Infection, ARDS & AIDS

Question 1

1. A 25-year-old man with a history of asthma presents with flu-like symptoms. He has peripheral blood eosinophilia and elevated serum IgE. Chest radiograph shows hyperinflation, lobar consolidation and 1-2cm ring shadows around the hilum and upper lobes. The peripheral bronchi are normal. Which of the following is the most likely diagnosis?

A. Noninvasive aspergillosis

B. Tuberculosis

C. Invasive aspergillosis

D. Hypersensitivity pneumonitis

E. Allergic bronchopulmonary aspergillosis (ABPA)

Answer 1

E. Allergic bronchopulmonary aspergillosis (ABPA)

In an asthmatic patient, ABPA is strongly suggested by the presence of randomly distributed, central, moderate to severe bronchiectasis predominantly involving the upper lungs, bronchial wall thickening and centrilobular nodules.

Question 2

3. Which is the most common cause for tree-in-bud appearance on chest CT?

A. Tumour emboli

B. Infection

C. Connective tissue disease

D. Aspiration pneumonitis

E. ABPA

Answer 2

3. B. Infection
   Bacterial causes include mycobacterium tuberculosis, mycobacterium avium intracellulare complex, staph aureus. Viral causes include Cytomegalovirus (CMV) and respiratory syncytial virus. Fungal causes include invasive aspergillosis.

Question 3

21. A 78-year-old male smoker with hospital admission 2 months ago for a dense left Middle Cerebral Artery (MCA) cerebral infarct presents. He has a 3 week history of low grade fevers and weight loss. Chest radiograph reveals new left lower lobe consolidation with areas of cavitation and air fluid levels, but no hilar lymphadenopathy. Which is the most likely diagnosis?

A. Hospital acquired pneumonia with lung abscess

B. Bronchogenic carcinoma

C. Bronchoalveolar cell carcinoma

D. Aspiration with anaerobic pneumonia

E. Traumatic contusion with lung cysts

Answer 3

21. D. Aspiration with anaerobic pneumonia

The superior segments of the lower lobes and posterior segments of the upper lobes are most commonly affected in aspiration pneumonia. Thick walled cavitation, frequently with air-fluid levels, can develop within weeks, mimicking post-primary TB.

Question 4

24. Which of the following features most favours melioidosis rather than tuberculosis?

A. Lobar consolidation

B. Cavitation

C. Lack of pleural involvement

D. Upper lobe predominance of nodular change

E. Rapid progression of clinical features

Answer 4

24. C. Lack of pleural involvement

There is significant overlap between the features of melioidosis, pneumonia and TB. However, in melioidosis, simultaneous involvement of other organs is common. Pleural involvement such as effusion, empyema, mediastinal or hilar adenopathy are rare, making them useful differentiating features from TB

Question 5

31. Which of the following most suggests active disease in an adult male with TB?

A. Mediastinal lymph nodes more than 1cm in short axis diameter

B. Right-sided paratracheal lymphadenopathy

C. A Ghon focus

D. Enlarged lymph nodes with low attenuation centres

E. Ranke complex

Answer 5

D. Enlarged lymph nodes with low attenuation centres

Enlarged nodes greater than 2cm often have low attenuation centres on CT due to necrotic change, and are highly suggestive of active disease.

Question 6

35. Which of the following most strongly indicates post-primary rather than primary TB?

A. Consolidation in the mid zones

B. Self-limiting course

C. The absence of lymphadenopathy

D. Pleural effusion

E. Atelectasis

Answer 6

C. The absence of lymphadenopathy

Although there may be overlap of features of primary and post-primary TB, the distinguishing features of postprimary TB include predilection for the upper lobes, the absence of lymphadenopathy and cavitation.

Question 7

36. Which of the following is the most common feature of Pneumocystis jiroveci infection on the CT of a 50-year-old man, 4 months post-bone marrow transplant?

A. Pneumatoceles

B. Diffuse bilateral ground-glass opacification

C. Focal areas of consolidation

D. Pleural effusions

E. Mediastinal lymphadenopathy

Answer 7

B. Diffuse bilateral ground-glass opacification

There are often diffuse bilateral ground-glass opacities and less often, focal areas of consolidation, pleural effusions, and mediastinal lymphadenopathy. Approximately 1⁄3 of patients develop pneumatocoeles, usually in the upper lobes, which usually resolve spontaneously, although infrequently can cause a pneumothorax.

Question 8

45. On reviewing a chest radiograph of a 26-year-old male, multiple small pulmonary nodules and a right-sided pneumothoraxare identified. Which is the most likely diagnosis?

A. Wegener’s granulomatosis

B. Septic emboli

C. TB

D. Alveolar cell carcinoma

E. Histiocytosis

Answer 8

E. Histiocytosis

Osteosarcoma, Wilms’ tumour and histiocytosis are causes of pulmonary nodules with pneumothorax.

Question 9

@#e 2) In acute respiratory distress syndrome what is the first change usually seen on the chest radiograph?

a. confluent consolidation

b. pleural effusions

c. increased heart size with globular shape

d. volume loss with atelectasis

e. patchy ill-defined opacities

Answer 9

e. patchy ill-defined opacities

Acute respiratory distress syndrome (ARDS) commences with interstitial edema, progressing to congestion and extensive alveolar, and interstitial edema and hemorrhage. The chest radiograph is often normal for the first 24 hours, before patchy opacities appear in both lungs. These progress to massive airspace consolidation over the following 2448 hours. True volume loss, atelectasis, cardiomegaly and effusions are not seen in ARDS.

Question 10

7) A 43-year-old man with a previous history of polytrauma requiring a long period in intensive care for acute respiratory distress syndrome presents with shortness of breath. An abnormal chest radiograph prompts a highresolution CT scan. What are the most likely findings?

a. bronchiectasis in the lower lobes

b. pleural effusions

c. fibrosis with volume loss in the upper lobes

d. reticular changes in the anterior aspects of the lungs

e. reticular changes in the posterior aspects of the lungs

Answer 10

d. reticular changes in the anterior aspects of the lungs

In most patients who survive acute respiratory distress syndrome (ARDS), there is no functional deficit. Where investigated, however, the most common abnormality detected is a reticular pattern in the ventral non-dependent lung. The extent of this is negatively related to the extent of opacification in the acute phase and strongly related to the duration of mechanical ventilation. Bronchiectasis is seen in both acute and chronic phases but is less common than reticular change. Upper-lobe fibrosis is not associated with ARDS.

Question 11

12) An 87-year-old male presents with fever and cough. A chest radiograph shows dense consolidation in the right mid-zone, which is seen to be in the apical segment of the lower lobe on a lateral view. The oblique fissure is seen to be bulging away from the consolidation. There is an associated effusion. What is the most likely diagnosis?

a. Haemophilus influenzae pneumonia

b. Staphylococcus aureus pneumonia

c. Streptococcus pneumoniae pneumonia

d. Klebsiella pneumonia

e. Legionnaires’ disease

Answer 11

d. Klebsiella pneumonia

Klebsiella pneumonia is typically seen in elderly, debilitated men and produces dense, lobar consolidation, with bulging of the fissure sometimes seen. This may also be seen with pneumococcal pneumonia, but less commonly. Klebsiella may also cause empyema (the commonest cause) and patchy bronchopneumonia. Cavitation occurs in 50%. Staphylococcus aureus pneumonia has a bronchopneumonia pattern which may coalesce, and cavitation is common. Multiple abscesses tend to occur in intravenous drug addicts. Effusions and empyema are common. Streptococcal pneumonia occurs in all ages, especially young adults, and often produces a lobar consolidation in the basal region. Haemophilus influenzae pneumonia has no characteristic appearance. Legionnaires’ disease causes a spreading consolidation of bronchopneumonia type.

