Lung Pathology

Question 1

An 18 year old male suffered a stab wound over the sixth intercostal space right anterior axillary line during a “gang-war” in his baranggay. He was brought to the ER wherein 5cc of bloody fluid was aspirated in his right chest. Patient appears pale with signs of difficulty in breathing. Which of the following types of atelectasis is he most likely to have?

A. Contraction
B. Compression
C. Resorption
D. Patchy

Answer 1

ANSWER: B. Compression

Compression atelectasis happens when something in the pleural cavity (air, fluid, or solid mass) occupies the pleural cavity and compresses the lung tissue; thus, causing displacement of lung tissue.

Mediastinum will shift AWAY from the affected lung.

REVERSIBLE.

Question 2

A patient underwent a major surgery under general anesthesia. What type of atelectasis is the patient likely to develop?

A. Contraction
B. Compression
C. Resorption
D. Patchy

Answer 2

ANSWER: RESORPTION ATELECTASIS (aka Obstructive atelectasis) due to the rentention of some secretions in the small airway. After the operation, patients are encouraged to have deep breathing exercises in order to prevent infection after surgery.

• Resorption atelectasis results from complete obstruction of an airway.
• Air is resorbed (absorbed/removed) from the dependent alveoli; which collapses. There is diminished lung volume due to the collapse.
• Mediastinum will shift TOWARDS the atelectatic lung
• Examples: aspirating foreign body, presence of thick mucus secretions not expelled, presence of mass

Question 3

A 50-year old male, smoker, presented with cough, copious sputum, and progressive dyspnea on exertion for the last two years. On physical examination, he has wheezes all over his lung fields, and cyanotic lips. Morphologic findings of the lungs in this condition will most likely show a/an:

A. Abnormally large alveoli separated by thin septa and deformed respiratory bronchioles
B. Enlargement of the mucus-secreting glands of the bronchi and hyperemia and edema of the mucus membranes.
C. Dilatation of bronchi and bronchioles caused by destruction of the muscle and elastic tissue.
D. Thickening of the basement membrane, edema and inflammatory infiltrate in the bronchial walls.

Answer 3

ANSWER: B.

Rationale:
-smoker, cough (most striking clinical manifestation), copious sputum, progressive dyspnea on exertion for the last 2 years (chronic), wheezes
Diagnosis: Chronic Bronchitis

Question 4

Abnormally large alveoli separated by thin septa and deformed respiratory bronchioles. There is dyspnea. Mostly caused by smoking.

A. Emphysema
B. Bronchitis
C. Bronchiectasis
D. Asthma

Answer 4

Answer: A. Emphysema

Emphysema is defined as permanent, abnormal enlargement of airspaces distal to the terminal bronchiole. It is accompanied by destruction of their walls without obvious fibrosis.

The most common form is centriacinar which is caused by smoking.

Question 5

It is the dilation of bronchi and bronchioles caused by destruction of the muscle and elastic tissue. Start of pathogenesis is bronchial obstruction.

A. Emphysema
B. Bronchitis
C. Bronchiectasis
D. Asthma

Answer 5

ANSWER: C. Bronchiectasis

Bronchiectasis is the permanent dilatation of bronchi and bronchioles often associated with necrotizing inflammation. Its main contributing factor is chronic persistent necrotizing infection plus obstruction.

Question 6

It is the thickening of the basement membrane, edema and inflammatory infiltrate in the bronchial walls. There is bronchospasm which leads to wheezing.

A. Emphysema
B. Bronchitis
C. Bronchiectasis
D. Asthma

Answer 6

ANSWER: D. Asthma

It is similar to chronic bronchitis but it is differentiated with the following:

• Wheezing is the hallmark of asthma.
• strong family history
• onset is during childhood (oftentimes)
• strong allergic role
• atopic or non atopic
• chronic small airway obstruction and infection

Microscopic features

1. Mucus hypersecretion with plugging
2. Lymphocytes/eosinophils
3. Lumen narrowing
4. Smooth muscle hypertrophy

Question 7

A 55 year old man was suffering from recurrent attacks of persistent cough. He was rushed to the ER due to severe difficulty of breathing. PE revealed wheezes over lung fields. Mucous plugs were collected and histologically examined revealing collections of crystalloid made up of eosinophil membrane protein. These are:

A. Charcot-Leyden Crystals
B. Reinke crystals
C. Curschmann spirals
D. Psammoma bodies

Answer 7

ANSWER: A. Charcot-Leyden Crystals

These are crystals formed due to the action of an enzyme released by the eosinophils in asthma.

