rare cases has a granulomatous pattern, but the granulomas would be small and unlikely to lead to hemoptysis.
(D) Incorrect. Small cell anaplastic carcinomas are centrally located. They are unlikely to be found with epithelioid cells.

(C) CORRECT. He is most likely to have Pneumocystis carinii (jirovecii) pneumonia in association with the acquired immunodeficiency syndrome. PCP has an exudate composed of the Pneumocystis cysts and trophozoites with little accompanying inflammation. The clinical findings in this case are typical as well.
(B) Incorrect. Aspergillus often produces a fungus ball, or a defined mass, rather than infiltrates. It does not produce an acellular exudate.
(D) Incorrect. Pulmonary hemorrhage in the setting of AIDS is not common. The clinical features suggest an acute infection.