Question 12

43) A 35 year old with asthma presents with malaise, flu-like illness and cough. Previous similar episodes have occurred. A chest radiograph shows patchy airspace opacification in the mid and upper zones. Which feature on highresolution CT would make allergic bronchopulmonary aspergillosis a more likely diagnosis than extrinsic allergic alveolitis?

a. widespread centrilobular micronodules ,3 mm

b. tubular finger-like opacities

c. bronchiectasis

d. upper-zone fibrosis

e. pleural effusion

Answer 12

b. tubular finger-like opacities

Allergic bronchopulmonary aspergillosis (ABPA) is hypersensitivity to aspergillus in people with asthma. Typical features are of a migratory pneumonitis, predominantly in the upper lobes. It may cause bronchiectasis and upper-zone fibrosis, which are features also seen in extrinsic allergic alveolitis (EAA). Tubular opacities, indicating mucus plugging, are seen in ABPA, but not in EAA. Centrilobular nodules are seen in EAA, along with mosaic perfusion and patchy ground-glass change. Pleural effusions are rarely seen in EAA and not in ABPA.

Question 13

3) Which of the following would be most in keeping with the appearance of pulmonary hydatid disease?

a. multiple subcentimetre nodules throughout both lungs with no cavitation

b. unilateral patchy alveolar changes with unilateral hilar lymphadenopathy

c. solitary ovoid mass with air–fluid level and floating debris

d. bilateral basal reticular change

e. 3 cm, rounded mass with central calcification

Answer 13

c. solitary ovoid mass with air–fluid level and floating debris

The lungs are the second most frequent site affected by hydatid disease in adults, being involved in up to 25% of cases. Commonly, a solitary ovoid or spherical mass is seen in the lower lobes. These can be quite large, measuring up to 20cm in size. There is communication with the bronchial tree, producing air–fluid levels, and the wall of the cyst may be visible, and may appear as a curvilinear opacity or floating debris. Calcification may occur within the wall of the cyst in a few cases.

Question 14

@# 41- Which of the following CT features indicates post-primary rather than primary pulmonary tuberculosis?

(a) Miliary nodules

(b) Bronchiectasis

(c) Cavitation

(d) Tree-in—bud opacification

(e) Lymphadenopathy

Answer 14

(a) Miliary nodules

The difference between primary and post—primary (reactivated) TB is in the degree Of previous exposure the patient has had to T B. Most features are seen in both to some degree with the exception of miliary nodules.

Question 15

43- With respect to Mycoplasma pneumoniae infection, which of the statements is not true?

(a) It is the commonest non—bacterial cause of pneumonia

(b) It usually affects previously healthy individuals

(c) It usually affects the upper lobes

(d) Cavitation is not a feature

(e) Radiographic resolution may take up to 2 months

Answer 15

(c) It usually affects the upper lobes

Mycoplasma pneumoniae infection has a predilection for the lower lobes, although isolated upper lobe infection is well recognized. A nodular interstitial pattern may also be seen, the frequency of this finding varies significantly between series, as does the prevalence of pleural effusion.

Question 16

48- The ITU team to discuss a chest radiograph on. one of their patients- Which of the following features suggest ARDS over- cardiogenic pulmonary edema?

(a) Ratio of arterial oxygenation to inspired oxygen fraction 300

(b) Bilateral pulmonary infiltrates

(c) Pulmonary arterial wedge pressure 20 mmHg

(d) Heart size 15 cm

(e) Bilateral pleural effusions

Answer 16

(d) Heart size 15 cm

ARDS is a response of the lung to injury which may be direct or indirect; radiological features are those of noncardiogenic edema which develops as a consequence but unlike simple edema an interstitial fibrosis may develop. Mechanical ventilation is thought to contribute to this process. Pulmonary arterial wedge pressure 18 mmHg suggests raised left atrial pressures. The diagnosis of ARDS requires the ratio of arterial oxygenation to inspired oxygen to be < 200 mmHg.

Question 17

1 A 36 year old man has returned from a long adventure holiday in South-Eastern USA. He had an episode of fever, dry cough and polyarthralgia. He still has dyspnoea and on examination is noted to have erythema nodosum on his shins. CXR shows diffuse bilateral tiny calcific nodules, some with central calcification, and hilar and mediastinal ‘popcorn’ calcified lymphadenopathy. What is the most likely diagnosis?

(a) Acute sarcoidosis

(b) Histoplasmosis

(c) Langerhans Cell Histiocytosis

(d) TB

(e) Varicella pneumonia

Answer 17

(b) Histoplasmosis

Histoplasmosis is endemic in certain areas of the USA, particularly Ohio, Mississippi, and the St Lawrence river valley. Acute infection produces flu-like symptoms (polyarthralgia, fever). Acute CXR findings may be non-specific, but include diffuse subsegmental opacities, +/lymphadenopathy. Sub-acute infection results in small calcific nodules and there may be hilar or mediastinal LNs which can display popcorn calcification. The ‘target lesion’ with central calcification is said to be pathognomonic.

Question 18

24 A patient undergoing induction chemotherapy for the treatment of acute myeloid leukaemia undergoes a chest CT. This shows several foci of consolidation with a halo of ground glass opacification. What is the most likely diagnosis?

(a) Leukaemic infiltrate

(b) Mycobacterium avium infection

(c) Klebsiella spp. infection

(d) Pulmonary thromboembolic disease

(e) Angioinvasive aspergillosis

Answer 18

(e) Angioinvasive aspergillosis

This group of patients are severely immuno-suppressed and are particularly prone to fungal chest infections, which need to be recognised early and treated aggressively.

Question 19

33 An 18 year old woman with proven hydatid disease of the liver presents with chest pain and fever. She has a CXR which shows an 8 cm cystic lesion in the right lung. Which of the following features would be least expected in lung echinococcosis?

(a) Calcification of the cyst wall

(b) Water lily sign

(c) An air/fluid level within cyst

(d) Ground glass change around the cyst

(e) The size of the lesion

Answer 19

(d) Ground glass change around the cyst

Lung involvement occurs in 15-25% of hydatid cases with a lower lobe preponderance. The cystic lesion is solitary in up to 75% of cases. It has a sharply defined ovoid/ spherical appearance and can measure up to 20 cm. It is characterised by varying degrees of collapse of the endocystic membrane leading to the so called ‘water lily’, ‘serpent’ and ‘cumbo’ signs. Rib and vertebral erosion is rarely seen.

Question 20

57 What is the most common thoracic complication of HIV worldwide?

(a) Bacterial pneumonia

(b) Kaposi’s sarcoma

(c) Pneumocystis infection

(d) Lymphoma

(e) Tuberculosis

Answer 20

(e) Tuberculosis

Tuberculosis co-infection is the commonest complication worldwide. In the UK, bacterial infection is commonest, with unusual organisms seen more commonly than in the general population.

