Alveolar, Airway & Collapse

Question 1

9. A 16-year-old boy presents with mild cough and dyspnea that has persisted for several years. He is afebrile with normal WCC, but with an elevated LDH. Chest radiograph shows dense bilateral consolidation with relative sparing of the apices and costophrenic angles. No evidence of lymphadenopathy. Which is the most likely diagnosis?

A. PCP pneumonia

B. Alveolar proteinosis

C. Infective exacerbation of asthma

D. Lymphoma

E. Pulmonary oedema

Answer 1

B. Alveolar proteinosis

The typical chest radiographic findings are of bilateral central and symmetric lung opacities with relative sparing of the apices. A range of findings are possible however, including asymmetric opacities and diffuse consolidation. The most common elevated serologic marker is LDH, although this is non-specific. There can be a marked disparity between the often moderate symptoms and extensive radiologic findings. CT demonstrates areas of ground-glass opacification with areas of sparing and prominent septal lines (a crazy paving pattern).

Question 2

25. A 40-year-old non-smoking female with a month-long history of shortness of breath has an HRCT which shows patchy ground glass opacities in a centrilobular distribution, air trapping, and some spared areas of normal parenchyma. Which is the most likely diagnosis?

A. Centrilobular emphysema

B. Paraseptal emphysema

C. NSIP

D. Sarcoidosis

E. Hypersensitivity pneumonitis

Answer 2

E. Hypersensitivity pneumonitis

Characteristic HRCT features in hypersensitivity pneumonitis include ground glass opacity, air trapping and centrilobular ground glass opacities.

Question 3

32. Which of the following features is most strongly associated with active alveolitis on HRCT in a 40-year-old woman with a diagnosis of systemic sclerosis?

A. Ground glass opacification without traction bronchiectasis in the middle lobe

B. Basal ground glass opacification

C. Lower lobar consolidation

D. Interlobular septal thickening

E. Pleural effusion

Answer 3

A. Ground glass opacification without traction bronchiectasis in the middle lobe

The presence of ground glass opacification (without evidence of traction bronchiectasis) in the middle lobe and lingula is strongly associated with active alveolitis. Basal ground glass shadowing is a non-specific finding and a poor predictor of alveolitis.

Question 4

@# 39. The following finding is more in keeping with chronic eosinophilic pneumonia rather than Churg-Strauss:

A. Centrilobular nodules within areas of ground-glass change

B. Peripheral consolidation with tendency towards lobular distribution

C. Transient opacities, shifting over days

D. Homogenous peripheral airspace consolidation

E. Interlobular septal thickening

Answer 4

D. Homogenous peripheral airspace consolidation

Chronic eosinophilic pneumonia is characterised by the presence of homogenous peripheral airspace consolidation on CT, whereas the peripheral consolidation in Churg-Strauss has a tendency towards lobular distribution and is often associated with centrilobular nodules within the ground glass opacity.

Question 5

46. Which of the following is most likely to show peripheral reverse bats wings infiltrates on a chest radiograph?

A. Eosinophilic pneumonia

B. Pulmonary oedema

C. Proeteinosis

D. Lymphoma

E. Goodpasture’s syndrome

Answer 5

A. Eosinophilic pneumonia

Eosinophilic pneumonia, resolving pulmonary oedema, desquamative interstitial pneumonia and sarcoidosis are causes of reverse bats wings peripheral infiltrates.

Causes of perihilar bats wings infiltrates include pulmonary oedema, proeteinosis, sarcoidosis, lymphoma, Goodpasture’s syndrome and alveolar cell carcinoma.

Question 6

50. Which of the following features distinguishes hypersensitivity pneumonitis from lymphocytic interstitial pneumonia?

A. Ill-defined centrilobular nodules

B. Ground glass opacification

C. Diffuse lung involvement

D. Subpleural small nodules

E. Cystic spaces

Answer 6

E. Cystic spaces

Although ground glass changes and small centrilobular nodules are present in hypersensitivity pneumonitis, there are no cystic spaces, or thickening of the bronchovascular bundles.

Question 7

14) A 42-year-old male presents with stridor and persistent cough. He previously has had several nose bleeds. Bloods show mild renal impairment. A chest radiograph shows multiple cavitary lesions with irregular lining, predominantly in the lower lobes. What is the most likely diagnosis?

a. metastatic disease from nasopharyngeal carcinoma

b. Wegener’s granulomatosis

c. sarcoidosis

d. pyogenic abscesses

e. systemic lupus erythematosus

Answer 7

b. Wegener’s granulomatosis

The combination of nosebleeds and cavitatory nodules is very suggestive of Wegener’s granulomatosis, especially with renal impairment. In the lungs, there is often patchy alveolar infiltration, pleural effusions and cavitatory nodules.

Systemic lupus erythematosus produces similar appearances by the same mechanism of vasculitis.

Sarcoidosis produces many lung changes but cavitatory nodules are rare.

Metastatic nasopharyngeal carcinomas are usually squamous cell tumors and can produce cavitatory metastases, but primary tumors usually present with nasal obstruction, although they may cause epistaxis. Renal impairment is not a feature.

Multiple abscesses are not usually associated with epistaxis and present acutely, typically in intravenous drug users

Question 8

16) A 50-year-old male with known chronic asthma is seen in an outpatient clinic. He has no current symptoms. A ‘routine’ chest radiograph is performed. Which feature is most likely to be seen?

a. hyper expansion

b. peribronchial cuffing

c. bronchiectasis

d. parenchymal scars

e. normal chest radiograph

Answer 8

e. normal chest radiograph

In chronic asthma, the majority of patients (73%) have normal appearances on chest radiographs between acute episodes. Features such as bronchiectasis or parenchymal scarring may be seen, especially with episodes of repeated infection. Hyper expansion and peribronchial cuffing are features seen during acute exacerbations of asthma.

Question 9

19) A 68-year-old man presents with increasing dyspnea. He has a history of asbestos exposure. CT of the chest demonstrates bilateral pleural thickening with calcification, and a 3 cm, rounded, lower lobe mass. This is related to an area of pleural thickening, with Broncho vascular markings coursing from it towards the hilum in a curved path. What is the most likely diagnosis?

a. rounded atelectasis

b. bronchogenic carcinoma

c. tuberculosis

d. silicosis

e. round pneumonia

Answer 9

a. rounded atelectasis

Rounded atelectasis is an in folding of pleura associated with atelectasis, which occurs in the posterior lower lobes and abuts an area of pleural thickening. Often a ‘comet’s tail’ of Broncho vascular markings is seen curving towards the hilum.

Bronchogenic carcinoma may occur with asbestos exposure, but is usually of bronchioalveolar cell type and has a latent period of 25–35 years.

Round pneumonia produces spherical consolidation with air bronchograms.

Silicosis may cause conglomerate masses, usually in the mid or upper zones,

or progressive massive fibrosis, but reticulonodular changes predominate.

Question 10

20) A 43-year-old female with Churg–Strauss syndrome has a high-resolution CT. What is the most likely finding?

a. small centrilobular nodules

b. bullous disease

c. bilateral, symmetrical, hilar lymphadenopathy

d. tumor-like mass

e. pleural effusion

Answer 10

a. small centrilobular nodules

Churg–Strauss syndrome is rare, though pulmonary abnormalities are a common feature of the condition.

Typically, airspace and airway patterns are seen with the following features – centrilobular nodules, ground glass opacities, bronchial wall thickening, bronchiectasis, consolidation and septal thickening.

