Pleural Diseases — MCQs
In primary tuberculosis, what is seen?
What is the emergent management of tension pneumothorax?
A patient presented with complaints of dyspnoea. The shown X-ray is suggestive of:
All the following in the Light's criteria are suggestive of exudative pleural effusion except.
A person had an accident and came to casualty with contusion on left precordium. There was decrease in breath sounds on left side, trachea deviated to right side and normal heart sounds. Which of the following is the first line of management?
Which of the following is more prone to produce mesothelioma?
What is a likely diagnosis for a patient with persistent fever after treatment for pneumonia?
A case of spontaneous pneumothorax comes to you what will be earliest t/t of choice :
Which of the following is not typically associated with allergic pulmonary aspergillosis?
True regarding the presentation of primary tuberculosis is
Pleural Diseases Indian Medical PG Practice Questions and MCQs
Question 1: In primary tuberculosis, what is seen?
- A. Ghon's focus (Correct Answer)
- B. Pleural effusion
- C. Miliary mottling
- D. Fibrosis
Explanation: ***Ghon's focus*** - A **Ghon's focus** is the primary parenchymal lesion that develops at the site of initial infection in **primary tuberculosis**. - It consists of a small area of caseous necrosis in the lung parenchyma, typically in the **mid or lower zones**. - Combined with hilar lymph node involvement, it forms the **Ghon complex (primary complex)**, which is the pathological hallmark of primary TB. - This represents the **characteristic pathological finding** that defines primary tuberculosis [2]. *Pleural effusion* - **Pleural effusion** is actually a **common manifestation of primary tuberculosis**, particularly in adolescents and adults [3]. - It develops due to a hypersensitivity reaction to tubercular antigens in the pleural space. - While frequently seen in primary TB, it is a **clinical manifestation** rather than the defining pathological lesion (Ghon's focus). - Can occur in both primary and post-primary TB [3]. *Miliary mottling* - **Miliary mottling** on chest X-ray is characteristic of **miliary tuberculosis**, a severe form where the infection disseminates hematogenously [1]. - This represents a **complication of primary TB** due to lymphohematogenous spread, not the typical presentation [1]. - Shows multiple small nodules (1-3mm) scattered throughout both lung fields. *Fibrosis* - **Fibrosis** refers to scarring of lung tissue that occurs during the **healing phase** of tuberculosis. - It is a **sequela of TB infection**, not an acute finding in primary tuberculosis. - Develops after the active infection has been controlled or treated [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 320-321. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, pp. 379-380. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 728-729.
Question 2: What is the emergent management of tension pneumothorax?
- A. Chest X-ray
- B. Emergency room thoracotomy in unstable patients
- C. Tube thoracostomy in 5th intercostal space
- D. Insert needle in 2nd intercostal space (Correct Answer)
Explanation: ***Insert needle in 2nd intercostal space*** - The **emergent management** for a **tension pneumothorax** is immediate **needle decompression** to relieve the trapped air and restore hemodynamic stability. The 2nd intercostal space in the midclavicular line is the primary site due to easy access and anatomical safety. - This procedure converts a tension pneumothorax into a simple pneumothorax, allowing the heart and great vessels to return to their normal position. *Chest X-ray* - A **chest X-ray** is a diagnostic tool but should **not delay emergent intervention** in a patient with a suspected tension pneumothorax, as the diagnosis is clinical. - Delaying treatment to obtain imaging can lead to **cardiorespiratory collapse** and death due to rapid deterioration. *Emergency room thoracotomy in unstable patients* - **Emergency room thoracotomy** is a procedure typically reserved for patients with **penetrating trauma** in extremis, particularly those with cardiac arrest, to directly address life-threatening intrathoracic injuries. - It is **not the primary emergent management** for tension pneumothorax, which is relieved by needle decompression. *Tube thoracostomy in 5th intercostal space* - A **tube thoracostomy** (chest tube insertion) is the definitive treatment for a pneumothorax, but it is typically performed **after needle decompression** has stabilized the patient in a tension pneumothorax. - While the 5th intercostal space at the mid-axillary line is a common site for chest tube insertion, needle decompression in the 2nd intercostal space is the **immediate life-saving step**.