Question 21

2. A 35 year old woman presents with chest infection and pyrexia and the plain film reveals dense lobar consolidation with bulging fissures. The likely micro-organism is:

a. Legionella pneumophila

b. Pneumocystis carinii

c. Staphylococcus

d. Streptococcus

e. Klebsiella

Answer 21

e. Klebsiella

Klebsiella Klebsiella causes a dense pneumonia with bulging of fissures often associated with an empyema. Pneumococcal pneumonitis can also mimic this

Question 22

@#1 6. A 35 year old man undergoes autologous bone marrow transplantation following successful treatment of lymphoma. Two weeks later he develops scattered bilateral progressive breathlessness and dry cough. HRCT demonstrates several areas of bilateral ground glass changes with associated reticular changes, but no effusions. What is the most likely explanation?

a. Angioinvasive aspergillosis

b. Lymphoid interstitial pneumonia

c. CMV pneumonia

d. Drug toxicity

e. Pulmonary oedema

Answer 22

d. Drug toxicity

Drug toxicity Post transplant pulmonary complications may develop in up to 40–60% of patients.

In the first two weeks or so after transplantation, neutropaenia is the underlying cause for most of these.

Angioinvasive aspergillosis presents in the first two to three weeks, usually as multiple ground glass nodules with or without cavitation and peribronchiolar consolidation.

Lymphoid interstitial pneumonia (LIP) is a late-phase complication usually seen more than three months after transplantation and may be an indication of chronic graft-versus-host response.

CMV pneumonia may manifest at any time in the first 100 days after transplantation. Multiple nodules with associated ground glass changes or consolidation are usually seen, but reticular change is not a feature.

Pulmonary oedema is also seen in the neutropaenic phase in the first two to three weeks. Whilst ground glass changes and interstitial lines are seen in pulmonary oedema, associated pleural effusion is common.

Drug toxicity due to a variety of chemotherapeutic agents is seen in the neutropaenic phase as a combination of ground glass and reticular changes…

Question 23

@#e 12. A 22 year old is diagnosed with tuberculosis. Which of the following features will make a diagnosis of primary tuberculosis more likely?

a. Mediastinal enlargement

b. Septal thickening

c. Upper zone cavitation

d. Miliary nodules

e. Apical consolidation

Answer 23

a. Mediastinal enlargement

Mediastinal enlargement Mediastinal lymph node enlargement is a feature of primary TB. The others are seen with reactivation or fibrocavitary TB. Miliary TB can be seen in any phase with haematogenous dissemination but primary presentation is uncommon.

Question 24

29. A 22 year old asthmatic presents with recurrent wheeze and productive cough with expectoration of brown sputum. Plain chest radiograph demonstrates multiple pulmonary infiltrates. Which of the following appearances on HRCT would be the most appropriate for acute allergic bronchopulmonary aspergillosis?

a. Finger-in-glove opacity

b. Thick-walled cavity

c. Pleural thickening with or without an effusion

d. Endobronchial mass with distal atelectasis

e. Tree-in-bud appearance

Answer 24

a. Finger-in-glove opacity

Finger-in-glove opacity Acute allergic bronchopulmonary aspergillosis is seen as homogeneous, tubular, finger-inglove areas of increased opacity in a bronchial distribution, usually involving the upper lobes. These shadows are related to plugging of airways by hyphal masses with distal mucoid impaction and can migrate from one region to another on HRCT. Thickwalled cavities and pleural thickening are features of saprophytic aspergillosis. Endobronchial lesion with distal atelectasis is seen mainly in chronic necrotising aspergillosis, whilst tree-in-bud appearance is seen with bronchiolitis in airway invasive aspergillosis.

Question 25

@# 32. A 35 year old female presents with generalised malaise and cough, occasionally bringing up grape-skin-like material. Blood screen reveals eosinophilia. The patient has a history of travel to several countries worldwide. Which of the following plain film features is unlikely?

a. Homogenous ovoid opacity

b. Cyst with a fluid level

c. Bilateral opacities

d. Calcification.

e. Lower zone location

Answer 25

d. Calcification.

Calcification The case describes hydatid disease. Hydatid cyst of the lungs can present as solid ovoid solitary or occasionally multiple lesions on plain films. When the cyst communicates with a bronchial tree, an air fluid level is demonstrated. Several other signs are described. Whilst bilaterality is less likely (up to 20%), calcification is extremely rare (0.7%).

Question 26

33. A 33 year old male patient suffering from AIDS presents with constitutional symptoms and dry cough. His CD4 count is 150. HRCT is least likely to show:

a. Pleural effusion

b. Ground glass changes

c. Bilateral interstitial infiltrates

d. Diffuse alveolar infiltrates

e. Pneumatocoeles

Answer 26

a. Pleural effusion

Pleural effusion Pneumocystis carinii is the most common cause of pneumonia at this stage of the disease. Pleural effusions and lymphadenopathy are not features of PCP.

Question 27

A 25-year-old asthmatic man is referred to the chest outpatient clinic with a fever, cough and shortness of breath. A course of antibiotics has not improved his symptoms. Investigations performed in the clinic include a positive skin test for Aspergillus jumigatus and an elevated serum IgE. The patient is known to be immunocompetent with no previous history of sarcoidosis or tuberculosis. Which one of the following are the most likely high-resolution CT (HRCT) findings?

A A lower lobe predominance

B An air crescent sign

C Central bronchiectasis

D The halo sign

E Wedge-shaped peripheral infarcts

Answer 27

C Central bronchiectasis

Allergic bronchopulmonary aspergillosis (ABPA) is part of a spectrum of disease caused by Aspergillus fumigatus. Hypersensitive individuals (commonly those with asthma) can present with ABPA and the key radiological features are central airway mucoid impaction leading to central bronchiectasis.

Question 28

A 27-year-old, previously fit and well man presents to his GP with a short history of pyrexia, cough and haemoptysis. He has never previously been admitted to hospital. Sputum culture has grown Streptococcus pneumoniae. What is the most likely chest radiograph finding?

A Bronchopneumonia

B Cavitation

C Empyema

D Large pleural effusion

E Lobar consolidation.

Answer 28

E Lobar consolidation.

Many community-acquired pneumonias are caused by Streptococcus pneumoniae with radiographic features of peripheral, homogeneous opacification. Air bronchograms may be present, but cavitation and empyema are uncommon.

Question 29

An 80-year-old man has been admitted to hospital with shortness of breath and a productive, purulent cough. A CXR reveals left lower lobe consolidation. Which additional radiological finding is most likely to suggest a diagnosis of Klebsiella pneumoniae rather than Legionella pneumophild

A Bulging fissures

B Mediastinal lymphadenopathy

C Pleural effusion

D Pneumothorax

E Septal thickening

Answer 29

A Bulging fissures

Klebsiella pneumoniae leads to an extensive exudative response leading to cavitating lobar consolidation and bulging fissures. Legionnaire’s disease, on the other hand, tends to present with multifocal lobar, homogeneous opacities with a tendency to appear like masses.

Question 30

QUESTION 20 A 7-year-old girl, who has recently migrated to this country from India, presents with a productive cough, fever, night sweats and weight loss. A CXR demonstrates marked consolidation in the right upper lobe. Sputum cytology reveals the presence of acid fast bacilli. What additional radiological finding is most likely to suggest a diagnosis of current primary tuberculosis as opposed to post-primary tuberculosis?