Lymphadenopathy may be seen in the mediastinum and at the hila but is not a common feature.

Large nodules may occur but a tumorlike mass is not a feature.

Pleural effusions and bullae are not seen.

Question 11

27) A 45-year-old female presents with malaise and cough. She has a history of multiple allergies. Her blood results show an eosinophilia, and the chest radiograph reveals two areas of peripheral consolidation. A further chest radiograph 2 days later shows these to be resolving. Which of the following is the most likely diagnosis?

a. histiocytosis

b. pseudomonas pneumonia

c. Klebsiella pneumonia

d. Loeffler’s syndrome

e. lipoid pneumonia

Answer 11

d. Loeffler’s syndrome

Loeffler’s syndrome is of unknown aetiology and is characterized by areas of non-segmental consolidation, which are peripherally situated and transient.

Histiocytosis produces ill-defined nodules which cavitate, first producing thick-walled and then thin-walled cysts.

Klebsiella pneumonia usually affects the upper lobes, producing dense, lobar consolidation, sometimes with bulging fissure and empyema.

Pseudomonas pneumonia is patchy but extensive and usually in the lower lobes.

Lipoid pneumonia is segmental and homogeneously dense, and changes only slowly.

Question 12

47) A 52-year-old male presents with dyspnea and cough. A chest radiograph shows an ill-defined opacity in the right mid-zone, obscuring the heart border. A lateral view shows a thin wedgeshaped opacity with base in contact with the pleura anteroinferiorly, and pointing posterosuperiorly. What is the most likely diagnosis?

a. right middle lobe collapse

b. right middle lobe consolidation

c. right lower lobe collapse

d. right lower lobe consolidation

e. encysted pleural fluid

Answer 12

a. right middle lobe collapse

In right middle lobe collapse, the horizontal fissure and lower half of the oblique fissure converge.

This creates a wedge-shaped opacity on the lateral chest radiograph.

On the frontal chest radiograph, there is an ill-defined midzone opacity.

With right middle lobe consolidation, there is a mid-zone opacity with a well-defined superior margin, as the horizontal fissure remains in a normal position and is tangential to the radiograph beam.

Both obscure the right heart border.

Lower lobe collapse and consolidation cause basal opacity with loss of clarity of the right hemidiaphragm.

The lateral view shows a triangular opacity at the right base posteriorly, larger in consolidation than collapse.

Question 13

49) A 50-year-old male presents with gradual onset dyspnea and cough. There is no preceding history. A chest radiograph shows bilateral ‘bat-wing’ consolidation, with normal heart size and no effusion. High-resolution CT shows diffuse ground-glass change with intralobular and interlobular septal thickening (‘crazy paving’ ppearance). What is the most likely diagnosis?

a. pulmonary edema

b. atypical pneumonia

c. pulmonary alveolar proteinosis

d. acute respiratory distress syndrome

e. hypersensitivity pneumonitis

Answer 13

c. pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis is due to accumulation of proteinaceous material in the alveoli, which causes hypoxia. There is a variable combination of airspace and interstitial changes, but diffuse ground-glass opacification and ‘crazy-paving’ are typical. A geographic distribution is also described. Lack of other features (such as cardiomegaly, lymphadenopathy and effusion) helps to distinguish it from infection and edema. The lack of precipitating event and slow onset makes acute respiratory distress syndrome unlikely. Hypersensitivity pneumonitis often shows no abnormality on chest radiograph, but high-resolution CT shows surprisingly marked ground-glass change and centrilobular nodules with peripheral sparing.

Question 14

79) An 18-year-old male presents with a chest radiograph performed for immigration purposes. He is noted to have dextrocardia. Further investigation reveals nasal polyposis and bronchiectasis. Which further investigation should be considered?

a. renal function

b. CTof brain

c. fertility assessment

d. renal angiogram

e. thyroid function test

Answer 14

c. fertility assessment

The presence of dextrocardia, nasal polyposis and bronchiectasis raises the possibility of Kartagener’s syndrome. This is immotile/dysmotile cilia syndrome and may also present with deafness and infertility. There is also an association with transposition of the great vessels, pyloric stenosis, post-cricoid web and epispadias. Situs inversus is seen in 50% of cases

Question 15

97) On high-resolution CT of the chest, how can mosaic perfusion be distinguished from ground-glass opacification?

a. the opaque areas have abnormally small vessels

b. the lucent areas have abnormally small vessels

c. mosaic perfusion is restricted to lower zones

d. mosaic perfusion is restricted to sub pleural regions

e. cannot be reliably distinguished

Answer 15

b. the lucent areas have abnormally small vessels

Mosaic perfusion refers to areas of altered attenuation on CT and reflects vascular obstruction or abnormal ventilation. Differentiation from ground-glass opacification can be difficult but can usually be done by assessment of the centrilobular vessels. In comparing ‘lucent’ and ‘opaque’ areas, the area in which the vessels appear larger is generally the normal area, though this may be a difficult differentiation to make in practice, as the vessels may be of the same size throughout the lung. In mosaic perfusion, the vessels appear abnormal in the ‘lucent’ area, whereas, in ground-glass opacification, the vessels appear abnormal in the ‘opaque’ area. Expiratory scans may then help to distinguish airway causes from vascular causes, by the presence of air trapping, which is seen with airway disease.

Question 16

@# 10- A 46-year-old man presents to an A&E department with shortness of breath. The CXR shows a diffuse opacity in the RUL. On a previous film, taken 3 months ago, he had a similar appearance in the LUL which cleared on a CXR taken 10 days later; there was a similar episode a year prior to this with an opacity in the middle lobe, which subsequently cleared. Which of the following conditions is the least likely diagnosis?

(a) Chronic eosinophilic pneumonia

(b) Chug-Strauss syndrome

(c) Extrinsic allergic alveolitis

(d) Good pasture’s syndrome

(e) Loeffler’s syndrome

Answer 16

(a) Chronic eosinophilic pneumonia

Loeffler’s syndrome is also known as transient pulmonary eosinophilia Churg-Strauss syndrome (allergic angiitis granulomatosis) classically presents with fleeting pulmonary opacities.

Causes of pulmonary hemorrhage/vasculitis can also give this appearance (e.g. Wegener’s granulomatosis or Good pasture’s syndrome).

EAA can occur following exposure to the relevant trigger, which subsequently resolves on its removal.

Chronic eosinophilic pneumonia typically has a peripheral distribution (the ‘photographic negative’ of pulmonary edema) and appearances typically remain unchanged for weeks or months.

Question 17

31- A 68-year-old retired shipbuilder presents with shortness of breath. CXR shows a round 4 cm sub pleural mass and a CT is performed. Which of the following CT signs is not a feature of folded lung?

(a) Air bronchograms

(b) Interval growth

(c) Adjacent pleural thickening

(d) Cavitation

(e) Enhancement following intravenous contrast medium

Answer 17

(d) Cavitation

Rounded atelectasis is the end result of an exudative pleural effusion; fibrous strands cause invagination of the pleura as the fluid resolves. Hence the ‘mass’ has a smooth margin except where the bronchi and vessels enteroften seen pulled in to the mass and described as a ‘comet-tail’ or ‘crow’s-foot’ appearance.

Question 18

@# 9 A 45 year old man is referred from chest clinic with a cough and intermittent breathlessness. A CT of his thorax demonstrates ill-defined centrilobular nodules and a mosaic attenuation pattern, exacerbated on expiratory phase imaging. What is the most likely diagnosis?

