Patología Pulmonar

Question 1

An 8-year-old boy at birth appeared to be a normal term baby, but his neontal course was complicated by the development of meconium ileus. His sweat chloride and immunoreactive trypsinogen are both found to be elevated. Throughout childhood he has experienced multiple increasingly severe bouts of pneumonia with a productive cough, often with Pseudomonas aeruginosa, and later Burkholderia cepacea, cultured from sputum. He is at greatest risk for development of which of the following pulmonary abnormalities?

Answer 1

Bronchiectasis

Question 2

A 70-year-old woman at an extended care facility for the past two years has increasing inability to perform activities of daily living. She can no longer recognize family members. She is lethargic and spends most of her days in a wheelchair or in bed. She develops an acute febrile illness and is noted to be coughing up increasing quantities of yellowish sputum. Her temperature is 38°C. A chest x-ray shows infiltrates involving the left lower lobe. A sputum sample shows numerous neutrophils and gram-positive diplococci. Which of the following infectious agents is most likely to cause her pulmonary disease?

Answer 2

Streptococcus pneumoniae

Question 3

An 11-year-old girl has experienced dyspnea for the past 2 weeks. Her temperature is 37.3°C, pulse 85/minute, respiratory rate 30/minute, and blood pressure 110/60 mm Hg. On physical examination, her lung fields are clear to auscultation. Her heart rate is regular and no murmurs or gallops are heard. A chest radiograph shows prominent hilar lymphadenopathy along with a 1 cm peripheral right middle lobe nodule. No infiltrates are present. A sputum gram stain shows normal flora and routine bacterial culture reveals no pathogens. Which of the following conditions is she most likely to have?

Answer 3

Mycobacterium tuberculosisinfection

Question 4

On the 11th postoperative day following a radical prostatectomy for adenocarcinoma, a 70-year-old man is recovering uneventfully. He then ambulates to the bathroom, but upon returning to his bed he suddenly becomes extremely dyspneic and diaphoretic, with chest pain, palpitations, and a feeling of panic. Which of the following post-operative pulmonary complications has he most likely developed?

Answer 4

Thromboembolus

Question 5

50-year-old woman has lived in Stockholm, Sweden all her life and worked as a seamstress. She is a non-smoker, but she has had increasing shortness of breath, fever, weight loss, and night sweats for the past 4 months. On physical examination her temperature is 37.6°C. There are fine rales auscultated in all lung fields. A chest radiograph reveals hilar lymphadenopathy and a reticulonodular pattern of small densities in all lung fields. She demonstrates anergy by skin testing to mumps andCandidaantigens. A transbronchial biopsy is performed that microscopically shows numerous small pulmonary interstitial non-caseating granulomas. Which of the following is the most likely diagnosis?

Answer 5

Sarcoidosis

Question 6

A 43-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum production. On physical examination there is bilateral hyperresonance to percussion in all lung fields. A chest x-ray reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally. The right heart border is prominent. A chest CT scan demonstrates decreased attenuation in all lung fields, particularly lower lobes. Which of the following laboratory findings is she most likely to have?

Answer 6

Decreased serum alpha-1-antitrypsin

Question 7

A 55-year-old man with a 50 pack year history of smoking cigarettes has recently experienced an episode of hemoptysis along with his usual cough. On physical examination he has no abnormal findings. A sputum for cytology on microscopic examination shows atypical cells with hyperchromatic nuclei and orange-pink cytoplasm. Labortory studies show a serum calcium of 11.3 mg/dL, with phosphorus 2.1 mg/dL. Which of the following chest radiographic findings is this man most likely to have?

Answer 7

Large hilar mass

Question 8

During a cardiac arrest, a 58-year-old man, a non-smoker, receives cardiopulmonary resuscitative measures and is brought to the hospital, where he is intubated. During the intubation procedure he suffers aspiration of gastric contents. Over the next 10 days he develops a non-productive cough along with a fever to 37.9°C. A chest radiograph reveals a 4 cm diameter mass with an air-fluid level in the right lung. A sputum gram stain reveals mixed flora. Which of the following conditions is he most likely to have?