A Cavitation

B Mediastinal lymphadenopathy

C Multifocal lesions

D Ranke complex

E Rasmussen aneutysm

Answer 30

B Mediastinal lymphadenopathy

Primary tuberculosis causes a pneumonia that mimics Streptococcus pneumoniae in its radiographic appearance and, in children, lymphadenopathy is the most common manifestation.

Question 31

QUESTION 21 A 30-year-old male engineer has recently returned from North America having inspected a number of construction sites. He develops flu-like symptoms and a CXR reveals the presence of a solitary well-defined nodule. What additional finding would make a diagnosis of Histoplasmosis infection more likely, rather than Cryptococcus infection?

A Air bronchograms

B Cavitation

C Central calcification

D Lymphadenopathy

E Pleural effusion

Answer 31

C Central calcification

Histoplasma capsulatum is a fungus found in moist soil and bird/bat excreta and histoplasmosis occurs most commonly in areas of construction or regions near bat caves. A ‘target’ lesion describes a solitary, well-defined nodule (a histoplasmoma) with central calcification and is very specific for thiscondition.

Question 32

QUESTION 22 A 35-year-old man complains of a cough and is sent for a CXR by his GP. This demonstrates a solitary cystic structure within the left lower lobe, measuring approximately 6 cm in diameter. The peripheral aspect of the cystic structure lies in contact with the chest wall and appears slightly flattened. Within this structure there appears to be a floating membrane. What is the most likely diagnosis?

A Aspergillosis

B Coccidioidomycosis

C Hydatid disease

D Mycoplasma pneumoniae

E Tuberculosis

Answer 32

C Hydatid disease

Hydatid cyst rupture can lead to a variety of appearances: an air-fluid level, a floating membrane (the water lily sign), crumpled membranes in the dependent part of the cyst and a cyst with all contents expectorated (empty cyst sign).

Question 33

QUESTION 23 A 30-year-old man is HIV positive with a most recent CD4 count — 100 cells/pL. He presents to the infectious diseases team with a cough, dyspnea and general malaise. A CXR demonstrates bilateral, diffuse, medium-sized reticular opacities. An air-filled parenchymal cavity (pneumatocoele) is seen, but there is an absence of either mediastinal lymphadenopathy or a pleural effusion. What is the most likely underlying opportunistic infection?

A Streptococcus pneumoniae

B Ciyptococcus neoformans

C Cytomegalovirus

D Mycobacterium avium complex

E Pneumocystis carinii

Answer 33

E Pneumocystis carinii

Pneumatocoeles will generally disappear over time and the majority of radiological signs of PCP will resolve with treatment.

Question 34

1. A 33-year-old driver is severely injured in a motor vehicle accident. He develops increasing dyspnoea and hypoxia, and requires intubation. A chest x-ray (CXR) was normal on admission and his pulmonary capillary wedge pressure is normal. A repeat CXR performed at over 24 hours after the trauma is not normal. He is reimaged during his intensive care unit (ICU) stay and at one point undergoes a computed tomography pulmonary angiography (CTPA), which is negative for pulmonary embolism (PE). The clinical team suspect acute respiratory distress syndrome (ARDS). Which of the following radiographic features is inconsistent with this diagnosis?

A. Bronchial dilatation on computed tomography (CT).

B. Bilateral heterogeneous air-space opacities.

C. Diffuse reticular changes.

D. Pneumothorax.

E. Bilateral pleural effusions.

Answer 34

1. E. Bilateral pleural effusions.

The underlying diagnosis is ARDS. The causes may be direct lung injury (e.g. pneumonia, toxic gas inhalation, aspiration) or indirect lung injury (e.g. trauma, sepsis, and pancreatitis). Diagnostic guidelines require a partial pressure of arterial O2/fraction of inspired O2 (PaO2/FiO2) < 200 mmHg and no evidence of left heart failure, and thus the presence of a pleural effusion casts doubt on the diagnosis; the appearance of ARDS can otherwise mimic pulmonary edema.

Bronchial dilatation is frequently seen on CT. The alveolar changes are heterogeneous, showing a density gradient in both the cranio-caudal and antero-posterior directions (the dorsal/dependent and lower lobes are denser than the ventral/non-dependent and upper lobes). Radiographic changes tend to be absent for the first 24 hours (with the exception of direct lung injury), then increase to remain static for days or weeks, and then begin to resolve. Pneumothorax can occur secondary to ventilation. Reticular changes, with a predilection for non-dependent lung, may be secondary to the underlying process or to barotraumas (seen in 85% of survivors in one study; the mortality of ARDS is approximately 50%).

Question 35

26. A 28-year-old Asian male immigrant presents with low-grade fever, weight loss and productive cough. There is no history of immunosuppression. Which of the following CXR findings is most in keeping with postprimary TB?

A. Unilateral hilar lymphadenopathy.

B. Cavitating parenchymal opacity.

C. Pleural effusion.

D. Multiple bilateral non-calcified nodules <3 mm diameter.

E. Right lower lobe atelectasis.

Answer 35

26. B. Cavitating parenchymal opacity.

In persons with normal immune function, radiologic manifestations can be categorized into the two distinct forms of primary and post-primary disease that develop in individuals without and with prior exposure and acquired specific immunity. Lymphadenopathy is the radiologic hallmark of primary TB, although the prevalence decreases with increasing age. Parenchymal involvement in primary TB commonly appears as an area of homogenous consolidation. Obstructive atelectasis may occur from compression by adjacent enlarged lymph nodes. Pleural effusion occurs in approximately 30% of adults with primary TB. The characteristic manifestation of postprimary disease is an apical parenchymal opacity associated with cavitation. Other manifestations of post-primary TB are ill-defined opacities and tuberculomas. Lymphadenopathy is uncommon and pleural effusion is seen more frequently with primary disease. Multiple non-calcified nodules <3mm in diameter are characteristic of military TB.

Question 36

31. A 30-year-old caucasian man, recently treated with bone marrow transplantation for acute myeloid leukaemia, presents with fever and cough. HRCT chest demonstrates multiple, small centrilobular nodules of soft tissue attenuation connected to linear branching opacities. What is the most likely cause of this finding?

A. Endobronchial tuberculosis.

B. Primary pulmonary lymphoma.

C. Invasive aspergillosis.

D. Obliterative bronchiolitis.

E. Diffuse panbronchiolitis.

Answer 36

31. A. Endobronchial tuberculosis.

The CT findings describe the ‘tree-in-bud’ pattern, which results from centrilobular bronchiolar dilatation and filling by mucus, pus, or fluid that resembles a budding tree. It is usually most pronounced in the lung periphery. All of the options provided are differentials for ‘tree-in-bud’, although infective causes are most common, classically endobronchial spread of active TB. The patient in this case is also at risk of invasive aspergillosis, although typically the ‘tree-in-bud’ pattern occurs in combination with consolidation accompanied by a halo of GGO. Obliterative bronchiolitis occurs in bone marrow transplantation in the setting of chronic graft-versus-host disease. The most sensitive CT finding in this condition is air-trapping on expiratory CT. Diffuse panbronchiolitis is of unknown cause, but occurs almost exclusively in Eastern Asia. Primary pulmonary lymphoma is also a rare cause of ‘tree-in-bud’. Other potential differentials of this pattern include cytomegalovirus infection, cystic fibrosis, aspiration, connective tissue disease, and tumour emboli.