(a) Respiratory bronchilitis-interstitial lung disease

(b) Chronic pulmonary thrombo-embolism

(c) Sarcoidosis

(d) Extrinsic allergic alveolitis

(e) Lymphocytic interstitial pneumonitis

Answer 18

(d) Extrinsic allergic alveolitis

The clinical features are non-specific, but many patients with EAA (also known as hypersensitivity pneumonitis) have exacerbati,on of symptoms on exposure to the antigen, e.g. returning to the workplace.

EAA has acute, sub acute and chronic phases which may progress to widespread pulmonary fibrosis.

The mosaic attenuation with gas trapping described here is a characteristic finding.

Question 19

28- Which of the following respiratory conditions is not associated with cigarette smoking?

(a) Idiopathic pulmonary fibrosis

(b) Langerhans’s cell histiocytosis

(c) Extrinsic allergic alveolitis

(d) Desquamative interstitial pneumonitis

(e) Respiratory bronchiolitis-interstitial lung disease

Answer 19

(c) Extrinsic allergic alveolitis

Smoking appears to have a somewhat protective effect in EAA, with the vast majority of patients being nonsmokers. This may be due to peripheral airway constriction- The remaining conditions are associated with smoking, although curiously smokers with IPF appear to have better survival than non-smokers.

Question 20

37 A 3 year old boy who has recently arrived in the UK presents to A&E. His mother explains that he has suffered repeated respiratory infections from the neonatal period. CXR shows bilateral lower zone bronchiectasis and dextrocardia. What is the likeliest diagnosis?

(a) Cystic fibrosis

(b) Kartagener’s syndrome

(c) Yellow nail syndrome

(d) Pulmonary sequestration

(e) Tuberculosis

Answer 20

(b) Kartagener’s syndrome

Kartagener’s syndrome is due to abnormal ciliary motility. There is a high familial incidence and in addition to the above, is associated with chronic sinusitis, conductive deafness and other congenital abnormalities such as pyloric stenosis.

Question 21

39 A 74 year old man presents with progressive dyspnoea. CXR shows bilateral, lower zone, peripheral subpleural reticulation. Which of the following is least likely?

(a) Amiodarone toxicity

(b) Usual interstitial pneumonitis

(c) Asbestosis

(d) Rheumatoid arthritis

(e) Chronic extrinsic allergic alveolitis

Answer 21

(e) Chronic extrinsic allergic alveolitis

The acute and subacute forms of EAA can cause lower zone reticular change but the chronic form typically has an upper lobe distribution. Other drugs that can cause lower zone reticulation include bleomycin, methotrexate and nitrofurantoin. Asbestosis refers specifically to interstitial fibrosis in the context of asbestos exposure rather than the benign pleural asbestos related diseases. UIP is the commonest histological type of pattern found in idiopathic pulmonary fibrosis.

Question 22

45 An infant is seen by the GP non-acutely, with stridor. He is systemically well and is not in distress. Tracheomalacia is suspected as a possible cause and further investigations are arranged. Regarding tracheomalacia, which of the following statements is correct?

(a) It is associated with trachea-oesophageal fistula

(b) It is the commonest cause of inspiratory stridor

(c) Expiratory CT is the definitive method of diagnosis

(d) Resolution occurs in late childhood

(e) The trachea typically collapses in inspiration

Answer 22

(a) It is associated with trachea-oesophageal fistula

Tracheomalacia can be congenital due to immaturity of the tracheal cartilage and is associated with TOF. Secondary causes include vascular rings, infective, inflammatory or post-instrumentation. It is frequently found in children who have undergone TOF repair. There is collapse of the airway on expiration with associated expiratory stridor, although rarely, if the extra-thoracic trachea is affected, there may be inspiratory collapse/ strider. Majority have resolution of symptoms by 1 year. Chest fluoroscopy can confirm diagnosis, but bronchoscopy is more definitive; CT may not reveal its dynamic nature.

Question 23

55 What is the most common cause of eosinophilic lung disease in developed countries?

(a) Allergic bronchopulmonary aspergillosis

(b) Drug-induced disease

(c) Churg-Strauss syndrome

(d) Hypereosinophilic syndrome

(e) Rheumatoid disease

Answer 23

(a) Allergic bronchopulmonary aspergillosis

This accounted for 78% of cases in one large series. The importance of this condition is that repeated episodes lead to progressive lung damage that may be controlled by corticosteroids.

Question 24

46 A 36 year old man presents with cough, shortness of breath, fever and night sweats. The eosinophil count is

1.3 x 109/1. The CXR shows bilateral interstitial infiltrates. Subsequent CT chest shows diffuse ground-glass opacities and interlobular septal thickening. Which of the following is the least likely underlying diagnosis?

(a) Allergic broncho-pulmonary aspergillosis

(b) Churg-Strauss syndrome

(c) Lofgren’s syndrome

(d) Schistosomiasis

(e) Wegener’s granulomatosis

Answer 24

(c) Lofgren’s syndrome

Eosinophilia is defined as a peripheral eosinophil count > 0.44 x 109/1. Causes of eosinophilia and pneumonia include acute eosinophilic pneumonia (Loeffler’s syndrome), drugs (nitrofurantoin, sulfonamides), parasitic (ascariasis, schistosomiasis), fungal (ABPA), and those associated with angitis/granulomatosis (WG, ChurgStrauss, RhA, scleroderma, Sjogren’s). Lofgren’s syndrome is acute sarcoidosis, and has a triad of erythema nodosum, bilateral hilar adenopathy and arthritis and is associated with a good prognosis.

Question 25

49 A CT examination in a 56 year old patient shows bronchial dilatation due to retained secretions and appearing as V- or Y-shaped tubular or branching structures. What term should be used to describe this appearance?

(a) Bronchiectasis

(b) Bronchiolectasis

(c) Tree-in-bud

(d) Traction bronchiectasis

(e) Bronchocoele

Answer 25

(e) Bronchocoele

This mucoid impaction is usually due to proximal obstruction by congenital (e.g. bronchial atresia) or acquired (e.g. carcinoma) abnormalities. Bronchiectasis and Bronchiolectasis are abnormal, irreversibly dilated bronchi or bronchioles. Traction bronchiectasis is dilatation due to adjacent fibrosis. Tree-in-bud pattern is seen in a spectrum of endo- and peribronchiolar disorders; airway dilatation is not a feature.

Question 26

68 A 54 year old man presents with a cough and breathlessness 1 year after bone marrow transplantation. A CT study demonstrates bronchial wall thickening and dilatation, with gas trapping on expiratory phase images. What is the most likely diagnosis?

(a) Organising pneumonia

(b) Non-specific interstitial pneumonitis

(c) Extrinsic allergic alveolitis

(d) Obliterative bronchiolitis

(e) Engraftment syndrome

Answer 26

(d) Obliterative bronchiolitis

These are the typical features of OB, which is a late complication (>100 days) after BMT.

Organising pneumonia typically has patchy peribronchovascular consolidation and may be secondary to drugs or infection.