Question 8

A 40 year old female has multiple history of severe necrotizing pneumonia since childhood caused by Staphylococcus aureus and Pseudomonas sp. Currently, she has productive cough with purulent sputum. Chest Xray reveals areas of consolidation in the right lower lobe. There is also marked dilatation of the right lower lobe bronchi. Which of the following mechanism is the likely cause of her disease?

A. Damage to the mucosa by eosinophils
B. Recurrent inflammation with bronchial wall destruction
C. Diffuse infiltration by a mass along the right lower lobe bronchi
D. Defect resulting from CFTR mutation

Answer 8

ANSWER: B

Pertinent data:

• multiple bouts of severe necrotizing pneumonia since childhood
• productive cough with purulent sputum
• areas of consolidation in the right lower lobe
• marked dilatation of the right lower lobe bronchi

Diagnosis: bronchiectasis

Question 9

A senior citizen who previously worked as a construction worker had dyspnea that has worsened over the past year. Rales were observed in both lungs during PE. Chest xray revealed bilateral diaphragmatic pleural plaques with focal calcification as well as diffuse interstitial lung disease. A sputum cytology showed macrophages engulfed with golden, beaded rod-shaped fiber. These findings are most likely to suggest prior exposure to which of the following environmental agents?

A. Asbestos
B. Silica
C. Organic dust
D. Carbon

Answer 9

ANSWER: A. Asbestos

• retired construction worker
• increasing dyspnea for the past year
• rales on both lungs
• bilateral diaphragmatic pleural plaques with focal calcification as well as diffuse interstitial lung disease
• asbestos bodies = macrophages engulfed with golden-beaded, rod-shaped fiber

Question 10

An 18-year old female diagnosed with cystic fibrosis has recurrent episodes of productive cough described as greenish and foul smelling. The doctor advised her to seek prompt treatment as to prevent what possible condition?

A. Bronchial asthma
B. Bronchiectasis
C. Interstitial lung disease
D. Emphysema

Answer 10

Answer: B. Bronchiectasis

Question 11

A 60-year old man has a 50 pack year history of smoking. For the past 5 years, he had cough of copious mucoid sputum. Which of the following condition most likely explains the clinical course?

A. Bronchiectasis
B. Bronchial Asthma
C. Chronic Bronchitis
D. Emphysema

Answer 11

Answer: C. Chronic Bronchitis

Question 12

A 13 year old is planning to go to US. She has to bring her medications to prevent wheezing. She has a history of bronchial asthma. Which of the following is true about her condition?

A. The inflammatory response is IgE mediated in a genetically predisposed individual.
B. Eosinophils play a key role in the inflammatory response
C. Repeated bouts of exposure to the allergen will result to structural changes in the bronchial airway known as airway remodelling
D. All of the above

Answer 12

Answer: D. All of the above

Question 13

A newly hired 16-year old boy is assigned to work in the farm with pigeons. He developed signs and symptoms associated with:

A. Hypersensitivity pneumonitis
B. Pulmonary tuberculosis
C. Bronchial asthma
D. Centriacinar emphysema

Answer 13

Answer: A. Hypersensitivity pneumonitis

Question 14

A 45-year old female, non-smoker, increasing shortness of breath. Chest radiograph of hilar lymph adenopathies and reticulonodular pattern of small densities. If this is a case of sarcoidosis, the other features to search for are?

A. Schaumann bodies
B. Asteroid bodies
C. Caseation necrosis
D. All of the above 
E. Only A and B are correct

Answer 14

ANSWER: E. Only A and B are correct. Sarcoidosis produces a noncaseating granuloma.

Question 15

A thromboembolus is noted in the pulmonary artery. What is the most probable clinical event that would have taken place?