Question 37

36. A 64-year-old man with a history of alcoholism presents with acute onset fever and productive cough. What feature on his admission CXR would be in keeping with Klebsiella pneumonia as opposed to pneumococcal pneumonia?

A. Lobar consolidation.

B. Parapneumonic effusion.

C. Reticulonodular opacity.

D. Bulging interlobar fissure.

E. Spherical opacity.

Answer 37

36. D. Bulging interlobar fissure.

Klebsiella (Gram-negative) pneumonia occurs predominantly in older alcoholic men and debilitated hospitalized patients. On the CXR it appears as a lobar opacification with air bronchograms. A bulging interlobar fissure is secondary to inflammatory exudate, increasing the volume of the involved lobe. This sign, however, is not specific and is also seen with Haemophilus influenzae and Staphylococcus aureus. Pneumococcal (Streptococcus) pneumonia typically presents as lobar consolidation. Parapneumonic effusions are seen in up to 50%. Reticulonodular opacity is a recognized atypical presentation. In children it typically presents as a spherical opacity (round pneumonia).

Question 38

41. A 28-year-old HIV-positive IV drug user presents with progressive exertional dyspnoea, fever and nonproductive cough. CXR demonstrates bilateral parahilar fine reticular opacities. There is no appreciable lymphadenopathy. What is the most likely diagnosis?

A. Mycobacterium avium-intracellulare.

B. Pneumocystis jirovecii (formerly P. carinii).

C. Toxoplasmosis.

D. Coccidioidomycosis.

E. Candidiasis.

Answer 38

41. B. Pneumocystis jiroveci (formerly P. carinii).

This is most common in AIDS patients, usually when CD4 <200 cells/mm3. Despite highly active antiretroviral therapy (HAART) and prophylaxis, it remains the most common AIDS-defining opportunistic infection. The CXR may be normal initially, but eventually a fine parahilar reticular or ground-glass pattern develops. Pleural effusions and lymphadenopathy are uncommon.

Mycobacterium avium-intracellulare primarily affects the GI tract, but chest involvement in disseminated disease typically manifests as lymphadenopathy. Diffuse reticular opacities and hilar lymphadenopathy are a feature of toxoplasmosis. Diffuse miliary nodules are seen in coccidioidomycosis. Candida pneumonia demonstrates diffuse, bilateral nonsegmental airspace opacities.

Question 39

42. A 50-year-old man has developed graft v host disease following a bone marrow transplant. He develops some breathlessness and has pulmonary function tests showing irreversible obstruction. Constrictive (obliterative) bronchiolitis is suspected. Which of the following findings on HRCT is likely to be most helpful in making this diagnosis?

A. ‘Tree in bud’ opacities.

B. Bronchiolectasis.

C. Air-trapping.

D. Centrilobular nodules.

E. Cystic change.

Answer 39

42. C. Air-trapping.

All of the answers, apart from cystic change, are recognized HRCT features of small airways disease. Air-trapping is an indirect finding of small airway narrowing/obliteration and is the most common and identifying imaging feature of constrictive bronchiolitis. Air-trapping is accentuated on expiratory scans.

Constrictive or obliterative bronchiolitis is a category of disorders recognized by a pattern of peribronchiolar fibrosis resulting in complete cicatrization of the bronchiolar lumen. Although most commonly idiopathic, other known causes include infections, toxic fume inhalation (oxides of nitrogen, chlorine), autoimmune disorders, including RA, graftversus-host disease, lung transplantation, inflammatory bowel disease, and drug reactions, e.g. D-penicillamine.

Question 40

46. A 24-year-old serviceman presents with insidious onset of fever, headache and worsening non-productive cough. His white cell count and erythrocyte sedimentation rate (ESR) are elevated and serum cold agglutination is positive. He had failed to improve with initial antibiotic therapy. HRCT of chest demonstrates areas of ground-glass opacity, air-space consolidation, centrilobular nodules and thickening of bronchovascular bundles. What is the most likely diagnosis?

A. Chlamydia pneumonia.

B. Mycoplasma pneumonia.

C. Pneumococcal pneumonia.

D. Legionella pneumonia.

E. Staphylococcal pneumonia.

Answer 40

46. B. Mycoplasma pneumonia.

The given clinical history is classical of mycoplasma pneumonia, which usually affects younger adults in closed populations such as prisons or the military. It is one of the most common causes of community acquired pneumonia in otherwise healthy individuals. Serum cold agglutination is positive in up to 70%. On HRCT areas of ground-glass attenuation tend to be around areas of consolidation. Centrilobular nodules and peribronchovascular thickening are common associated findings.

Question 41

(Ped) 46. A 6-year-old presents to A&E with a history of a productive cough associated with green sputum and mild wheeze. This child had a similar event 2 years earlier. Clinical examination reveals mild tachypnoea and coarse breath sounds. A CXR is requested. Your consultant points out the salient findings on the CXR as being the presence of hyperinfl ation, possible areas of air trapping, peribronchial wall oedema bilaterally, subsegmental atalectasis in the right midzone, and slight perihilar haziness. Your consultant asks you what you would do with this child given the findings. What do you say?

A. Send them home and reassure the parents.

B. Repeat CXR in 4 weeks to look for resolution.

C. Start antibiotics and reassess in 2 weeks.

D. Do expiratory films to rule out inhaled foreign body.

E. Respiratory consult and HRCT chest due to air-trapping.

Answer 41

46. A. Send them home and reassure the parents.

This radiograph has all the classic hallmarks of a viral pneumonia in a child. Air-trapping is common due to the small airways, which become occluded secondary to peribronchial wall oedema. There is no focal consolidation or pleural effusion seen, features that would indicate a bacterial pneumonia requiring antibiotics. In children it is not necessary to repeat imaging to ensure appearances resolve as long as the symptoms settle. Bilateral inhaled foreign bodies, causing the bilateral air-trapping, would be very unusual, especially in a well child. Respiratory consult would only be indicated if the symptoms failed to settle or there was a significant associated history, e.g. CF.

Question 42

47. A 51-year-old woman has a past history of a prolonged ICU admission following a subarachnoid haemorrhage 2 years previously. Despite the stormy course in ICU, she made a good neurological recovery, but has had persistent breathlessness on exertion since discharge. Her imaging shows interstitial fibrosis. Which part of the lung is likely to be relatively spared by the interstitial process?

A. Posterior aspect of the lungs.

B. Anterior aspect of the lungs.

C. Periphery of the lungs.

D. Lower zones of the lungs.

E. Mid-zones of the lungs.

Answer 42

7. A. Posterior aspect of the lungs.

The stem of the question is pointing towards ARDS during the ICU admission, resulting in pulmonary fibrosis. Classically HRCT shows relative sparing of the posterior aspect of the lungs.

This pattern of sparing is unusual in other causes of peripheral fibrosis and is an important clue to the aetiology. During the acute and subacute phases of ARDS in the supine patient, the dependent portions of the lungs usually demonstrate extensive consolidation and atelectasis. It is postulated that these areas may be protected from the longterm effects of barotrauma & high oxygen exposure as they are essentially non-aerated during acute & subacute phases.

Question 43

51. A 28-year-old woman presents with fever, myalgia and cough. Due to a current community outbreak, the clinical team suspect that she has H1N1 influenza (swine flu). Which finding on her admission CXR is most strongly predictive of an adverse outcome?