Answer 8

Lung abscess

Question 9

A 66-year-old woman has had a worsening non-productive cough with malaise for the past week. Her temperature increases to 37.4°C. A chest radiograph reveals diffuse bilateral pulmonary interstitial infiltrates in all lung fields. A sputum gram stain reveals normal flora and few neutrophils. She recovers over the next two weeks without sequelae. Infection with which of the following organisms most likely caused her illness?

Answer 9

Influenza A virus

Question 10

A 58-year-old man has developed a non-productive cough worsening over the past 2 months. Last week he noted the appearance of blood-streaked sputum. On physical examination there are some expiratory wheezes auscultated over the left lung. A chest radiograph reveals a 5 cm mass near the left lung hilum. A sputum cytology reveals the presence of small clusters of very hyperchromatic, pleomorphic cells with scant cytoplasm. Which of the following is the most likely predisposing factor to development of his pulmonary disease?

Answer 10

Smoking

Question 11

A 41-year-old man with a 6 kg weight loss over the past 3 months now has had worsening fever, non-productive cough, and dyspnea for the past 3 days. His temperature is 38.2°C and there are diffuse rales in both lungs on auscultation. A chest radiograph shows patchy infiltrates in both lungs. Laboratory studies show WBC count 3250/microliter with 81 segs, 3 bands, 5 lymphs, and 11 monos. His CD4 lymphocyte count is 79/microliter. Cryptosporidium parvum organisms are found in a stool specimen. A bronchoalveolar lavage is performed, yielding fluid that microscopically demonstrates pink, foamy exudate with little inflammation. Which of the following additional findings on microscopic examination is he most likely to have in the BAL specimen?

Answer 11

Multiple cysts with GMS stain

Question 12

A 64-year-old man has a 90 pack year history of smoking. For the past 5 years, he has had a cough productive of copious amounts of mucoid sputum for over 3 months at a time. He has had episodes of pneumonia with Streptococcus pneumoniae and Klebsiella pneumoniae cultured. His last episode of pneumonia is complicated by septicemia and brain abscess and he dies. At autopsy, his bronchi microscopically demonstrate mucus gland hypertrophy. Which of the following conditions is most likely to explain his clinical course?

Answer 12

Bronchial asthma

Question 13

A 66-year-old man has had increasing dyspnea for the past year. He is retired from the construction business. There are some rales auscultated in both lungs on physical examination. A chest radiograph reveals bilateral diaphragmatic pleural plaques with focal calcification as well as diffuse interstitial lung disease. A sputum cytology shows no atypical cells, only ferruginous bodies. Pulmonary function studies reveal a low FVC and a normal FEV1/FVC ratio. These findings are most likely to suggest prior exposure to which of the following environmental agents?

Answer 13

Asbestos crystals

Question 14

A 58-year-old man has been a smoker for 40 years. He has worsening orthopnea over the past year. On examination he has a body mass index of 35 kg/m2. He is afebrile. His blood pressure is 165/110 mm Hg. Auscultation of his chest reveals rales in lower lung fields bilaterally. A chest x-ray shows bilateral lower lobe infiltrates and a prominent left heart border. Laboratory studies show his Hgb A1C is 10%. Which of the following pulmonary problems is he most likely to have?

Answer 14

Edema

Question 15

A 47-year-old man has lost 6 kg in 5 months. He has had a cough with hemoptysis along with pleuritic chest pain for the past 2 weeks. On physical examination his temperature is 37.5°C. A chest x-ray reveals a bilateral and predominantly upper lobe reticulonodular pattern of infiltrates with cavitation. A sputum sample is obtained and on light microscopic examination shows epithelioid cells with necrotic debris. Laboratory studies show a WBC count of 5890/microliter with 78% granulocytes, 15% lymphocytes, and 7% monocytes. Which of the following additional histologic findings is most likely to be present in his sputum?