A. Acute cor pulmonale
B. Dilation of the right ventricle
C. A precipitous pulmonary hypertension
D. Both A and B

Answer 15

Answer: D.

Question 16

A large, 4cm, interstitil septal defect can give rise to?

A. Interstitial fibrosis
B. Granulomatous inflammation
C. Pulmonary hypertension
D. Pulmonary infarction

Answer 16

Answer: C. Pulmonary hypertension

Question 17

The following are clinical manifestation of pulmonary disease except:

A. Dyspnea
B. Hemoptysis
C. Chest pain
D. Clubbing
E. None of the above

Answer 17

E. None of the above

Question 18

It is the underdevelopment of one or both sides of the lung tissue. It is usually observed among premature babies (before 28 weeks).

A. Foregut cyst
B. Pulmonary hypoplasia
C. Pulmonary sequestration
D. Pulmonary atresia

Answer 18

Answer: B. Pulmonary hypoplasia

Question 19

The following are clinical manifestations observed among babies with pulmonary hypoplasia except:

A. Alkalosis
B. Hypercapnia
C. Cyanosis
D. Early respiratory distress
E. None of the above

Answer 19

Answer: A. Alkalosis. They experience acidosis.

Question 20

Foregut cyst arises form an abnormal budding of the primitive foregut. Where is it commonly located?

A. Upper lobes of the lung
B. Base of the lung
C. Anterior mediastinum
D. Hilum

Answer 20

Answer: D. Hilum or middle mediastinum

Question 21

This is the most common classification of a foregut cyst.

A. Enteric
B. Esophageal
C. Bronchogenic

Answer 21

C. Bronchogenic cyst. The cyst mimics the wall of the structure. Thus, the lining is ciliated pseudostratified columnar epithelium.

Question 22

The following is true about pulmonary sequestration.

A. There are lobes or segments without normal connection to the airway system.
B. The anomalies come into attention when the child develops some disorder like recurrent pulmonary infection.
C. There are 2 forms: extralobar and intralobar.
D. All of the above.

Answer 22

Answer: D.

Question 23

Neonatal atelectasis is the collapse of a neonatal lung. True or False.

Answer 23

False. Neonatal atelectasis is the incomplete expansion of the lungs

Question 24

Contraction atelectasis is reversible. True or False.

Answer 24

False. It is irreversible.

Contraction atelectasis occurs when there is local or generalized fibrotic changes in the lung or pleura to prevent its full expansion.

Question 25

Acute pulmonary injury can be caused by the following except:

A. Acute interstitial pneumonia
B. Diffuse alveolar damage
C. Cor Pulmonare
D. Pulmonary edema

Answer 25

Answer: C. Cor Pulmonare

Question 26

Pulmonary edema caused by indirect injury to the alveolar wall.

A. Bacterial pneumonia
B. Inhaled gases
C. Burns
D. Radiation

Answer 26

C. Burns

Question 27

High altitude can cause pulmonary edema. True or false.

Answer 27

True

Question 28

Increased hydrostatic pressure can lead to left sided heart failure which causes pulmonary edema. True or false.

Answer 28

True.

Question 29

A 3-year-old girl presents to the emer- gency department with fever, hoarseness,
a “seal bark-like” cough, and inspiratory stridor. Her father states that she has had a cold for the past few days, with runny nose, nasal congestion, sore throat, and cough. He is now concerned because her cough has become loud, harsh, and brassy. Which of the following is the most likely cause of her ailment?

(a) Fungus
(B) Gram-negative bacteria 
(c) Gram-positive bacteria 
(D) Parasite
(e) Virus

Answer 29

the answer is e. This is a classic case of acute laryngotracheobronchitis (croup), an acute inflammation of the larynx, trachea, and epiglottis. The most common cause of croup is a viral (parainfluenza virus type I) infection.