A. Upper lobe consolidation.

B. Bilateral central opacity.

C. Multizonal peripheral opacity.

D. Air bronchogram.

E. Pleural effusion.

Answer 43

51. C. Multizonal peripheral opacity.

The majority of H1N1 influenza cases have been mild, but the 2009 strain can cause severe illness, including in young previously healthy persons. Radiological findings in four or more lung zones distributed bilaterally and peripherally, are significantly more often seen on the CXR obtained at admission in patients with poor outcome (requiring mechanical ventilation) compared to those with good clinical outcome. Central GGO is the most common radiographic abnormality, but is not significantly associated with poor outcome. Pleural effusions are uncommon, although bilateral effusions are an independent predictor of short-term mortality in community acquired pneumonia. It should be noted that an initial normal CXR does predict against a poor outcome.

Question 44

66. A 50-year-old chronic alcoholic and smoker presents with chronic cough. CXR shows bilateral upper lobe consolidation with nodular opacities and cavitation. These changes are slowly progressive over serial x-rays. A bronchoscopy is arranged and washouts from the upper lobes are negative for mycobacterial infection. Aspergillus titres are positive. How is the disease process best described?

A. Allergic bronchopulmonary aspergillosis.

B. Bilateral aspergillomas with background COPD.

C. Semi-invasive aspergillosis.

D. Invasive aspergillosis.

E. Chronic aspiration pneumonia (aspergillus titres irrelevant).

Answer 44

66. C. Semi-invasive aspergillosis.

This is also known as chronic necrotising aspergillosis and typically runs a more indolent, but slowly progressive, course than angio-invasive aspergillosis and occurs in patients with mildly impaired immunity (e.g. chronic alcoholism). The radiographic findings consist of upper lobe consolidation, multiple nodules, and cavitatory disease. The gold standard for diagnosis of semi-invasive aspergillosis is the histological demonstration of tissue invasion by the fungus and growth of aspergillus on culture. However, in practice this is difficult to achieve and therefore the combination of the characteristic clinical and radiological features and either positive serological results for aspergillus or the isolation of aspergillus from respiratory samples is highly indicative of semi-invasive aspergillosis. Angio-invasive aspergillosis occurs in more severely immuno-compromised patients (e.g. AIDS patients). Rapidly progressive nodular opacities occur to form single or multiple homogeneous consolidations. The lesions show a characteristic halo sign on CT, reflecting an area of alveolar haemorrhage around a central nodule.

ABPA is a hypersensitivity reaction to aspergillus fumigatus that occurs in patients with asthma or cystic fibrosis. It is characterized by inspissated mucus plugs containing aspergillus organisms and eosinophils, resulting in chronic inflammation in the airway and bronchial ectasia. The most common CT finding is central bronchiectasis with upper lobe predominance and mucus impaction. Aspergilloma is a mycetoma (fungus ball), which typically occurs in ectatic airways or parenchymal cavities (e.g. old TB, chronic sarcoid). CT characteristically shows an intracavitatory mass with a surrounding air crescent, more commonly in the upper lobes.

Question 45

37 The chest radiograph of a severely dyspnoeic patient with AIDS showed bilateral diffuse interstitial and airspace infiltrates with a symmetrical perihilar distribution. What would you expect the CD4 count to be (in cells/ microlitre)?

a 1000

b 750

C 600

d 400

e 150

Answer 45

37 Answer E: 150

Question 46

38 A chest radiograph taken of an adult female with underlying chronic lung disease demonstrates hyperinflated lungs, patchy upper lobe consolidation and several 1- to 2-cm ring shadows in a predominantly upper lobe distribution. A recent full blood count showed an eosinophilia. What is the most likely diagnosis?

a Hypersensitivity pneumonia

b Eosinophilic pneumonia

C Allergic bronchopulmonary aspergillosis

d Tuberculosis

e Lipoid pneumonia

Answer 46

38 Answer C: Allergic bronchopulmonary aspergillosis

This is classically described in patients with long-standing asthma and is the commonest cause of a pulmonary eosinophilia in the UK. The pulmonary infiltrates are often migratory and other key features include a finger-in-glove appearance of mucus plugs within dilated second-order bronchi.

Question 47

40 A previously healthy adult male has been diagnosed with active pulmonary tuberculosis infection. What feature on imaging would suggest primary rather than reactivated pulmonary tuberculosis?

a Cavity formation

b Calcification

C Tuberculoma formation

d Non-specific pneumonitis

e Fibrosis and distortion of lung architecture

Answer 47

40 Answer D: Non-specific pneumonitis

The division between primary and secondary tuberculosis infection is not always clear-cut, as approximately 10% of primary infections progress uninterrupted into a more chronic progressive disease. It is generally accepted that the predominant radiological features of primary infections are adenopathy and foci of tuberculous pneumonitis (randomly distributed and ranging from small ill-defined airspace opacification to segmental and lobar consolidation).

Question 48

(Ped) 43 An 11-month-old girl recently recovers from a viral chest infection but now develops shortness of breath and wheezing. Her CXR shows peribronchial thickening, some hyperinflation, and small parenchymal opacities. What is the most likely diagnosis?

a Asthma

b Bronchitis

C Reactive airways disease

d Cystic fibrosis

e Bronchopulmonary dysplasia

Answer 48

43 Answer C: Reactive airways disease

Reactive airways disease (RAD) may be precipitated by respiratory syncytial virus (commonest cause of pneumonia in infants) and Aspergillus. Asthma is diagnosed on the basis of recurrent RAD and is not diagnosed within the first year. Apparent severity of RAD on CXR does not correlate with clinical severity.

Question 49

@#1 45 A patient who was known to have HIV presented with shortness of breath and underwent further investigations. Their CD4 count was 208 cells per cu mm. What AIDS-defining illness would be most likely with this CD4 count?

a Lymphoma

b Histoplasmosis

C Kaposi’s sarcoma

d Pneurnocystis carinii pneumonia

e Pulmonary CMV

Answer 49

45 Answer C: Kaposi’s sarcoma

Lymphoma, histoplasmosis, Pneurnocystis and CMV are all usually seen when the CD4 count is below 200.

Question 50

48 A 32-year-old male was found by the roadside in respiratory distress. There is very little clinical history, but his condition deteriorated in the Emergency Department and he was intubated, ventilated and transferred to ICU. His initial chest radiograph showed widespread alveolar infiltrates of a nonspecific nature. He had a CT of the chest with high-resolution sections. What additional finding would be most compatible with a diagnosis of adult respiratory distress syndrome?

a The presence of pneumatoceles

b Predominantly dependent abnormality

C Ground glass attenuation

d Pneumothorax

e Septal nodularity

Answer 50

48 Answer B: Predominantly dependent abnormality

Almost all patients with ARDS will have bilateral dependent abnormalities.

Ground-glass attenuation is seen but in less than 10%.

Pneumothorax and pneumatoceles are uncommon.