Engraftment syndrome is an early complication which manifests as diffuse lung injury

Question 27

16. A 40 year old man presents with worsening breathlessness, fever and chills following a visit to an aviary earlier in the day. HRCT is most likely to demonstrate:

a. Mid-zone interstitial lines

b. Areas of air-space shadowing

c. Pleural effusions

d. Lymphadenopathy

e. Crazy paving

Answer 27

16. b. Areas of air-space shadowing

Acute extrinsic allergic alveolitis is predominantly a type III hypersensitivity reaction. There is poor correlation between the clinical presentation and the radiological changes. Lymphadenopathy is unusual in the acute phase, but is seen more commonly in recurrent disease. The early changes are mainly in the mid zones, but the fibrosis that develops in chronic extrinsic allergic alveolitis is mainly in the upper zones. In the acute phase, diffuse airspace shadowing or multiple opacities are seen.

Question 28

24. A 45 year old man presents with a history of cough and occasional haemoptysis. Plain chest radiograph demonstrates a right paracardiac shadow with loss of the right heart border. Bronchoscopy demonstrates an endoluminal obstructive mass. The most likely site of the lesion would be:

a. Right upper lobe anterior segmental bronchus

b. Right lower lobe lateral basal segmental bronchus

c. Bronchus intermedius

d. Right upper lobe posterior segmental bronchus

e. Right middle lobe bronchus

Answer 28

24. e. Right middle lobe bronchus

The features described are of an endoluminal lesion causing right middle lobe collapse. A lesion in the bronchus intermedius is likely to cause both middle and lower lobe collapse.

Question 29

31. A young man presents with progressive productive cough and halitosis. He had severe pneumonia as a child. Plain chest radiograph demonstrates bronchial dilatation and bronchial wall thickening with some volume loss. Which of the following HRCT findings is the most sensitive finding for bronchiectasis?

a. Air trapping

b. Mucous-filled dilated bronchi

c. Bronchial wall thickening

d. Bronchi seen in the subpleural region

e. Lack of bronchial tapering

Answer 29

31. e. Lack of bronchial tapering

Whilst all the above can be seen in patients with bronchiectasis, a lack of progressive tapering of the bronchi is the most sensitive (80%).

Question 30

39. A 36 year old asthmatic attends an outpatient respiratory clinic complaining of recent increasing dyspnoea. Bloods show an elevated white cell count and eosinophilia. Chest radiograph reveals multiple areas of ill-defined peripherally based consolidation. Subsequent chest radiographs over the coming week show the consolidation to resolve in places but commence in other previously unaffected areas. The most likely cause is:

a. Alveolar sarcoidosis

b. Bronchioalveolar carcinoma

c. Acute eosinophilic pneumonia

d. Chronic eosinophilic pneumonia

e. Loffler syndrome

Answer 30

39. e. Loffler syndrome

This is described as simple eosinophilic pneumonia but is of unknown aetiology. Pathologically, there is interstitial and alveolar oedema. Patients are usually asthmatic/atopic but have mild or no symptoms. Classical chest radiograph appearance is of fleeting infiltrates with transient and shifting peripheral consolidation.

Question 31

QUESTION 24 A 38-year-old man is referred to a chest physician for evaluation of a chronic productive cough. Over the past 10 years he has experienced increased expectoration of mucoid sputum that became purulent during infective exacerbations. On plain radiography the trachea had a corrugated outline. CT evaluation revealed dilatation of the trachea and mainstream bronchi. Which one of the following is the most likely diagnosis?

A Amyloidosis

B Mounier-Kuhn disease

C Relapsing polychondritis

D Tracheal leiomyoma

E Wegener’s granulomatosis

Answer 31

B Mounier-Kuhn disease

Mounier-Kuhn disease (tracheobronchomegaly) describes patients with marked dilatation of the trachea and mainstream bronchi and is a radiological diagnosis.

Question 32

CVS) QUESTION 25 A 20-year-old woman with cystic fibrosis undergoes an HRCT chest as a result of worsening respiratory function. Nontapering, thickened bronchi are easily seen within 1 cm of the costal pleura. The internal bronchial diameter is greater than that of the adjacent pulmonary artery and the bronchial lumen has assumed a beaded configuration. Whilst there are V- and Y-shaped densities, the ‘tree in bud’ sign and mosaic perfusion are not seen. What is the most likely diagnosis?

A Bronchiolitis

B Cylindrical bronchiectasis

C Cystic bronchiectasis

D Infective consolidation

E Varicose bronchiectasis

Answer 32

E Varicose bronchiectasis

Bronchiectasis (irreversible dilatation of the bronchi) is classified into three pathological subtypes of increasing severity: cylindrical (relatively uniform airway dilatation), varicose (the bronchial lumen assumes a beaded configuration) and cystic (a string or cluster of cystic structures).

Question 33

QUESTION 26 A 15-year-old girl has a follow-up CXR and ultrasound scan of her liver. She is known to have had meconium ileus at birth and has subsequently suffered with recurrent chest infections, poor weight gain, loose malodorous stools and multiple gallstones. Which of the following findings is most likely to be present on the CXR?

A Bronchiectasis with a predominant lower lobe distribution

B Ground glass opacity

C In-dwelling venous catheter

D Pleural effusion

E Reduced lung volumes

Answer 33

C In-dwelling venous catheter

Recurrent, long courses of intravenous antibiotics often lead to medium/longterm venous access in patients with CF. Bronchiectasis is seen in a predominantly upper lobe distribution, with mucus plugging and hyperinflation.

Question 34

QUESTION 27 A 60-year-old woman with rheumatoid arthritis presents with a flu-like illness and nonproductive cough. Her symptoms have not responded to an appropriate course of antibiotics. An HRCT is performed and demonstrates widespread mosaic perfusion. Which additional CT finding would suggest a diagnosis of obliterative bronchiolitis rather than diffuse pulmonary haemorrhage?

A Increased calibre pulmonary vessels in the hyperattenuated area

B Increased calibre pulmonary vessels in the hypoattenuated area

C Normal calibre pulmonary vessels in the hyperattenuated area

D Reduced calibre pulmonary vessels in the hypoattenuated area

E Reduced calibre pulmonary vessels in the hyperattenuated area

Answer 34

D Reduced calibre pulmonary vessels in the hypoattenuated area

Obliterative bronchiolitis describes bronchiolar and peribronchiolar inflammation affecting the membranous and respiratory bronchioles. Affected areas display decreased attenuation as a result of air trapping and decreased perfusion relative to normal areas

Question 35

QUESTION 28 A 50-year-old lifelong male smoker has presented to his GP with increasing shortness of breath. A CXR shows that the right atrial border is a little indistinct. On the lateral view there is a triangular density with its apex directed towards the lung hilum. Which one of the following is the most likely diagnosis?

A Left lower lobe collapse

B Left upper lobe collapse

C Right middle lobe collapse

D Right lower lobe collapse

E Right upper lobe collapse

Answer 35

C Right middle lobe collapse

The collapsed right middle lobe will lie adjacent to the right heart border and as there is no longer a clear heartlung interface, then the right heart border appears indistinct.

Question 36

@# QUESTION 29 You are asked to review the CT scan of an elderly female patient who has evidence of left upper lobe collapse on a CXR. On CT, in which one of the following directions will the left upper lobe have collapsed?

A Anteriorly and laterally

B Anteriorly and medially

C Inferiorly and medially

D Posteriorly and medially

E Superiorly and medially

Answer 36

B Anteriorly and medially

Left upper lobe collapse results in volume loss in an anterior and medial direction, as opposed to superior and medial collapse of the right upper lobe collapse.

Question 37

Ped) 1. An HRCT chest is carried out on a 3-year-old girl. This child has a history of mild wheeze and tachypnoea, which has developed in the last few months. Standard treatment with bronchodilators and inhaled steroid for presumed asthma has been unsuccessful. The CXR is abnormal, showing mild increased airspace density. The HRCT shows a bilateral pattern of groundglass change. The interlobular septa are markedly thickened, giving a ‘crazy paving’ pattern. What is the most likely diagnosis?