Answer 15

Acid fast bacilli

Question 16

A 20-year-old man falls to the ground while jogging. He suffers a minor abrasion to his left hand. However, within minutes he becomes dyspneic with right-sided chest pain. Bystanders call an ambulance. On arrival at the hospital, he has tachypnea and tachycardia. On physical examination breath sounds are absent over the right lung fields. A chest radiograph shows that the mediastinum is shifted to the left, and there are no fractures. A thoracentesis on the right yields a rush of air. Which of the following conditions is he most likely to have?

Answer 16

Distal acinar emphysema

Question 17

Following a vehicular accident with blood loss leading to prolonged, severe hypotension, a 30-year-old man is intubated and placed on a mechanical ventilator. He has progressively decreasing oxygen saturations despite increasing PEEP and FIO2 content of 100%. He remains afebrile. He dies 3 days later. At autopsy, the distal lungs show pink hyaline membranes, thickened interstitium, and many macrophages but few neutrophils. Which of the following pulmonary diseases most likely complicated his course?

Answer 17

Diffuse alveolar damage

Question 18

A 51-year-old man complains of a slight cough he has had for a week. He is a non-smoker. On auscultation of the chest his lung fields are clear. A chest radiograph shows a subpleural ‘coin lesion’ 2 cm in diameter in the right upper lobe. Which of the following is the most likely diagnosis for this lesion?

Answer 18

Granuloma

Question 19

61-year-old man has had a cough without production of much sputum for the past week. On physical examination he is afebrile. There are decreased breath sounds at the right lung base. A chest x-ray reveals an area of consolidation in the right lower lobe. He is given antibiotic therapy, but a month later the radiographic picture has not changed, and his cough continues. A bronchoalveolar lavage is performed and yields atypical cells along with scattered alveolar macrophages. Which of the following is the most likely diagnosis?

Answer 19

Adenoccarcinoma-in-situ

Question 20

A 25-year-old man receives a hematopoietic stem cell transplant for treatment of acute myelogenous leukemia. He develops increasing dyspnea 3 weeks later, along with fever and cough. On physical examination his temperature is 37.8°C. A chest radiograph shows irregular interstitial infiltrates. A bronchoalveolar lavage is performed an on cytologic examination shows cells that are enlarged and have prominent intranuclear inclusions. He is most likely to have an infection with which of the following organisms?

Answer 20

Cytomegalovirus

Question 21

54-year-old woman has had fever and dyspnea for a month along with a 2 kg weight loss. On physical examination her temperature is 37.7°C. A chest radiograph shows a reticulonodular pattern along with prominent hilar lymphadenopathy. A transbronchial lung biopsy is performed, and microscopic examination shows no viral inclusions, no fungi, no acid fast bacilli, and no atypical cells. Which of the following diseases is she most likely to have?

Answer 21

Sarcoidosis

Question 22

A 59-year-old man has been a cigarette smoker for the past 42 years. He has noted some blood-streaked sputum on coughing during the past week. He also has back pain. A chest radiograph shows a small 3 cm right hilar mass with several 1 to 2 cm peripheral lung nodules. A bone scan reveals multiple areas of increased uptake in the vertebrae, ribs, and pelvis. A sputum cytology reveals the presence of clusters of small cells having hyperchromatic nuclei and almost no cytoplasm. Which of the following laboratory test findings is he most likely to have as a consequence of his lung disease?

Answer 22

Serum sodium of 113 mmol/L

Question 23

A 40-year-old woman has had a high fever for a week, accompanied by a cough productive of yellowish sputum. On physical examination her temperature is 38.2°C. There are diffuse rales in all lung fields. Her chest radiograph reveals patchy infiltrates in all lung fields, and there is a 4 cm rounded area of consolidation in the left upper lobe that has an air-fluid level. Examination of her sputum reveals numerous neutrophils. Which of the following infectious agents is most likely causing her pulmonary disease?

