Alveolar, Airway & Collapse Flashcards
- 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
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).
- 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
E. Hypersensitivity pneumonitis
Characteristic HRCT features in hypersensitivity pneumonitis include ground glass opacity, air trapping and centrilobular ground glass opacities.
@#1 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
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.
@# 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
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.
@#1 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
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.
- 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
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.
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
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
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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
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
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.
@# 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
(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.
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
(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.
@# 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
(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.
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
(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.
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
(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.
@#1 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
(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.
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
(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.
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
(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.
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
(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.
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
(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.