A. Pneumocystis jirovecii pneumonia.

B. Lymphocytic interstitial pneumonitis.

C. Alveolar proteinosis.

D. Childhood idiopathic pulmonary haemosiderosis.

E. Childhood sarcoidosis.

Answer 37

1. C. Alveolar proteinosis.

Intersitial lung disease in children is uncommon, but it is important to be aware of as 50% of children present with a history of wheeze. Chronic idiopathic pulmonary haemosiderosis does not cause a ‘crazy paving’ pattern. It is a rare disorder (although common in exams) and when present in children usually presents before 3 years of age. Whilst a ‘crazy paving’ pattern was originally described as being typical of alveolar proteinosis, it has since been described in numerous conditions and as such a knowledge of these processes is necessary to differentiate them. Pneumocystis jirovecii pneumonia would not normally be considered in the absence of a history of immunocompromise. Whilst NSIP can cause this appearance, in children it more typically has an upper zone and peripheral predominance with associated ground-glass changes and a degree of honeycombing. The imaging characteristics of NSIP, LIP and DIP overlap in children and often require lung biopsy to differentiate them. LIP is also usually associated with immunodeficiency disorders, as in adults. Sarcoidosis in children is very rare and usually presents in older children, around 13–15 years of age.

Question 38

9. You are carrying out a CT chest scan on a patient who is under the joint care of the respiratory physicians and the rheumatologists. The patient reports slowly progressing stridor. The patient has already been assessed by ear, nose and throat (ENT) due to collapse of the nasal turbinates, but this is felt to be unconnected to his stridor. His inflammatory markers are elevated. A nasal biopsy showed an inflammatory infiltrate in the cartilage causing dissolution, but no granuloma formation or vasculitis. The CT shows smooth thickening of the anterior trachea, with early calcium deposition, with relative sparing of the posterior trachea. This pattern is most marked in the subglottic region. There is narrowing of the airway. This pattern is unaffected on the expiratory scan as compared to the inspiratory scan. The transverse diameter of the trachea is 60% of the sagittal diameter. What is the likely cause?

A. Wegener’s granulomatosis.

B. Amyloidosis.

C. Relapsing polychondritis.

D. Mounier–Kuhn disease.

E. Tracheobronchomalacia.

Answer 38

9. C. Relapsing polychondritis.

Wegener’s granulomatosis and amyloidosis can both give a similar appearance to that described. Amyloid can occur as an isolated condition or as a part of systemic amyloidosis. It gives smooth narrowing, but can also give multifocal stenoses or plaques, and is frequently associated with calcification. Wegener’s commonly affects the subglottic region, giving an identical appearance, although it can cause a more irregular pattern of thickening and ulcer formation. Similarly Wegener’s commonly affects the cartilage in the nose. However, histologically, Wegener’s causes vasculitis and granuloma formation. Mounier–Kuhn disease is also known as tracheobronchomegaly. It can be associated with tracheobronchomalacia, which may give a similar CT appearance to that described. The key difference is that this condition is characterized by a reduction in calibre of >50% of the airway lumen during expiration, as compared to inspiration. Relapsing polychondritisis a systemic condition also affecting the cartilage of the nose, ears, and joints.

Question 39

12. A 65-year-old man has kept pigeons for over 20 years. He is complaining of gradually worsening shortness of breath. A CXR shows increased interstitial markings, with reduction in lung volumes. A subsequent HRCT of chest shows quite marked pulmonary fibrosis with areas of honeycomb formation. Which part of the lung is likely to be relatively spared by the fibrotic process?

A. Upper zones.

B. Mid zones.

C. Posterior costophrenic sulci.

D. Central peribronchovascular regions.

E. Subpleural lung.

Answer 39

12. C. Posterior costophrenic sulci.

The question is leading to chronic hypersensitivity pneumonitis as the most likely underlying diagnosis. The fibrotic process, in advanced stages, affects both the subpleural lung and the peribronchovascular interstitium. There may be honeycomb formation at the lung bases, but unlike usual interstitial pneumonia/idiopathic pulmonary fibrosis, the honeycombing typically spares the most extreme posterior costophrenic sulci. Classically, the fibrotic process is more pronounced in the mid and upper lung zones.

Question 40

15. A 28-year-old man is being investigated for haemoptysis. He has a history of sinusitis. Full blood picture is normal. He is referred for a CT of chest during which intravenous (IV) contrast was withheld by the radiographer due to a reduction in estimated glomerular filtration rate (eGFR). It reveals bilateral nodules in a peribronchovascular distribution, some of which show cavitation. There are peripheral wedge-shaped areas of consolidation. There are also areas of bronchial stenosis and thickening. No mediastinal or hilaradenopathy is present. What is the most likely diagnosis?

A. Goodpasture’s syndrome.

B. Sarcoidosis.

C. Churg–Strauss syndrome.

D. Wegener’s granulomatosis.

E. Pulmonary tuberculosis.

Answer 40

15. D. Wegener’s granulomatosis.

The history of sinusitis, pulmonary haemorrhage, and renal involvement (reduced eGFR) point towards Wegener’s granulomatosis. This is a systemic autoimmune disease characterized by granulomatous vasculitis of the upper and lower respiratory tracts, glomerulonephritis, and small vessel vasculitis. It predominantly affects male patients. There is pulmonary involvement in most patients. The most common radiographic appearance is lung nodules or irregularly marginated masses with no zonal predilection. The nodules are solitary in up to 25% and cavitating in 50% of cases. The cavities usually have a thick, irregular wall. With treatment they may resolve or result in a scar. Peripheral areas of wedge-shaped consolidation representing infarction may occur. Pleural effusions occur in less than 10% and mediastinal/hilar adenopathy is uncommon. Tracheal and bronchial thickening can be smooth or nodular. Haemorrhage can result in focal areas of dense consolidation, patchy bilateral areas of consolidation, or diffuse consolidation (these may be difficult to distinguish from infection).

The main differential diagnosis would be Churg–Strauss syndrome, which involves asthma, eosinophilia (which would be noticed in the full blood picture), and less severe renal and sinus disease. Patchy transient consolidation, which may be peripheral, is the norm and nodules may occur, although cavitation is rare. Wegener’s granulomatosis is associated with c-ANCA and Churg–Strauss with p-ANCA.

Goodpasture’s syndrome is associated with glomerulonephritis and pulmonary haemorrhage, but the findings are initially extensive perihilar and basal consolidation with sparing of the apices, which is subsequently replaced by an interstitial pattern. Cavitating nodules are not a feature. Haemoptysis is uncommon in sarcoidosis and cavitating nodules rare; one would typically expect perilymphatic nodules and in classic cases adenopathy. TB can produce cavitating nodules and haemoptysis, but the other features are more consistent with Wegener’s granulomatosis.

Question 41

25. A 61-year-old man has a history of chronic myeloid leukaemia. He presents with mild dyspnoea and dry cough. A CXR shows symmetrical, perihilar reticulo-nodular opacities with relative sparing of the apices and costophrenic angles, without cardiomegaly or pleural effusion. An HRCT reveals smoothly thickened septal lines with intervening GGO and sharply marginated areas of geographic sparing. Bronchoalveolar lavage (BAL) is negative for organisms. What is the most likely diagnosis?