Answer 23

Staphylococcus aureus

Question 24

At autopsy, a 60-year-old man is found to have a peripheral 7 cm area of golden-yellow consolidation on sectioning of the left lung, distal to a 3 cm hilar mass. Microscopically, this golden-yellow area has alveoli filled with foamy macrophages. Which of the following conditions involving his lung is most likely to be responsible for these findings?

Answer 24

Squamous cell carcinoma

Question 25

Question 25
A 12-year-old girl has the acute onset of dyspnea and wheezing. She coughs up a large, thick mucus plug. She has experienced similar previous episodes for the past 4 years, all of which lasted 1 to 4 hours. On physical examination her vital signs include T 37.1°C, P 120/minute, RR 40/minute, and BP 90/60 mm Hg. There are decreased breath sounds in all lung fields. A chest radiograph reveals hyperinflation but no infiltrates. Laboratory studies show WBC count of 8300/microliter with differential count of 60 segs, 3 bands, 16 lymphs, 10 monos, and 11 eosinophils. A sputum sample examined microscopically has increased numbers of eosinophils. Which of the following is the most likely diagnosis?

Answer 25

Bronchial asthma

Question 26

A 41-year-old previously healthy woman, a non-smoker, has had episodes of fever, non-productive cough, and dyspnea over the past 3 months. Her symptoms disappeared after a month’s vacation, but reappeared when she returned home to take care of her canaries. On physical examination there are no abnormal findings. A chest radiograph shows fine diffuse and nodular infiltrates in all lung fields. Her disease is most likely to be produced via which of the following inflammatory mechanisms?

Answer 26

Antigen-antibody complex formation

Question 27

A 63-year-old woman has had increasing dyspnea for 5 years. On physical examination her lungs are hyper-resonant without dullness. Tactile vocal fremitus is slightly decreased over all lung fields. Scattered expiratory wheezes and inspiratory rhonchi are present without basal crackles. She has a chest radiograph that reveals increased lung volumes and flattening of the diaphragmatic leaves. Spirometry demonstrates an FEV1 that is decreased more than the FVC so that the FEV1/FVC ratio is less than 70% of normal. Which of the following inhaled substances, which increases the elaboration of neutrophil elastase, is most likely to cause her pulmonary disease?

Answer 27

Nicotine

Question 28

A 29-year-old woman develops a high fever with dyspnea, non-productive cough, headaches, and loss of smell over the past 2 days. On exam her temperature is 39°C. Her peripheral blood oxygen saturation is 80%. Her BMI is 30 kg/m2. A chest radiograph shows extensive interstitial infiltrates and ground glass opacifications. A single-stranded RNA virus is recovered from respiratory tract secretions. She recovers, but 3 months later continues to have myalgias, along with dyspnea, headaches, fatigue, joint pains, and memory loss, She is most likely infected with which of the following viruses?

Answer 28

Coronavirus

Question 29

A 44-year-old woman, a non-smoker, has had a fever and cough for the past 4 days. She does not have hemoptysis. She has not experienced weight loss, malaise, nausea, or vomiting. On physical examination her temperature is 37.6°C. There are decreased breath sounds over the right upper lung. A chest radiograph reveals a 6 cm area of infiltrates in the right upper lobe. She is given a course of antibiotic therapy, but her cough persists. A month later her chest x-ray now reveals a 3 cm peripheral mass in the right upper lobe. Which of the following neoplasms is most likely to be present in this woman?

Answer 29

Adenocarcinoma

Question 30

A 70-year-old woman has been bedridden for 5 weeks following a cerebrovascular accident (CVA). She has the sudden onset of dyspnea, but has no further symptoms until two days later when she experiences left sided pleuritic chest pain. A radiologic imaging study show a wedge-shaped area consistent with hemorrhage based on the pleura of the left lower lobe. Which of the following pathologic findings in her pulmonary arterial branches is she most likely to have?