Question 3: A patient presented with complaints of dyspnoea. The shown X-ray is suggestive of:
- A. Pleural effusion (Correct Answer)
- B. Pneumothorax
- C. Hydropneumothorax
- D. Consolidation
Explanation: ***Pleural effusion*** - The X-ray shows a significant **right-sided pleural effusion** with blunting of the costophrenic angle and a meniscus sign characteristic of fluid accumulation in the pleural space. - Key radiological features include: **homogeneous opacity** in the lower zone, **obliteration of the costophrenic angle**, and the typical **concave upper border (meniscus sign)** of fluid layering. - The presence of dyspnea with these radiological findings is consistent with pleural effusion. **Note:** While the X-ray confirms pleural effusion, **differentiating between exudative and transudative effusion requires pleural fluid analysis** (Light's criteria), not imaging alone. *Pneumothorax* - A pneumothorax would appear as a **dark, air-filled space** with a visible **visceral pleural line** where the lung has collapsed away from the chest wall. - The image clearly shows **fluid opacity** (white/grey) in the right hemithorax, not air (black). *Hydropneumothorax* - This condition involves both **fluid and air** in the pleural space, typically presenting with a **straight horizontal air-fluid level** on an erect chest X-ray. - The X-ray here shows a **curved meniscus** rather than a straight air-fluid level, indicating pure fluid without air. *Consolidation* - Consolidation (as seen in pneumonia) appears as a **homogenous opacity within the lung parenchyma**, often with **air bronchograms**. - The image shows fluid in the **pleural space** (outside the lung), **displacing the lung medially**, rather than an opacity within the lung tissue itself.
Question 4: All the following in the Light's criteria are suggestive of exudative pleural effusion except.
- A. Pleural fluid LDH : serum LDH ratio > 0.6
- B. Pleural fluid ADA < 16 (Correct Answer)
- C. Pleural fluid protein : serum protein ratio > 0.5
- D. Pleural fluid LDH > two-thirds of the upper limit of serum LDH
Explanation: ***Pleural fluid ADA < 16*** - **Adenosine deaminase (ADA)** levels are used to diagnose **tuberculous pleural effusions**, with high levels (>40 U/L) suggesting exudate. [1] - A pleural fluid ADA of < 16 U/L is indicative of a **transudative effusion**, as it rules out tuberculosis. [1] *Pleural fluid LDH : serum LDH ratio > 0.6* - This criterion, where the ratio of **pleural fluid LDH** to **serum LDH** is greater than 0.6, is one of the classic **Light's criteria** for identifying an exudative effusion. [1] - An exudate typically has higher protein and enzyme content due to increased capillary permeability or local production. [1] *Pleural fluid protein : serum protein ratio > 0.5* - This indicates that the **protein concentration** in the pleural fluid is significantly higher than in the serum. [1] - This ratio is a key component of **Light's criteria** and suggests an inflammatory or exudative process. [1] *Pleural fluid LDH > two-thirds of the upper limit of serum LDH* - This is another major criterion in **Light's criteria** for defining an exudative pleural effusion. [1] - An elevated **pleural fluid LDH** suggests increased cellular activity or cell breakdown within the pleural space, characteristic of an exudate. [1]
Question 5: A person had an accident and came to casualty with contusion on left precordium. There was decrease in breath sounds on left side, trachea deviated to right side and normal heart sounds. Which of the following is the first line of management?