A. Pulmonary haemorrhage.

B. Left ventricular failure.

C. Pulmonary alveolar proteinosis.

D. Pneumocystis pneumonia.

E. Radiation fibrosis.

Answer 41

25. C. Pulmonary alveolar proteinosis.

This is rare, but most commonly develops in a primary idiopathic form (90%), chiefly in middleaged smokers, with a male predominance. It can also occur secondary to industrial dust exposure, immunodeficiency disorders (HIV and iatrogenic causes), and, as in the question, secondary to underlying haematological malignancies. There is also a congenital form.

The typical plain film appearance is that described in the question, but less commonly there can be multifocal asymmetric opacities or extensive diffuse consolidation. The radiological findings are often out of proportion with the disease severity. The HRCT findings described are those of ‘crazy-paving’. There is a wide differential diagnosis for this, including pulmonary oedema, pneumocystis pneumonia, haemorrhage, bronchoalveolar carcinoma, ARDS, lymphangitis carcinomatosis, radiation or drug-induced pneumonitis, hypersensitivity pneumonitis, and pulmonary veno-occlusive disease. The distinguishing factor in our case is the history of leukaemia; this would also predispose to infection, but the BAL has ruled pneumocystis out. In alveolar proteinosis, BAL or lung biopsy reveals intra-alveolar deposits of proteinaceous material, dissolved cholesterol, or eosinophilic globules. Symptomatic treatment includes whole lung lavage and multiple procedures may be required.

Question 42

30. A 43-year-old patient presents with cough, shortness of breath and fever which has lasted a month. An HRCT reveals bilateral areas of consolidation, predominantly in a peripheral distribution. There are also areas of GGO, predominantly in the middle and upper zones, with band-like subpleural attenuation. The plain film findings have remained unchanged for days. What is the most likely diagnosis?

A. Chronic eosinophilic pneumonia.

B. Allergic bronchopulmonary aspergillosis (ABPA).

C. Acute eosinophilic pneumonia.

D. Loffler’s syndrome.

E. Eosinophilic granuloma.

Answer 42

30. A. Chronic eosinophilic pneumonia.

This has been described as the radiological ‘photographic negative’ of pulmonary oedema. It is a disease of middle age and affects females more commonly than males. The history is that described, with a common history of atopy. The predominant histologic finding is filling of the alveolar airspaces with an inflammatory infiltrate containing a high proportion of eosinophils. There is usually also a cellular infiltration of the interstitium and peripheral blood eosinophilia. There is a dramatic response to steroid therapy within days.

ABPA and acute eosinophilic pneumonia do produce blood eosinophilia, but the former is characterized by bronchiectasis and mucus plugging with the possibility of mosaic perfusion in addition to peripheral consolidation, while the latter is characterized by diffuse GGO, defined nodules, smooth interlobular septal thickening, and often the presence of pleural effusion.

Loffler’s syndrome (simple pulmonary eosinophilia) refers to predominantly peripheral transient parenchymal consolidation accompanied by eosinophilia. There are minimal or no pulmonary symptoms, the plain film appearances change within one to several days and spontaneous resolution occurs within one month. Eosinophilic granuloma is nodular/cystic, a pulmonary form of Langerhan’s cell histiocytosis, and should not be confused with the eosinophilic pneumonias.

Question 43

45. A 45-year-old male presents with a 3-month history of a non-productive cough and dyspnoea, which was preceded by a flu-like illness. Pulmonary function tests reveal a restrictive pattern and a CXR shows multifocal bilateral consolidation. HRCT of chest reveals bilateral peripheral subpleural well-defined areas of consolidation, some of which are surrounded by ground-glass opacity and some of which show an air bronchogram. There is also a focal area of GGO, which is surrounded by a smooth-walled ring of consolidation. Which of the following is the most likely diagnosis?

A. Sarcoidosis.

B. TB.

C. Cryptococcosis.

D. Obliterative bronchiolitis.

E. Cryptogenic organizing pneumonia.

Answer 43

45. E. Cryptogenic organizing pneumonia.

An area of GGO surrounded by a ring of consolidation describes the ‘ring halo’ sign. This is not specific to COP, but has been described in tuberculosis, active sarcoidosis, cryptococcosis, and blastomycosis. However it has been found that granulomatous infectious diseases and sarcoidosis, which cause the ‘ring halo’ sign, result in a nodular ring, whereas COP results in a smooth-walled ring. COP is rapidly responsive to steroids, but the latter can have deleterious effects in infectious diseases. Thus it has been suggest that a nodular ring can be used as a discriminator.

COP (also known as idiopathic BOOP) is a patchy organizing pneumonia caused by bronchiolar obstruction by plugs of loose organizing connective tissue that may wax and wane. The main finding of COP is consolidation, seen in 90% and usually multifocal and bilateral. In 50% the consolidation is subpleural or peribronchovascular. It has a lower zone predominance, but can affect any lobe. Dilated airways are often seen on CT and air bronchograms give the appearance of acute pneumonia. GGO is a prominent pattern in 60%. Linear opacities occur in isolation or in association with multifocal areas of consolidation. Nodules are seen in 30–50% and lung volumes are preserved in 75%. COP is a clinical–pathological entity and is diagnosed when the correct clinical picture and radiological findings are present. If these features are uncertain, lung biopsy is required. Organizing pneumonia can be idiopathic (COP) or secondary to viral infection, toxic fume inhalation, RA, systemic lupus erythematosis (SLE), organ transplantation, drug reaction, or chronic aspiration.

The hallmark of obliterative bronchiolitis is air-trapping and hyperinflation. It has many causes, including RA and other connective tissue diseases.

Question 44

52. A 56-year-old man presents with shortness of breath. He subsequently has an HRCT of chest performed. This shows a mosaic attenuation pattern throughout the lung parenchyma, but you are having some difficulty determining if the more lucent areas are normal or abnormal. Which of the following findings is most likely to be helpful in confirming that the lucent areas are the abnormal areas and you are not dealing with multifocal GGO?

A. Increased calibre of vessels in denser areas.

B. Decreased calibre of vessels in denser areas.

C. Increased calibre of vessels in lucent areas.

D. Decreased caliber of vessels in lucent areas.

E. Calibre of vessels is unhelpful and expiratory scans must be used.

Answer 44

52. D. Decreased calibre of vessels in lucent areas.

When mosaic lung attenuation is observed, it often is in an extensive, but patchy, distribution and it is important to determine if it is the lucent or denser areas of lung that are abnormal.

If the blood vessels in the lucent areas are smaller, then the lucent areas are probably abnormal. The paucity of vessels in these regions may be secondary to focal air-trapping or poor ventilation and subsequent reflex vasoconstriction.

If areas of lucency are exaggerated on expiratory scans (air trapping), then this is the hallmark of small airways disease.

Alternatively, if the areas of lucency do not become more prominent on the expiratory scans, small airways disease is not the likely cause. In this situation, the inhomogeneous lung attenuation is probably secondary to changes in vessel calibre, and secondary to pulmonary hypertension, including chronic PE, emphysema, or inflammatory vasculopathies.

If the blood vessels in the regions of relative lucency are equal in size to vessels in surrounding areas, the regions of relative opacity are most likely abnormal, e.g. areas of GGO.

Question 45

61. A junior doctor requests your opinion on a postero-anterior (PA) CXR of a 21-year-old man admitted with chest pain. She suspects that the patient has right middle lobe consolidation. What feature on the patient’s radiograph allows you to reassure her that the imaging appearances are secondary to pectus excavatum?