Question 30

60-year-old man, a heavy smoker, pres- ents for advice to stop smoking. On physi- cal examination, he is thin and has a ruddy complexion. He has a productive cough
and a barrel-shaped chest. He sits leaning forward with his lips pursed to facilitate his breathing. A diagnosis of emphysema is made. Which of the following is the most likely histologic finding in the lungs?
(a) Bronchial smooth muscle hypertrophy with proliferation of eosinophils
(B) Diffuse alveolar damage with leakage of protein-rich fluid into alveolar spaces
(c) Dilation of air spaces with destruction of alveolar walls
(D) Hyperplasia of bronchial mucus-secret- ing submucosal glands
(e) Permanent bronchial dilation caused by chronic infection, with bronchi filled with mucus and neutrophils

Answer 30

the answer is c. Emphysema is an example of COPD. Due to the destruction of alveolar walls, a lack of elastic recoil causes air to become trapped in alveoli, and, thus, airflow obstruction occurs on expiration. In COPD, FEV1 is decreased, whereas FVC is normal or increased; therefore, patients with COPD have a decreased FEV1:FVC ratio.

Question 31

60-year-old woman with a heavy smok- ing history presents with chronic productive
cough that has been present for three con- secutive months over the past two consecu- tive years. On physical examination, her skin has a bluish tinge, and she is overweight. The patient is diagnosed with chronic bronchitis. Which of the following is the most likely his- tologic finding in this patient’s lungs?
(a) Bronchial smooth muscle hypertrophy with proliferation of eosinophils
(B) Diffuse alveolar damage with leakage of protein-rich fluid into alveolar spaces
(c) Dilation of air spaces with destruction of alveolar walls
(D) Hyperplasia of bronchial mucus- secreting submucosal glands
(e) Permanent bronchial dilation caused by chronic infection, with bronchi filled with mucus and neutrophils

Answer 31

the answer is D. Chronic bronchitis is an example of COPD. The pathologic hallmark of chronic bronchitis is marked hyperplasia of bronchial submucosal glands and bronchial smooth muscle hypertrophy, which can be quantified by the Reid index, a ratio of glandu- lar layer thickness to bronchial wall thickness.

Question 32

65-year-old woman with a significant smoking history presents with cough and shortness of breath. Computed tomography of the chest reveals a central mass near the left mainstem bronchus. Biopsy of the mass is performed. Histologic examination reveals small round blue cells, and a diagnosis of small cell carcinoma is made. Which of the following is a frequent characteristic of this form of lung cancer?
(a) Generally amenable to surgical cure at time of diagnosis
(B) More common in women, and a less clear relation to smoking than other forms of lung cancer
(c) Secretes a parathyroid-like hormone (D) Secretes either corticotrophin or antidi-
uretic hormone
(e) Usually in a peripheral rather than in a
central location

Answer 32

the answer is D. Small cell carcinoma of the lung is the most aggressive type of broncho- genic carcinoma. The location of this cancer is usually central. This is an undifferentiated tumor with small round blue cells and is least likely to be cured by surgery because it is usually already metastatic at diagnosis. Associated paraneoplastic syndromes include secretion of adrenocorticotropic hormone and antidiuretic hormone.

Question 33

An 80-year-old woman, a retirement home resident, has multiple bouts of pneu- monia caused by Streptococcus pneumoniae. In an attempt to prevent such infections, polyvalent vaccines directed at multiple serotypes of the organism have been admin- istered but have not elicited long-acting immunity. Which of the following is the probable explanation for this phenomenon?
(a) Memory T lymphocytes respond poorly to polysaccharide antigens.
(B) S. pneumoniae evades host immune response by forming capsular coatings composed of host proteins and recog- nized as “self” antigens.
(c) The bacterial capsule binds C3b, facilitating activation of the alternative complement pathway, inducing com- plement-mediated lysis, and preventing immunization.
(D) The capsular polysaccharides of S. pneu- moniae have limited hapten potential.
(e) The surface carbohydrate capsule on the surface of the organism acts as an opso- nin, facilitating phagocytosis by neutro- phils, thus preventing immunization.

Answer 33

the answer is a. Antibody responses to the more than 80 differing carbohydrate capsular antigens of the various strains of S. pneumoniae are generally T-cell–independent, and antibody formation is entirely B-cell–mediated. Because of this, memory cells are not formed, and long-lasting immunity is not achieved.