Question 51

33 A 29-year-old gentleman presented with recurrent right hypochondrial pain and jaundice. He had a peripheral eosinophilia and his chest radiograph showed a cystic structure that contained an air fluid level with a thin radiolucent crescent in the upper part of the lesion. His Casoni skin test was positive. What is the most likely diagnosis?

a Hamartoma

b Staphylococcus abscess

C Aspergillosis

d Hydatid

e Metastatic hepatocellular carcinoma

Answer 51

33 Answer D: Hydatid

Question 52

@#1 40 In a 74-year-old female with chronic obstructive pulmonary disease (COPD), which of the following descriptions on HRCT would increase the possibility of a Mycobacterium avium intracellulare (MAI) versus Mycobacterium tuberculosis?

a Pulmonary consolidation

b Irregular pleural thickening

C Diffuse bronchiectasis and centrilobular nodulation

d Lesions affecting predominantly the apical segments of the lower lobes

e Apical cavitation

Answer 52

40 Answer C: Diffuse bronchiectasis and centrilobular nodulation

In the majority of cases the two organisms produce virtually indistinguishable radiological features. The history of COPD in an elderly woman should raise the possibility of MAI, and in this subset of patients diffuse bronchiectasis and centrilobular nodules are suggestive of the diagnosis. In favour of tuberculosis is the greater incidence of interlobular septal thickening. Often failure of response to antituberculous therapy leads to the consideration of MAI.

Question 53

@#1 52 A 62-year-old patient with ongoing dyspnoea underwent CT of the chest. Among other findings it demonstrated two ill-defined foci of consolidation within the posterior and apical segments of the right upper lobe. In addition, within the remainder of the right lung, and to a lesser extent the left lung, there was a more diffuse abnormality characterised by small (<4 mm) centrilobular, well-defined nodules within 1 cm of the pleural surface. These nodules were connected by linear, branching opacities. What is the most likely cause for these findings?

a Obliterative bronchiolitis

b Primary pulmonary lymphoma

C Respiratory syncytial virus infection

d Reactivation tuberculosis

e Renal cell carcinoma metastases

Answer 53

52 Answer D: Reactivation tuberculosis

The description of interconnected subpleural nodules is that of `tree-in-bud’. This represents bronchiolar luminal impaction with mucus, pus or fluid. The causes are myriad (in fact all the options are potential causes). Infection is the commonest cause, and tuberculosis (via endobronchial spread) is the commonest infection accounting for this appearance.

Question 54

@#1 59 A 32-year-old flight attendant presented with shortness of breath, fever, cough and haemoptysis. There were bilateral crepitations on auscultation and several blue/red raised skin lesions were noted. His CD4 lymphocyte count is 120 (normal >500). HRCT of the chest demonstrated patches of numerous, ill-defined nodules in a perihilar distribution and septal thickening. There was moderate hilar lymphadenopathy but no pleural effusion. What is the most likely diagnosis?

a Streptococcus pneumonia

b Pneumocystis carinii pneumonia

C Kaposi’s sarcoma

d Mycobacterium avium-intracellulare infection

e AIDS-related lymphoma of B-cell origin

Answer 54

59 Answer C: Kaposi’s sarcoma

Kaposi’s sarcoma tends to affect patients whose CD4 count has fallen below 200. Pneurnocystis carinii pneumonia is the commonest cause of opportunistic pulmonary infection in HIV, but the presence of characteristic skin lesions confirms the diagnosis in this instance. Imaging features of Pneurnocystis carinii pneumonia include bilateral groundglass infiltrates, interstitial infiltrates and pneumatoceles. Adenopathy and effusions are rarely seen.

Question 55

60 A 40-year-old homeless man presented to the Emergency Department with dyspnoea, fever and cough. Crepitations and bronchial breathing were heard on auscultation. Blood analysis revealed a neutrophilia, macrocytic anaemia and high gamma-glutamyl transpeptidase and alkaline phosphatase. There was bilateral patchy airspace opacification on his chest radiograph and CT demonstrated moderate upper zone centrilobular emphysema with consolidation within the posterior segments of both upper lobes and middle and right lower lobes. What is the most likely diagnosis?

a Mycoplasma pneumonia

b Primary tuberculosis

C Aspiration pneumonia

d Streptococcal pneumonia

e Invasive aspergillosis

Answer 55

60 Answer C: Aspiration pneumonia

The blood tests point to chronic alcohol excess. Acute alcohol intoxication is a common cause of aspiration. The clue as to the diagnosis lies in the predominantly dependent distribution of changes and relative sparing of the left lung.

Question 56

33 A 29-year-old gentleman presented with recurrent pain and jaundice. He had a peripheral eosinophilia and his chest radiograph showed a cystic structure that contained an air-fluid level with a thin radiolucent crescent in the upper part of the lesion. His Casoni skin test was positive. Where is this lesion most likely to be located within the lungs?

a Left apex

b Right lower lobe

C Perihilar region

d Within a fissure

e Peribronchial

Answer 56

33 Answer B: Right lower lobe

In Hydatid disease the parasite reaches the thorax via haematological spread from the liver. Lung lesions are usually single and located in the lower lobes or posterior mediastinum. The cyst can communicate with the bronchial tree. Complications include rupture and infection. Surgery may be required for excision.

Question 57

9 A previously fit and well 56-year-old female presented with a two-day history of chest pain, pyrexia and productive cough. She had a neutrophilia and her PA and lateral chest radiographs demonstrated a 4-cm round mass in the left lower lobe. What is the most likely causative organism?

a Staphylococcus aureus

b Streptococcus pneumoniae

C Mycobacterium tuberculosis

d Streptococcus pyogenes

e Klebsiella

Answer 57

39 Answer B: Streptococcus pneurnoniae

Streptococcus pneurnoniae is the commonest cause of all community-acquired bacterial pneumonias, and also the commonest cause of a round pneumonia, which are more common in children.

Question 58

40 A 65-year-old male returned from travelling abroad in South America and presented with fever, cough and malaise. A chest radiograph demonstrated non-specific subsegmental infiltrates. The patient recovered with no medical intervention and a repeat chest radiograph obtained a year later as part of a visa application showed multiple punctate calcifications. What is the most likely diagnosis?

a Tuberculosis

b Histoplasmosis

C Coccidioidomycosis

d Blastomycosis

e Sarcoidosis

Answer 58

40 Answer B: Histoplasmosis

This is a typical history for histoplasmosis. It is usually symptomatic only in the very young and the older age group and more likely to be symptomatic in men. It is predominantly self-limiting and endemic to South America. The multiple punctate calcifications in the follow-up film with the history of self-limiting illness are also consistent with histoplasmosis, which is the commonest endemic mycosis. Tuberculosis is less likely to have the punctate calcifications a year later. Sarcoidosis usually presents in a younger age group.

Question 59

@#1 45 A 45-year-old man presented to the Emergency Department with severe dyspnoea, pleuritic chest pain, malaise and diarrhoea. Blood tests showed hyponatraemia and a chest radiograph showed a moderate-sized pleural effusion, unilateral pulmonary infiltrates and prominent lymphadenopathy. In view of a recent local outbreak of Legionnaires’ disease at a local conference centre this diagnosis was considered. What finding in the work-up would make a different diagnosis more likely?

a Prominent lymphadenopathy

b A moderate pleural effusion

C Unilateral pulmonary infiltrates

d Hyponatraemia

e Pleuritic chest pain

Answer 59

45 Answer A: Prominent lymphadenopathy

Lymphadenopathy is a rare finding.

Question 60

59 A 54-year-old man with a known history of HIV infection presented with a five-day history of severe dyspnoea and malaise but minimal cough. His CD4 count was 90. Bronchoalveolar lavage was performed and a sample showed Pneurnocystis carinii. What appearance would be likely on his chest radiograph?

a Unilateral upper zone confluent consolidation and effusion

b Bilateral lower zone consolidation with small effusions and hilar adenopathy

c Normal CXR

d Bilateral perihilar consolidation and ground-glass change

e Lower-zone bilateral thin-walled cysts

Answer 60

59 Answer D: Bilateral perihilar consolidation and ground-glass change

PCP can manifest in a number of ways. In 80% of cases there are diffuse, bilateral, symmetrical airspace infiltrates.