A. Rightward displacement of the heart.

B. ‘Sevens’ appearance to ribs.

C. Indistinct right heart border.

D. Bilateral hilar enlargement.

E. Steeply angulated posterior ribs.

Answer 45

61. B. ‘Sevens’ appearance to ribs.

Pectus excavatum is a relatively common thoracic skeletal anomaly. The majority of cases are isolated, although it is associated with Marfan’s syndrome and congenital heart disease. The majority of patients are asymptomatic. On the PA CXR, the heart is shifted to the left. The right heart border is indistinct (suggesting right middle lobe consolidation). The posterior ribs appear horizontal and the anterior ribs are angulated steeply, giving rise to the ‘sevens’ appearance.

Question 46

41 A 56-year-old man presented with recurrent episodes of fever, dry cough and dyspnoea. On specific questioning he states he breeds pigeons. What feature would make the diagnosis of extrinsic allergic alveolitis (EAA) less likely?

a Pleural effusion

b A normal chest radiograph

c Fibrosis of middle and lower zones

d Traction bronchiectasis

e Diffuse ground-glass attenuation on high resolution CT

Answer 46

41 Answer A: Pleural effusion

In both the acute and late-phases of EAA a normal chest radiograph is seen in 30-95%. No radiological study is pathognomonic, but appearances that would support a diagnosis include patchy non-specific pneumonitis, small pulmonary nodules (which may be so small they give the appearance of ground-glass consolidation) and more chronic changes reflecting healing fibrosis such as bronchiectasis and scarring. Although the horizontal fissure may become thickened, in general pleural disease is not a feature.

Question 47

@# 50 A 40-year-old schoolteacher presented with a non-productive cough, dyspnoea and low-grade pyrexia. She has never smoked. The CXR demonstrated several bilateral areas of patchy consolidation which were confirmed on HRCT and shown to be in a mainly sub-pleural distribution. In addition there is also patchy ground-glass change and small (<5 mm) centrilobular nodules). What is the most likely diagnosis?

a Bronchoalveolar cell carcinoma

b Histoplasmosis

C Sarcoidosis

d Cryptogenic organising pneumonia

e Multifocal streptococcal pneumonia

Answer 47

50 Answer D: Cryptogenic organising pneumonia

These imaging findings are classical of COP. Effusions and adenopathy are also present in up to one third of patients. Bronchoalveolar cell carcinoma is an important differential, but is most commonly solitary and centrilobular nodules are not a feature, and there is a strong smoking association.

Question 48

51 At the weekly respiratory multidisciplinary team meeting you are asked to review a chest radiograph and CT of a 39-year-old man who presented with cough, fever, dyspnoea and chest pain. Blood biochemistry had demonstrated renal impairment. The imaging reveals bilateral reticulonodular interstitial opacification. The nodules vary in size, and the larger nodules show cavitation. What is the most likely diagnosis?

a Wegener’s granulomatosis

b Eosinophilic pneumonia

C Systemic lupus erythematosus (SLE)

d Multiple pulmonary emboli

e Goodpasture’s syndrome

Answer 48

51 Answer A: Wegener’s granulomatosis

The clinical differential diagnosis is between Wegener’s granulomatosis and Goodpasture’s syndrome and the imaging findings are classical for Wegener’s granulomatosis.

Findings in Goodpasture’s syndrome include consolidation with relative apical sparing in the acute stage, followed by an interstitial pattern of opacification in the later stages of the disease.

Question 49

53 You have been asked to review a chest radiograph by a junior doctor. The image demonstrates subtle hazy opacification of the upper part of the lower zone of the right lung. The right atrial border is indistinct and the horizontal fissure runs from the right hilum to the eighth rib in the mid axillary line. What is the most plausible explanation for these findings?

a Middle lobe collapse

b Middle lobe consolidation

C Pectus excavatum

d Right lower lobe mediobasal segment consolidation

e Right lower lobe anteriobasal segment consolidation

Answer 49

53 Answer A: Middle lobe collapse

The findings are those of middle lobe collapse. Signs on the frontal radiograph can be subtle, and it is more easily seen on the lateral radiograph. In this case the loss of clarity of the right atrial border indicates the pathology is located in the middle lobe. There is loss of volume (the normal horizontal fissure runs from the hilum to the sixth rib in the mid axillary line), therefore collapse of the middle lobe, rather than consolidation, is the likely cause for these appearances.

Question 50

58 A 40-year-old man presented to the Respiratory Clinic with a gradual onset of dyspnoea, weight loss, cough and haemoptysis. He was tachypnoeic at rest with crepitations on auscultation. His full blood count and renal profile were normal. A chest radiograph showed bilateral, patchy hazy opacification and there was a `crazy paving’ pattern of attenuation on HRCT with additional sparse patches of consolidation. There was no adenopathy, cardiomegaly or effusion and lung biopsy was performed. The interstitium was normal but there was filling of the alveoli with lipid and proteinacious material. What is the most likely diagnosis?

a Sarcoidosis

b Left heart failure and pulmonary oedema

C Goodpasture’s syndrome

d Wegener’s granulomatosis

e Alveolar proteinosis

Answer 50

58 Answer E: Alveolar proteinosis

Alveolar proteinosis (AP) is a rare condition predominantly affecting men. Symptoms are nonspecific.

It is caused by altered surfactant homeostasis leading to accumulation of lipoproteinacious material within the alveoli.

AP affects the airspaces only, and not the interstitium, and is a rare cause for a `crazy paving’ pattern on HRCT

Question 51

38 A 54-year-old male on long-term methotrexate therapy presented with increasing shortness of breath over several months. Pulmonary function tests demonstrated an obstructive picture and he had no response to a course of antibiotics. A chest radiograph was normal. HRCT reveals mosaic perfusion with air-trapping on expiratory scans, bronchial wall thickening, centrilobular groundglass and bronchiolectasis. What is the most likely diagnosis?

a Chronic eosinophilic pneumonia

b Bronchiolitis obliterans

C Usual interstitial pneumonia

d Tuberculosis

e Non-specific interstitial pneumonia

Answer 51

38 Answer B: Bronchiolitis obliterans

This is defined as inflammation of the bronchioles leading to obstruction of the lumen and is seen in patients with cystic fibrosis, connective tissue disorders, post-infection, in transplanted lungs, following inhaled toxins, drug therapy (methotrexate, bleomycin, cyclophosphamide, penicillamine), but can be idiopathic.

Question 52

42 A patient with shortness of breath was investigated with a chest radiograph that showed pulmonary infiltrate in a `reverse bat-wing’ distribution. What disease typically has demonstrated this appearance?

a Alveolar proteinosis

b Chronic eosinophilic pneumonia

C Lymphoma

d Goodpasture’s syndrome

e Alveolar cell carcinoma

Answer 52

42 Answer B: Chronic eosinophilic pneumonia

Alveolar infiltrates in a peripheral distribution can also be seen in resolving pulmonary oedema, desquamative interstitial pneumonia and sarcoidosis.

Question 53

48 A previously fit and healthy 15-year-old boy presents to his GP with an expiratory wheeze. The chest radiograph is normal. What is the most likely diagnosis?

a tracheal hamartoma

b Bronchogenic cyst

c Tracheobronchopathia osteoplastica

d Asthma

e Endobronchial carcinoid

Answer 53

48 Answer D: Asthma

Even though the chest radiograph is normal and he was previously fit and well, asthma is by far the commonest and therefore most likely answer.