Question 34

A 50-year-old man dies of a respiratory illness that had been characterized by dys- pnea, cough, and wheezing expiration of many years’ duration. Initially episodic, his “attacks” had increased in frequency and at the time of death had become continuous and intractable. At autopsy, which of the fol- lowing is the most likely histologic finding in the lungs?
(a) Bronchial smooth muscle hypertrophy with proliferation of eosinophils
(B) Diffuse alveolar damage with leakage of protein-rich fluid into alveolar spaces
(c) Dilation of air spaces with destruction of alveolar walls
(D) Hyperplasia of bronchial mucus- secreting submucosal glands
(e) Permanent bronchial dilation caused by chronic infection, with bronchi filled with mucus and neutrophils

Answer 34

the answer is a. Bronchial asthma, or hyperreactive airway disease, is a type of COPD caused by narrowing of airways. Asthma manifests morphologically by bronchial smooth muscle hypertrophy, hyperplasia of bronchial submucosal glands and goblet cells, and airways plugged by mucus-containing Curschmann spirals (whorl-like accumulations of epithelial cells), eosinophils, and Charcot-Leyden crystals (crystalloids of eosinophil-derived proteins).

Question 35

25-year-old man presents with a pro- gressive illness of several days’ duration characterized by nonproductive cough, fever, and malaise. A lateral view chest radiograph reveals platelike atelectasis. Elevated titers of cold agglutinins are detected. Which of the following is the most likely type of pneumonia in this patient?
(a) Bacterial pneumonia, most likely caused by S. pneumoniae
(B) Hospital-acquired pneumonia, most likely caused by P. aeruginosa
(c) Interstitial pneumonia, most likely caused by M. pneumoniae
(D) P. jiroveci (carinii) pneumonia, most likely related to an immunocompro- mised state
(e) Viral pneumonia, most likely caused by influenza virus

Answer 35

the answer is c. Interstitial (primary atypical) pneumonia is most commonly caused
by M. pneumoniae or viruses. Interstitial pneumonia is characterized by diffuse, patchy inflammation localized to the interstitial areas of alveolar walls, with no exudate in alveolar spaces, and intra-alveolar hyaline membranes. M. pneumoniae infection is associated with the presence of cold agglutinins, which are IgM antibodies that react nonspecifically with all human red blood cells. P. jiroveci (carinii) pneumonia is the most common opportunistic infection in patients with acquired immunodeficiency syndrome or other immunodeficiency disorders. Viral pneumonias are the most common type of pneumonia in childhood, caused most commonly by the influenza virus.

Question 36

60-year-old man presents with fever and chills, productive cough with rusty spu- tum, pleuritic pain, and shortness of breath for the past several days. A complete blood count reveals neutrophilia and an increase in band neutrophils. A chest radiograph reveals consolidation involving the entire left lower lobe. Which of the following microor- ganisms is the most likely etiologic agent?
(a) Hemophilus influenzae
(B) Klebsiella pneumoniae
(c) Staphylococcus aureus
(D) Streptococcus pneumoniae (e) Streptococcus pyogenes

Answer 36

the answer is D. The most common cause of lobar pneumonia is S. pneumoniae. The organism is also known as the pneumococcus, and the disease entity is often referred to as pneumococcal pneumonia.

Question 37

A 46-year-old woman presents with fever, hemoptysis, weight loss, and night sweats. She has never smoked. She recently returned from a month-long trip to Asia. A chest radiograph reveals apical lesions with cavitation in the left lung. A purified protein derivative (PPD) test is placed, and 48 hours later an 18-mm wheal develops. Sputum cul- tures reveal numerous acid-fast organisms. This patient is put on contact precautions, and a regimen for tuberculosis is started. Which of the following disorders does this patient most likely have?
(a) Acquired immunodeficiency syndrome (B) Congenital immunodeficiency
(c) Miliary tuberculosis, with seeding of
distal organs with innumerable small millet seed-like lesions
(D) Primary tuberculosis, characterized by the Ghon complex
(e) Secondary tuberculosis, resulting from activation of a prior Ghon complex, with spread to a new pulmonary site

Answer 37

the answer is e. Tuberculosis, at one time a frequent hazard in the United States, is now relatively uncommon except in immunocompromised individuals and persons returning from parts of the world where the disease remains a common problem. Primary tubercu- losis is the initial infection by M. tuberculosis, and is restricted to the primary, or Ghon, complex, a combination of a peripheral subpleural parenchymal lesion and involved hilar lymph nodes. Cavitation and selective localization to the pulmonary apices are charac- teristics of secondary tuberculosis. Secondary tuberculosis may spread through the lym- phatics and blood to other organs, resulting in miliary tuberculosis.