- A. Needle thoracocentesis (Correct Answer)
- B. Chest tube thoracostomy
- C. Pericardiocentesis
- D. Open surgery
Explanation: ***Needle thoracocentesis*** - The constellation of **decreased breath sounds** on the left, **tracheal deviation** to the right, and a history of trauma indicates a **tension pneumothorax**. - **Needle decompression** (thoracocentesis) is the immediate, life-saving intervention for tension pneumothorax to relieve pressure and restore cardiorespiratory function. *Chest tube thoracostomy* - While a **chest tube** (tube thoracostomy) is the definitive treatment for pneumothorax, it is not the *first-line* **emergency management** for a **tension pneumothorax** where immediate decompression is critical. - The delay in setting up and inserting a chest tube can be fatal in a **tension pneumothorax**. *Pericardiocentesis* - **Pericardiocentesis** is indicated for **cardiac tamponade**, which would typically present with muffled heart sounds, hypotension, and distended neck veins, none of which are noted here. - The presence of **tracheal deviation** and **decreased breath sounds** specifically points away from isolated cardiac tamponade. *Open surgery* - **Open surgery (thoracotomy)** is a major surgical procedure reserved for cases like massive hemorrhage or major airway injury, and not the initial rapid management for a tension pneumothorax. - Performing open surgery directly for a tension pneumothorax would be too slow and inappropriate as an initial intervention.
Question 6: Which of the following is more prone to produce mesothelioma?
- A. Crocidolite (Correct Answer)
- B. Anthophyllite
- C. Chrysotile
- D. Amosite (Brown asbestos)
Explanation: ***Crocidolite*** - Crocidolite, or **blue asbestos**, is the most hazardous type of asbestos linked to **mesothelioma** [1][2]. - Its **fibrous nature** and high durability result in significant inhalation exposure, increasing cancer risk. *Chrysolite* - Also known as **white asbestos**; is the least carcinogenic and less associated with mesothelioma compared to other asbestos types. - Primarily used in **ceiling tiles** and insulation, exposure levels are typically lower. *Anthophyllite* - Rarely used commercially and associated with a **lower incidence** of cancer compared to crocidolite or amosite. - Its exposure is more commonly linked to **contaminated talc**, not significant for mesothelioma. *Amosite* - Known as **brown asbestos**; while associated with lung cancer, it is less frequently linked to mesothelioma than crocidolite. - It poses risks primarily through prolonged exposure in industrial settings, but is not the most potent carcinogen for mesothelioma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 697-698. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 339-340.
Question 7: What is a likely diagnosis for a patient with persistent fever after treatment for pneumonia?
- A. Fungal pneumonia
- B. Bronchogenic carcinoma
- C. Lung abscess
- D. Empyema (pleural effusion with infection) (Correct Answer)
Explanation: ***Empyema (pleural effusion with infection)*** - **Empyema** is a collection of pus in the pleural space, often a complication of pneumonia, and can cause **persistent fever** despite appropriate antibiotic treatment for the initial pneumonia [1]. - The continued presence of infection in the pleural space, which is not directly targeted by standard pneumonia treatment, can lead to prolonged inflammatory symptoms [1]. *Fungal pneumonia* - While fungal pneumonia can cause persistent fever, it typically does not develop *after* treatment for bacterial pneumonia unless the patient is immunocompromised or has specific environmental exposures . - It would usually be considered if initial bacterial treatment failed or if there were specific risk factors for fungal infection. *Bronchogenic carcinoma* - This is a long-term, chronic condition that can cause fever, but it is unlikely to present as a *persistent fever immediately after treatment* for an acute pneumonia episode. - Fever associated with malignancy often has a different pattern and is usually accompanied by other systemic symptoms like weight loss. *Lung abscess* - A **lung abscess** is a pus-filled cavity within the lung parenchyma, which can cause persistent fever. - However, fever from a lung abscess often responds partially to antibiotics, and the diagnosis is usually made earlier during the initial pneumonia course or when treatment fails to resolve the infiltrates.