Answer 30

Thromboembolism

Question 31

A 38-year-old previously healthy woman has had a worsening non-productive cough for the past 4 days. On physical examination her temperature is 38.3°C. A chest radiograph shows patchy infiltrates and diffuse interstitial markings. Laboratory studies show a sputum gram stain with mixed flora. Her Hgb is 12.9 g/dL, platelet count 229,450/microliter, and WBC count 5815/microliter. Her cold agglutinin titer is elevated. Following a course of erythromycin therapy, she improves, with no complications. Which of the following infectious agents is the most likely cause for her pulmonary disease?

Answer 31

Mycoplasma pneumoniae

Question 32

A 23-year-old primigravida is found on prenatal testing to have an elevated hemoglobin A1C level. Her pregnancy is uncomplicated until the 33rd week of gestation, when she has the onset of premature labor and delivers a male infant 24 hours later. The infant initially has Apgar scores of 4 and 6 at 1 and 5 minutes, but within an hour is in severe respiratory distress and requires intubation with mechanical ventilation. Which of the following pharmacologic therapies administered to the mother prior to birth could have helped to prevent this infant’s neonatal respiratory distress?

Answer 32

Hydrocortisone

Question 33

For the past 5 months, a 51-year-old woman has noted increased swelling of her lower legs as the day progresses. She has no fever and no cough. On physical examination, she has pitting edema to the knees. A chest radiograph reveals bilateral pleural effusions, and the right heart border is prominent. Laboratory studies show a serum AST of 238 U/L, ALT 263 U/L, LDH 710 U/L, and CK 127 U/L. Which of the following underlying diseases is most likely to cause these findings?

Answer 33

Recurrent thromboembolism

Question 34

A 51-year-old man received an orthotopic cardiac transplant a month ago. He has developed a fever with cough over the past 5 days. On physical examination his temperature is 37.5°C. A chest CT scan shows consolidation with abscess formation involving the left lower lobe. A sputum gram stain reveals normal upper respiratory tract flora. He does not respond to antibiotic therapy over the next 6 months. His mental status deteriorates and MR imaging of the brain shows multiple abscesses. He is most likely to have an infection with which of the following organisms?

Answer 34

Nocardia brazilie

Question 35

A previously healthy 5-year-old girl develops a fever along with dyspnea. On physical examination her temperature is 37.9°C. Her lung fields are clear to auscultation but there are expiratory wheezes. A chest x-ray reveals clear lung fields. Laboratory studies show Hgb 13.6 g/dL, platelet count 183,600/microliter, and WBC count 14,480/microliter. Her dyspnea suddenly worsens, and emergent bronchoscopy reveals bronchi plugged by exudates. These findings are most consistent with infection by which of the following organisms?

Answer 35

Haemophilus influenzae

Question 36

Astudy is performed reviewing medical records of adults presenting with sudden onset of severe dyspnea. They were afebrile, with absent breath sounds over an entire lung, and chest x-ray showing pulmonary atelectasis of an entire lung. Which of the following conditions is most likely to produce these findings?

Answer 36

Penetrating chest trauma

Question 37

A newborn male infant develops increasing respiratory distress within an hour following an uncomplicated vaginal delivery at 36 weeks gestation. A plain film radiograph reveals near opacification of both lungs. Despite intubation and positive pressure ventilation, the baby dies within two days. At autopsy, the infant’s lungs demonstrate extensive pink hyaline membranes. Which of the following maternal conditions is most likely to increase the risk for this infant’s respiratory distress?

Answer 37

Gestational diabetes

Question 38

Following an acute pharyngitis lasting 4 days, a 10-year-old boy develops neck pain and marked halitosis. On physical examination is breath is very malodorous. A CT scan shows an abscess in the peritonsillar region. Laboratory studies include a culture of the abscess which grows anaerobic flora. Which of the following aerobic organisms is most likely to be cultured from his abscess?