Cysts (often perihilar) and diffuse interstitial infiltration can also occur.

Often there is a combination of these forms.

In 10% of cases no abnormality is seen on CXR.

Pleural effusions and adenopathy have only rarely been described

Question 61

16. A 20-year-old woman was admitted with pleuritic chest pain, cough and high fever with a history of intravenous drug abuse. The chest radiograph shows bilateral, multiple lung cavities with both thin and thick walls. Moderate left pleural effusion seen.

What is the most likely diagnosis?

(a) Metastatic disease

(b) Septic pulmonary emboli

(c) Eosinophilic pneumonia

(d) Rheumatoid lung

(e) Bronchitis obliterans organising pneumonia

Answer 61

16. (b) Septic pulmonary emboli

Given the history of intravenous drug abuse, multiple lung cavities are likely to be secondary to septic pulmonary emboli. Eosinophilic pneumonia and bronchitis obliterans organising pneumonia are unlikely to cause cavitation.

Question 62

17. A 37-year-old homosexual man who recently tested positive for HIV presents with cough and shortness of breath. The chest radiograph shows bilateral, thin walled upper lobe cavities and perihilar parenchymal opacities. There is a small right pneumothorax.What is the most likely diagnosis?

(a) Wegener’s granulomatosis

(b) Pneumocystis jirovecii infection

(c) Metastases

(d) Bronchiectasis

(e) Bacterial pneumonia

Answer 62

17. (b) Pneumocystis jirovecii pneumonia

Pneumocystis jirovecii pneumonia (previously called Pneumocystis carinii pneumonia) is seen in HIV positive individuals. Pneumatocoeles are seen in 10% of cases and some may progress to develop a pneumothorax.

Question 63

21. A recently diagnosed HIV-positive man presents with fever and cough. The chest radiograph shows bilateral perihilar interstitial infiltrates and apical ground-glass shadowing. The most likely causative microorganism is?

What is the most likely diagnosis?

(a) Cryptococcus neoformans

(b) Mycobacterium tuberculosis

(c) Pneumocystis jirovecii

(d) Candida albicans

(e) Toxoplasmosis

Answer 63

21. (c) Pneumocystis jirovecii

This organism is the commonest cause of chest infection in patients with AIDS. It usually has an insidious onset with bilateral perihilar infiltrates. There may also be diffuse bilateral alveolar infiltrates and ground-glass shadowing. Patients on prophylactic aerosolized pentamidine may show an apical predominance.

Question 64

38. A 62-year-old man with history of stroke and swallowing difficulties presents with persistent cough. HRCT shows patchy areas of bilateral ‘tree-in-bud’ pattern in the lower lobes. What is the most likely diagnosis?

(a) Sarcoidosis

(b) Miliary tuberculosis

(c) Chronic aspiration

(d) Hypersensitivity pneumonitis

(e) Langerhans cell granulomatosis

Answer 64

38. (c) Chronic aspiration

Given the history of swallowing difficulties and stroke, the patient is likely to have aspiration pneumonitis presenting as a result of severe bronchiolar impaction with clubbing of the distal bronchioles.

Question 65

42. A 64-year-old man presents with a history of chronic cough and chest pain. The chest radiograph shows a 2 cm soft tissue lesion in the left upper zone with a crescent shaped gas collection around. CT shows a dependent 2 cm round mass in a cavity. What is the most likely diagnosis?

(a) Wegener’s granulomatosis

(b) Aspergilloma

(c) Lung abscess

(d) Rheumatoid nodule

(e) Metastasis

Answer 65

42. (b) Aspergilloma

CT halo sign is characteristic for aspergilloma where a dependent, rounded nodule is seen in a cavity or a cyst. Prone and supine CT demonstrates mobility of mycetoma in the cavity.

Question 66

@# 47. A 45-year-old woman had allogenic bone marrow transplant for treatment of leukaemia. Two weeks later she developed cough and shortness of breath. CT demonstrates bilateral ground-glass shadowing, thickened interstitial lines and bilateral pleural effusion. What is the most likely diagnosis?

(a) Bronchiolitis obliterans

(b) Drug toxicity

(c) Pulmonary oedema

(d) Diffuse alveolar haemorrhage

(e) Bronchiolitis obliterans organising pneumonia

Answer 66

47. (c) Pulmonary oedema

This is usually secondary to fluid overload and associated renal dysfunction.

Bronchiolitis obliterans and bronchiolitis obliterans organising pneumonia are late complications seen after 3 months.

Drug toxicity and alveolar haemorrhages may present with ground-glass shadowing but do not show pleural effusions or interstitial involvement.

Question 67

1. Which of the following are correct regarding Adult respiratory distress syndrome (ARDS):

(a) CXR is usually normal in the first 24 h.

(b) The lung is uniformly abnormal on CT.

(c) Has 50% mortality.

(d) The most common CT abnormality in survivors in a reticular pattern.

(e) Bronchial dilatation is seen frequently on CT.

Answer 67

Answers:

(a) Correct

(b) Not correct

(c) Correct

(d) Correct

(e) Correct

Explanation:

Lung involvement is heterogeneous with a gradient density. Dependent lung is more densely opacified than nondependent lung.

Question 68

7. Which of the following are correct regarding pulmonary disease in AIDS patients: (T/F)

(a) Lymphocytic interstitial pneumonia usually progresses to lymphoma in children.

(b) Bilateral perihilar infiltrates on CXR are diagnostic of Pneumocystis Carinii pneumonia.

(c) The presence of Cytomegalovirus in bronchoalveolar lavage fluid indicates active infection.

(d) Lymphadenopathy is seen in <5% of cases of Kaposi’s sarcoma.

(e) Thick-walled cavities are a common HRCT finding of invasive pulmonary aspergillosis.

Answer 68

Answers:

(a) Not correct.

(b) Not correct.

(c) Not correct.

(d) Not correct.

(e) Correct.

Explanation:

Bilateral perihilar infiltrates are a non-specific findings seen in other opportunistic infections as well like CMV and Kaposi’s sarcoma. On HRCT, PCP is most commonly seen as bilateral, symmetric, patchy or confluent ground glass opacity. Less common findings on CXR and HRCT include focal areas of consolidation, mass lesions, multiple lung nodules, pleural fluid, pneumothorax, cavitation, lymphadenopathy and occasional nodal calcification.

CMV is the most common viral pathogen to cause morbidity and mortality in patients with AIDS. The HRCT findings are heterogeneous and include bilateral ground glass opacities, multiple nodules or mass like areas of consolidations and patchy bilateral consolidation.

Pulmonary KS occurs in 18% to 50% of patients with known cutaneous KS and can affect the lung parenchyma, pleural or tracheobronchial tree. Bilateral perihilar pulmonary infiltrates is the most common finding. Other common findings include intralobular septal thickening, lymphadenopathy and pleural effusion.

Lymphocytic interstitial pneumonia is a lymphoproliferative disorder seen with increased frequency in mainly children affected by AIDS. It is mostly benign and regresses spontaneously or with treatment.