Question 8: A case of spontaneous pneumothorax comes to you what will be earliest t/t of choice :
- A. ICD
- B. Wait and watch
- C. IPPV
- D. Needle aspiration (Correct Answer)
Explanation: ***Needle aspiration*** - For a **spontaneous pneumothorax**, especially a first-time episode and if the patient is stable, **needle aspiration** is often the earliest and least invasive treatment choice. - It involves inserting a small-bore needle to remove air from the pleural space, allowing the lung to re-expand and alleviating symptoms. *ICD* - An **intercostal drain (ICD)** insertion is typically reserved for larger pneumothoraces, symptomatic cases, or when needle aspiration has failed. - It is a more invasive procedure compared to needle aspiration and carries a higher risk of complications. *Wait and watch* - A "wait and watch" approach is only appropriate for very small, asymptomatic pneumothoraces (usually less than 1-2 cm) in a stable patient. - Given the general presentation of "spontaneous pneumothorax," it suggests a need for intervention beyond just observation [1]. *IPPV* - **Intermittent positive pressure ventilation (IPPV)** is a form of mechanical ventilation rarely used as the initial treatment for a spontaneous pneumothorax. - It is typically reserved for patients with severe respiratory compromise or those undergoing surgery, and positive pressure can worsen a pneumothorax if not managed carefully.
Question 9: Which of the following is not typically associated with allergic pulmonary aspergillosis?
- A. High IgE level
- B. Recurrent pneumonia (Correct Answer)
- C. Occurrence in patients with old cavitary lesions
- D. Pleural effusion
Explanation: ***Recurrent pneumonia*** - Allergic bronchopulmonary aspergillosis (ABPA) is characterized by a hypersensitivity reaction to *Aspergillus* antigens, leading to **bronchospasm** and **bronchiectasis**, not typically recurrent bacterial pneumonia. - While ABPA can cause **pulmonary infiltrates** that may be mistaken for pneumonia, these are eosinophilic and do not usually respond to antibiotics. *High IgE level* - **Elevated total serum IgE** is a hallmark diagnostic criterion for ABPA, reflecting the intense allergic response to *Aspergillus* antigens. - Specific **IgE and IgG antibodies to *Aspergillus*** are also typically present. *Occurrence in patients with old cavitary lesions* - This description is more characteristic of an **aspergilloma**, a fungal ball that forms in pre-existing lung cavities, often from tuberculosis or sarcoidosis. - ABPA is primarily a disease of **asthmatics** and **cystic fibrosis** patients, characterized by central bronchiectasis and mucous plugging. *Pleural effusion* - **Pleural effusions** are a rare manifestation in ABPA, which primarily affects the airways and lung parenchyma. - While other fungal infections can cause pleural effusions, it is not a typical feature of the allergic response seen in ABPA.
Question 10: True regarding the presentation of primary tuberculosis is
- A. B/L pleural effusion with negative Tuberculin test
- B. U/L hilar lymphadenopathy (Correct Answer)
- C. Sustained chronic pyrexia
- D. B/L pleural effusion with positive tuberculin test
Explanation: ***U/L hilar lymphadenopathy*** - A **unilateral hilar lymphadenopathy** is a classic radiographic finding in **primary pulmonary tuberculosis** in children and often in adults, representing the enlargement of lymph nodes draining the primary lung lesion. - The disease typically begins with a primary lesion (Ghon focus) in the lung parenchyma and regional **lymph node involvement** constitutes the primary complex [1]. *B/L pleural effusion with negative Tuberculin test* - **Bilateral pleural effusion** is an uncommon presentation for primary tuberculosis; typically, effusions are unilateral. - A **negative Tuberculin test** (PPD) would make a diagnosis of tuberculosis less likely, although it can be negative in immunocompromised individuals or in the very early stages of infection. *Sustained chronic pyrexia* - While fever (pyrexia) is a common symptom of tuberculosis, **sustained chronic pyrexia** is more characteristic of secondary (post-primary) or disseminated tuberculosis, not necessarily primary infection which is often asymptomatic or mildly symptomatic [2]. - Fevers in primary TB, if present, can be low-grade and intermittent rather than sustained and chronic. *B/L pleural effusion with positive tuberculin test* - Although a **positive Tuberculin test** indicates prior exposure to M. tuberculosis, **bilateral pleural effusion** is an unusual initial presentation of primary tuberculosis. - Pleural effusions in TB are typically unilateral and usually result from a hypersensitivity reaction or direct spread from a primary lesion, but bilateral involvement is less common.
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