Answer 38

Group A Streptococcus

Question 39

A 65-year-old man has had no major medical problems prior to the past year, when he noted increasing malaise along with an 8 kg weight loss. He is a non-smoker. He currently does not have fever, cough, dyspnea, or any respiratory difficulties. On physical examination, he has non-tender supraclavicular lymphadenopathy. The lungs are clear to auscultation. A chest x-ray shows multiple solid nodules ranging from 1 to 3 cm scattered throughout all lung fields. No infiltrates or areas of consolidation are noted. Laboratory studies show Hgb 11.6 g/dL, Hct 34.7%, MCV 83 fL, and WBC count 6280/microliter. Which of the following pathologic processes in his lungs is most likely to account for these findings

Answer 39

Metastatic carcinoma

Question 40

A 43-year-old woman who does not smoke becomes increasingly dyspneic over 8 years’ time. She does not have a cough or increased sputum production. She is afebrile. On physical examination she has decreased breath sounds with hyperresonance in all lung fields. A chest radiograph reveals increased lucency of all lung fields. Laboratory studies show her serum alpha-1-antitrypsin level is 18 mg/dL. Which of the following microscopic portions of the lung is most likely to be affected by her condition?

Answer 40

Alveolar duct

Question 41

A 30-year-old woman is in the 28th week of an uncomplicated pregnancy when she experiences the sudden onset of severe abdominal pain, followed by vaginal bleeding, then the onset of labor. A girl infant is delivered on the way to the hospital. On arrival within an hour, the baby is in respiratory distress and requires intubation and mechanical ventilation. A day later, a chest radiograph shows opacification of both lungs. The baby’s respiratory status does not improve. Which of the following histopathologic findings is most likely to be present in this baby’s lungs?

Answer 41

Minimal alveolar saccular development
Diffuse alveolar hemorrhage

Question 42

A 41-year-old woman has a 1 year history of episodic dyspnea. On physical examination there are expiratory wheezes. Her chest radiograph shows a few small 0.5 cm perihilar nodules involving bronchi, with bronchiectasis. Laboratory studies show an elevated serum IgE along with peripheral blood eosinophilia. A sputum sample shows eosinophils. Serum galactomannan is detected. Which of the following pathologic findings is most likely present in her bronchi?

Answer 42

Non-invasive aspergillosis

Question 43

A male infant has initial Apgar scores of 5 and 6 at 1 and 5 minutes following birth by normal vaginal delivery at 30 weeks gestation. However, increasing respiratory distress in the next hour requires intubation and positive pressure ventilation. Two months later, the infant is finally taken off the ventilator, but still does not oxygenate normally. Which of the following diseases has this infant most likely developed?

Answer 43

Bronchopulmonary dysplasia

Question 44

A 6-year-old child has the sudden onset of dyspnea with wheezing. On physical examination he is afebrile but has absent breath sounds on the right. His temperature is 37°C, pulse 110/minute, respiratory rate 42/minute, and blood pressure 100/60 mm Hg. An arterial blood gas measurement shows pO2 95 mm Hg, pCO2 25 mm Hg, and pH 7.55. Following administration of 100% FiO2 by nasal canula, a repeat measurement shows pO2 95 mm Hg, pCO2 25 mm Hg, and pH 7.55. Which of the following is the most likely diagnosis?

Answer 44

Foreign body aspiration

Question 45

A 60-year-old woman develops multiple organ failure 3 weeks following a pneumonia complicated by septicemia. Antibiotic therapy has resulted in sputum and blood cultures that are now without growth of organisms. Nevertheless, she requires intubation with mechanical ventilation, but it becomes progressively more difficult to maintain her oxygen saturations. Ventilatory pressures must be increased. A portable chest radiograph shows increasing opacification of all lung fields. Which of the following pathologic processes is most likely now to be present in her lungs?

Answer 45

Diffuse alveolar damage