Question 54

A 54-year-old female presented to the ENT Department with shortness of breath and increasing stridor. She had a history of chronic myeloid leukaemia and during a recent course of chemotherapy suffered from severe pneumonia and was admitted to ITU for support. CT demonstrated a short, concentric stenosis within the mid to distal trachea. What is the most likely explanation for these findings?

a Post-intubation stricture

b Secondary amyloidosis of the trachea

C Post-pneumonic stricture

d Squamous cell carcinoma of the trachea

e Tracheobronchopathia osteochondroplastica

Answer 54

58 Answer A: Post-intubation stricture

The findings are those of a short tracheal stricture. The most common cause for a discrete stricture is a traumatic insult, in this case likely to be due to the balloon cuff from an endotracheal tube. Other causes of tracheal strictures include previous radiotherapy or surgery and burns.

Question 55

48 On chest radiography, which of the following features is more in keeping with a diagnosis of bronchiectasis than bronchiolitis?

a Bronchial wall thickening

b Bronchial dilatation

c Atelectasis

d Tiny nodules

e Lobar consolidation

Answer 55

48 Answer B: Bronchial dilatation

The remaining findings are seen in bronchiolitis.

Question 56

52 A patient with known hypersensitivity pneumonitis (extrinsic allergic alveolitis) underwent HRCT of the chest after presenting to the Respiratory Clinic with increasing dyspnoea. During the last part of the scan a medical student asks you why the radiographer has scanned the patient prone on expiration. What is the most rational explanation?

a A functional test to see how mobile the patient is and how long they can exhale and hold their breath

b To accentuate differential lung attenuation caused by air trapping and obviate any gravitational (dependent) changes seen on the supine scan

C To obviate any gravitational (dependent) changes seen on the supine scan and reduce differential lung attenuation caused by air trapping

d To accentuate gravitational (dependent) changes and accentuate differential lung attenuation caused by air trapping

e To reduce differential lung attenuation caused by air trapping and accentuate gravitational (dependent) change

Answer 56

52 Answer B: To accentuate differential lung attenuation caused by air trapping and obviate any gravitational (dependent) changes seen on the supine scan.

Expiratory scanning is performed to accentuate the difference in attenuation between areas of trapped air and normal lung. Air trapping - caused by stenotic distal airways - is a feature of hypersensitivity pneumonitis, sarcoidosis and the pneumoconioses. Prone scanning can help differentiate between pathological areas of high attenuation seen in dependent locations on the supine scan from simple gravitational (dependent) change.

Question 57

69 A 70-year-old man with chronic obstructive airways disease underwent a CT scan and a tracheal diverticulum was identified. What is the most likely site of this abnormality?

a just below the larynx on the left anterolateral wall

b In the distal trachea on the anterior wall

c just above the carina on the posterior wall

d At the level of the thoracic inlet on the right posterolateral wall

e At a variable level on the anterior wall

Answer 57

69 Answer D: At the level of the thoracic inlet on the right posterolateral wall

Usually they occur between the cartilaginous and muscular portion of the wall and tend to be asymptomatic.

Question 58

14. A 35-year-old pet shop owner presents with shortness of breath. The chest radiograph is normal. HRCT shows diffuse ground-glass centrilobular opacities involving both lungs. No lymphadenopathy is seen. The most likely diagnosis is:

(a) Sarcoidosis

(b) Pneumoconiosis

(c) Hypersensitivity pneumonitis

(d) Cystic fibrosis

(e) Lymphangioleiomyomatosis

Answer 58

14. (c) Hypersensitivity pneumonitis

HRCT appearances are typical of subacute hypersensitivity pneumonitis. This is caused by inhalation of antigenic organic particles. The subacute phase is characterised by intermittent exposure to antigens with symptoms arising over weeks to months. The chronic phase is characterised by the presence of fibrosis.

Question 59

@# 40. A 60-year-old recently retired postman presents with chronic cough. The chest radiograph shows soft tissue opacity extending from the right hilum to the lateral chest wall, with loss of the right heart border. There is loss of right lung volume and the right costophrenic angle is seen. Bronchoscopy demonstrates a large endobronchial mass. What is the most likely bronchus involved?

(a) Right upper lobe bronchus

(b) Right middle lobe bronchus

(c) Right lower lobe bronchus

(d) Bronchus intermedius

(e) Right lower lobe apical segment bronchus

Answer 59

40. (d) Bronchus intermedius

The chest radiograph findings are suggestive of combined right middle lobe and right lower lobe collapse secondary to tumour obstructing the bronchus intermedius.

Question 60

50. A 38-year-old bird keeper presents with recurrent episodes of flu-like symptoms. The chest radiograph is normal. HRCT shows extensive bilateral symmetrical, small ill-defined centrilobular nodules. What is the most likely diagnosis?

(a) Sarcoidosis

(b) Idiopathic pulmonary fibrosis

(c) Scleroderma

(d) Hypersensitivity pneumonitis

(e) Respiratory bronchiolitis–interstitial lung disease

Answer 60

50. (d) Hypersensitivity pneumonitis

Given the history of bird keeping, and diffuse centrilobular shadowing in the lungs, the diagnosis is likely to be hypersensitivity pneumonitis

Question 61

8. Which of the following are correct regarding HRCT features of pulmonary alveolar proteinosis (PAP): (T/F)

(a) Usually shows a lower zone distribution.

(b) Pleural effusion is common at presentation.

(c) Lymphadenopathy is a common feature.

(d) Regions of emphysema are commonly observed.

(e) Crazy paving pattern is a specific feature

Answer 61

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Not correct

Explanation:

Pleural effusion is rare in untreated PAP.

Lymphadenopathy is uncommon.

Crazy paving pattern though suggestive of PAP, is also seen in ARDS, acute interstitial pneumonia and drug induced pneumonias

Question 62

9. Which of the following are correct regarding extrinsic allergic alveolitis (EAA): (T/F)

(a) A normal CXR excludes the diagnosis.

(b) Smoking is a risk factor.

(c) The upper zones are typically involved in acute EAA.

(d) Ground-glass opacity is a characteristic HRCT finding.

(e) Bronchiectasis is seen on HRCT in chronic EAA

Answer 62

Answers:

(a) Not correct

(b) Not correct

(c) Not correct

(d) Correct

(e) Correct

Explanation:

CXRs are generally normal in patients with mild symptoms and in some cases with severe symptoms.

Smokers are protected from EAA also called hypersensitivity pneumonitis.

The most common forms are farmer’s lung and bird fancier’s lung.

Typically mid to lower zones are affected with sparing of costophrenic angles.

Presentation is like pulmonary oedema with bilateral areas of increased opacity that may be heterogeneous or homogeneous.

Question 63

18. Which of the following are true regarding cryptogenic organising pneumonia (COP)? (T/F)

(a) The disease is rarely symptomatic.

(b) An obstructive pattern of lung function impairment is typical.

(c) Pleural effusions are common.

(d) Radiographic clearing occurs following steroid treatment.

(e) Bilateral basal peripheral consolidation is a common radiographic finding

Answer 63

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Correct

(e) Correct

Explanation:

50% of the patients are symptomatic presenting with fever, cough, breathlessness and malaise with peak incidence in5th and 6th decades of life. COP is also known as BOOP (bronchiolitis obliterans organizing pneumonia) or bronchiolitis obliterans with intramural polyps.

Pleural effusion is uncommon (5% cases