Question 38

A 25-year-old African-American woman presents with fatigue, dyspnea, nonpro- ductive cough, and chest pain. She does not smoke. A chest radiograph reveals prominent bilateral hilar lymphadenopa- thy (“potato nodules”) and diffuse reticular densities in the interstitium of the lung. Laboratory studies reveal polyclonal hyper- gammaglobulinemia, hypercalcemia, and increased serum angiotensin-converting enzyme. Which of the following is the most likely diagnosis?
(a) Acute respiratory distress syndrome (B) Adenocarcinoma of the lung
(c) Eosinophilic granuloma
(D) Idiopathic pulmonary fibrosis
(e) Sarcoidosis

Answer 38

the answer is e. Sarcoidosis most often presents as a restrictive pulmonary disease that
is characterized morphologically by noncaseating granulomas and can involve any organ system. Diagnostic features of note include highest incidence in persons of African lin- eage, somewhat higher incidence in women, bilateral interstitial pulmonary involvement, prominent hilar lymphadenopathy, polyclonal hypergammaglobulinemia, and hypercal- cemia. Increased serum angiotensin-converting enzyme activity is a nonspecific indicator of granulomatous inflammation.

Question 39

A 60-year-old man presents with dys- pnea on exertion and a nonproductive cough. He has never smoked, but he worked as a shipbuilder, with known asbestos expo- sure approximately 20 years ago. To which of the following conditions is this patient especially predisposed?
(a) Acute respiratory distress syndrome (B) Goodpasture syndrome
(c) Idiopathic pulmonary fibrosis
(D) Idiopathic pulmonary hemosiderosis (e) Malignant mesothelioma of the pleura

Answer 39

the answer is e. Asbestosis is caused by inhalation of asbestos fibers, characterized by yellow-brown, rod-shaped ferruginous bodies with clubbed ends that stain positively with Prussian blue. Asbestosis results in a marked predisposition to malignant mesothelioma of the pleura or peritoneum. Exposure to asbestos is also a risk factor for primary lung carci- noma, as well as for carcinoma of the oropharynx, esophagus, and colon. The risk of pri- mary lung carcinoma is greatly increased in cigarette smokers with exposure to asbestos.

Question 40

A female infant is born prematurely
at 28 weeks’ gestation. Shortly after birth, she shows signs of dyspnea, cyanosis, and tachypnea. She is placed on a ventilator for assisted breathing, and a diagnosis of neonatal respiratory distress syndrome (hyaline membrane disease) is made. Which of the following is the cause of this syndrome?
(a) Bronchopulmonary dysplasia
(B) Intraventricular brain hemorrhage (c) Lack of fetal pulmonary maturity and
deficiency of surfactant (D) Necrotizing enterocolitis (e) Patent ductus arteriosus

Answer 40

the answer is c. Neonatal respiratory distress syndrome (hyaline membrane disease) is the most common cause of respiratory failure in newborns and results from a deficiency of surfactant and immature development of the lungs. Surfactant reduces surface ten- sion within the lung, facilitating expansion by inspiration and thus preventing atelecta- sis during expiration. The classically referenced indicator of fetal pulmonary maturity
is a lecithin:sphingomyelin ratio of approximately 2:1 in the amniotic fluid, although techniques like lamellar body counts and the fluorescence polarization assay are now more commonly used to evaluate fetal lung maturity. Predisposing factors include prema- turity, maternal diabetes mellitus, and birth by cesarean section. Known complications of this condition include bronchopulmonary dysplasia, patent ductus arteriosus, intraven- tricular brain hemorrhage, and necrotizing enterocolitis.

