MD Pulmonary Disease Management 5 — Questions and Answers
Question 1: A 38-year-old presents with recurrent spontaneous pneumothorax. CT shows bilateral cystic lung disease. She has a history of renal angiomyolipomas. What is the most likely diagnosis?
- Langerhans cell histiocytosis
- Lymphangioleiomyomatosis (LAM) (Correct answer)
- Birt-Hogg-Dubé syndrome
- Lymphoid interstitial pneumonia
Correct answer: Lymphangioleiomyomatosis (LAM)
Lymphangioleiomyomatosis presents in women of childbearing age with bilateral thin-walled pulmonary cysts, spontaneous pneumothorax, and renal angiomyolipomas.
Question 2: A 55-year-old presents with progressive dyspnea and chest tightness. Spirometry shows FEV1 86% predicted, FVC 87% predicted, FEV1/FVC 0.79. Diffusing capacity (DLCO) is 48% predicted. What diagnosis is most consistent?
- Mild COPD
- Pulmonary vascular disease (Correct answer)
- Early restrictive lung disease
- Upper airway obstruction
Correct answer: Pulmonary vascular disease
Isolated severe reduction in DLCO with normal spirometry and FEV1/FVC ratio suggests pulmonary vascular disease (e.g., pulmonary hypertension or pulmonary emboli).
Question 3: Which antibiotic regimen is recommended for outpatient treatment of community-acquired pneumonia in a 45-year-old with no comorbidities and no recent antibiotic use?
- Amoxicillin-clavulanate plus azithromycin
- Amoxicillin monotherapy (Correct answer)
- Levofloxacin monotherapy
- Doxycycline monotherapy
Correct answer: Amoxicillin monotherapy
IDSA/ATS guidelines recommend amoxicillin as first-line monotherapy for outpatient CAP in otherwise healthy patients without comorbidities or risk factors for drug-resistant organisms.
Question 4: A patient with a large left-sided pleural effusion undergoes thoracentesis. After removal of 1.2 L, the patient develops acute chest tightness and CT shows ipsilateral pulmonary infiltrates. What is the most likely complication?
- Tension pneumothorax
- Re-expansion pulmonary edema (Correct answer)
- Hemothorax from intercostal vessel injury
- Paradoxical embolism
Correct answer: Re-expansion pulmonary edema
Re-expansion pulmonary edema is a rare but serious complication of rapid large-volume thoracentesis, caused by rapid re-expansion of the collapsed lung.
Question 5: A 48-year-old with rheumatoid arthritis develops a new pleural effusion. Pleural fluid analysis shows glucose of 18 mg/dL, pH 7.00, LDH 2,100 U/L, and protein 4.8 g/dL. What is the most likely etiology?
- Malignant effusion
- Parapneumonic empyema
- Rheumatoid pleuritis (Correct answer)
- Chylothorax
Correct answer: Rheumatoid pleuritis
Rheumatoid pleural effusions characteristically show very low glucose (<30 mg/dL), very low pH, and very high LDH due to immune complex deposition and impaired glucose transport.
Question 6: A 63-year-old male with a 40 pack-year history presents with hemoptysis, weight loss, and a right hilar mass. Biopsy shows small cell lung cancer. Staging workup reveals no distant metastases and disease confined to one hemithorax. What is the standard treatment?
- Surgery followed by adjuvant chemotherapy
- Concurrent cisplatin/etoposide chemotherapy with thoracic radiation (Correct answer)
- Immunotherapy with pembrolizumab
- Prophylactic cranial irradiation alone
Correct answer: Concurrent cisplatin/etoposide chemotherapy with thoracic radiation
Limited-stage SCLC is treated with concurrent platinum-based chemotherapy (cisplatin/etoposide) and thoracic radiation, followed by prophylactic cranial irradiation in responders.
Question 7: A 52-year-old presents with dyspnea and oxygen saturation of 88% at rest. ABG shows pH 7.32, PaCO2 58 mmHg, PaO2 52 mmHg, HCO3 28 mEq/L. Chest X-ray shows hyperinflation. What is the most appropriate initial ventilatory support?
- High-flow nasal cannula oxygen
- Noninvasive positive pressure ventilation (NPPV/BiPAP) (Correct answer)
- Immediate intubation and invasive mechanical ventilation
- Simple face mask at 40% FiO2
Correct answer: Noninvasive positive pressure ventilation (NPPV/BiPAP)
Noninvasive positive pressure ventilation is the preferred initial ventilatory support for acute hypercapnic respiratory failure in COPD exacerbation, reducing intubation rates and mortality.
MD Pulmonary Disease Management 5
A 38-year-old presents with recurrent spontaneous pneumothorax.
CT shows bilateral cystic lung disease.
She has a history of renal angiomyolipomas.
What is the most likely diagnosis?