Question 41

A 50-year-old woman has been immobilized in bed for several days after a motor vehicle accident. She had been improving, but this morning she suffered the sudden onset of pleuritic chest pain, hemoptysis, tachypnea, tachycardia, and dyspnea. What is the likely basis of this set of findings?
(a) Arterial thrombus originating in pulmo- nary blood vessels
(B) Arterial thrombus originating in the lower extremities with migration to pulmonary veins
(c) Deep venous thrombus of the lower extremities with embolization to branches of the pulmonary artery
(D) Mural thrombus originating in the left heart with migration to pulmonary blood vessels
(e) Venous thrombus originating in pulmo- nary blood vessels

Answer 41

the answer is c. Pulmonary embolism most often originates from venous thrombosis in the lower extremities or pelvis. An embolus migrates through the venous circulation to the right heart and gets trapped in branches of the pulmonary artery. Pulmonary embolism occurs in clinical settings of venous stasis, such as primary venous disease, congestive heart failure, prolonged bed rest or immobilization, or prolonged sitting while traveling.

Question 42

The chest radiograph of a 23-year-old medical student reveals a calcified cavitary pulmonary lesion. The tuberculin test is positive, but sputum smears and cultures are negative for Mycobacterium tuberculosis. A presumptive diagnosis of secondary tuber- culosis is made. If further studies, including a biopsy, were performed, which of the fol- lowing findings would justify the diagnosis of secondary tuberculosis, as contrasted to primary tuberculosis?
(a) Calcification
(B) Caseating granulomas
(c) Cavitation
(D) Langhans giant cells
(e) Positive tuberculin test result

Answer 42

the answer is c. Cavitation occurs only in secondary tuberculosis. Both primary and secondary tuberculosis are characterized by caseating granulomas, often with Langhans giant cells, which heal by scarring and calcification. The skin test result for tuberculin sensitivity is positive in both forms.

Question 43

A 50-year-old female presents with restrictive lung disease. She describes an aggressive clinical course with rapidly pro- gressive shortness of breath over the last year. A lung biopsy reveals a patchy process characterized by temporally heterogeneous areas of fibrosis. Which of the following is most likely of her expected clinical course?
(a) Symptoms should abate with smoking cessation and steroid treatment
(B) Prognosis is relatively good with the majority of patients surviving at 10 years
(c) Excellent prognosis following removal of environmental stimulus
(D) Poor prognosis with development of honeycomb lung and death within
5 years
(e) Symptoms should improve with antibi- otic therapy

Answer 43

the answer is D. This patient has UIp, which carries a dismal prognosis characterized by refractoriness to steroids and development of honeycomb lung resulting in death, often within 5 years of diagnosis. The key histologic feature is temporal heterogeneity in the fibrotic changes, whereas LIP shows chronologically uniform, diffuse fibrosis. In contrast to DIP, UIP is not related to smoking. It is not attributed to any environmental stimulus or pathogen.

Question 44

A 45-year-old woman with no smok- ing history presents with new onset of cough, shortness of breath, and weight loss. Imaging reveals a peripherally located lung mass with no evidence of primary tumor elsewhere in the body. On light microscopy, the tumor is comprised of poorly formed glands. Which of the following is most likely to be true of this tumor?
(a) Positive for synaptophysin immunos- taining
(B) Associated squamous dysplasia at the periphery of the tumor
(c) Most likely already metastatic, therefore surgery is not recommended
(D) Driven by tobacco-associated carcino- gens
(e) Positive for mutation in EGFR

Answer 44

the answer is e. This woman has an adenocarcinoma. These are the most likely lung cancers to arise in never-smokers and are more common in women. They have been associated with EGFR mutations, and EGFR mutation testing is rapidly becoming the standard-of-care for lung adenocarcinomas in order to direct chemotherapy (EGFR- mutated cases may respond to targeted tyrosine kinase inhibitors). Adenocarcinomas may be preceded by or associated with atypical adenomatous hyperplasia, not squamous dysplasia. Unlike small cell carcinomas, they do not show neuroendocrine features such as synaptophysin staining and metastasis at the time of presentation is not the rule.