Respiratory Pathology — MCQs

Respiratory Pathology Indian Medical PG Practice Questions and MCQs

Question 191: Which cells are most important in the causation of asthma?

A. Macrophages
B. Mast cells (Correct Answer)
C. Neutrophils
D. Lymphocytes

Explanation: **Explanation:** Asthma is a chronic inflammatory disorder of the airways characterized by reversible bronchoconstriction and airway hyperresponsiveness. The pathogenesis is primarily driven by a **Type I Hypersensitivity reaction** [1]. **Why Mast Cells are the Correct Answer:** Mast cells are the central effector cells in the acute phase of asthma [2]. Upon re-exposure to an allergen, specific IgE antibodies bound to high-affinity receptors (FcεRI) on mast cells cause **degranulation** [1]. This releases potent primary mediators like **histamine** and secondary mediators like **Leukotrienes (C4, D4, E4)** and **Prostaglandin D2** [2]. These substances are directly responsible for the hallmark features of an asthma attack: smooth muscle contraction (bronchospasm), increased vascular permeability (edema), and mucus hypersecretion [1]. **Analysis of Incorrect Options:** * **A. Macrophages:** While they act as antigen-presenting cells and secrete cytokines, they are not the primary initiators of the acute bronchoconstrictor response. * **C. Neutrophils:** These are more characteristic of severe asthma, smoking-related asthma, or COPD. In typical atopic asthma, the cellular infiltrate is predominantly eosinophilic, not neutrophilic. * **D. Lymphocytes:** Specifically, **TH2 cells** are crucial for orchestrating the immune response (secreting IL-4, IL-5, and IL-13) [1]; however, the immediate clinical manifestation of asthma is directly executed by mast cell products. **High-Yield NEET-PG Pearls:** * **Key Cytokines:** IL-4 (stimulates IgE production), IL-5 (activates eosinophils), and IL-13 (stimulates mucus secretion) [1]. * **Curschmann Spirals:** Whorls of shed epithelium found in mucus plugs. * **Charcot-Leyden Crystals:** Galectin-10 deposits derived from eosinophil membranes. * **Airway Remodeling:** Subepithelial fibrosis (thickening of the basement membrane) is a classic histological finding in chronic asthma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 688-689. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 210-212.

Question 192: Reactivation tuberculosis and primary squamous cell carcinoma of the lung are similar in that they both are commonly associated with:

A. Cavitation (Correct Answer)
B. Scar carcinomas
C. Silicosis
D. Ectopic secretion of a parathormone-like peptide

Explanation: **Explanation:** The correct answer is **A. Cavitation**. **Why Cavitation?** Cavitation is a hallmark feature shared by both reactivation (secondary) tuberculosis and squamous cell carcinoma (SCC) of the lung. [1] * **Reactivation TB:** Typically involves the lung apices. The hypersensitivity response leads to extensive caseous necrosis, which liquefies and drains into the bronchi, leaving behind a **thick-walled cavity**. * **Squamous Cell Carcinoma:** This tumor is characteristically **central/hilar** in location. Due to its rapid growth, the central portion of the tumor often outstrips its blood supply, leading to **central ischemic necrosis** and subsequent cavitation. [1] **Analysis of Incorrect Options:** * **B. Scar Carcinoma:** Historically associated with Adenocarcinoma (occurring at the site of old scars/infarcts), though this link is now debated. It is not a feature of TB. * **C. Silicosis:** While silicosis significantly increases the risk of developing Tuberculosis (Silicotuberculosis), it is not a common feature of Squamous Cell Carcinoma. * **D. Ectopic Parathormone-like Peptide (PTHrP):** This is a classic paraneoplastic syndrome specifically associated with **Squamous Cell Carcinoma** (causing hypercalcemia), but it is not seen in Tuberculosis. **High-Yield NEET-PG Pearls:** * **Location:** Secondary TB and SCC are both typically found in the upper lobes (TB in the apex; SCC centrally). * **Most common lung cancer to cavitate:** Squamous Cell Carcinoma. [1] * **Most common lung cancer in non-smokers:** Adenocarcinoma. * **Ghon Complex:** The hallmark of Primary TB (Subpleural focus + lymph node involvement), whereas cavitation is the hallmark of Secondary TB. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 336-337.

Question 193: Mesothelioma is most strongly associated with which variety of asbestos?

A. Serpentine
B. Amphibole (Correct Answer)
C. Both serpentine and amphibole asbestos
D. Neither serpentine nor amphibole asbestos

Explanation: **Explanation:** The correct answer is **Amphibole (Option B)**. Asbestos is a group of naturally occurring fibrous silicates categorized into two main forms: **Serpentine** (curly, flexible fibers) and **Amphibole** (straight, needle-like fibers). While both can cause lung disease, **Amphiboles are significantly more carcinogenic** regarding the development of malignant mesothelioma. The underlying medical concept lies in the physical properties of the fibers: * **Amphiboles** (e.g., Crocidolite, Amosite) are stiff and aerodynamic. They penetrate deep into the distal airways and reach the visceral pleura [1]. Their chemical composition makes them highly resistant to clearance, allowing them to persist in the lung tissue for decades, causing chronic inflammation and DNA damage. * **Serpentine** (Chrysotile) fibers are curly and tend to get trapped in the upper respiratory tract. They are more soluble and more easily cleared by macrophages, making them less likely to induce pleural malignancy. **Analysis of Options:** * **Option A (Serpentine):** While Chrysotile (serpentine) is the most commonly used industrial asbestos, it is less likely to cause mesothelioma compared to amphiboles. * **Option C & D:** These are incorrect because there is a clear, established difference in the oncogenic potential between the two fiber types. **High-Yield Clinical Pearls for NEET-PG:** * **Crocidolite (Blue asbestos)** is the most potent subtype of amphibole associated with mesothelioma. * **Latent Period:** Mesothelioma has a long lag period (25–40 years) after exposure [1]. * **Smoking Link:** Smoking does **not** increase the risk of mesothelioma in asbestos workers, but it synergistically increases the risk of **Bronchogenic Carcinoma** (the most common cancer in asbestos workers) [1]. * **Ferruginous Bodies:** Asbestos fibers coated with iron-containing protein (Prussian blue positive) seen in sputum or tissue. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 221-222.

Question 194: Histologic sections of lung (routine H&E stain) reveal alveoli filled with pale, nongranular pink fluid. Neither leukocytes nor erythrocytes are present within this fluid. What is the most likely cause of this abnormality?

A. Bacterial pneumonia
B. Congestive heart failure (Correct Answer)
C. Lymphatic obstruction by tumor
D. Pulmonary embolus

Explanation: ### Explanation **Correct Option: B. Congestive Heart Failure** The description of "pale, nongranular pink fluid" without inflammatory cells (leukocytes) or hemorrhage (erythrocytes) is the classic histological appearance of **Pulmonary Edema (Transudate)**. In Congestive Heart Failure (CHF), increased pulmonary venous hydrostatic pressure forces fluid out of the capillaries into the alveolar spaces [1]. Because the alveolar-capillary membrane remains intact, the fluid is protein-poor (transudate), appearing pale and homogenous on H&E stain. **Analysis of Incorrect Options:** * **A. Bacterial Pneumonia:** This would present as an **exudate**. Histology would show alveoli filled with numerous neutrophils (leukocytes), fibrin, and cellular debris, making the fluid appear granular and dense. * **C. Lymphatic Obstruction:** While this causes edema, it primarily results in **interstitial edema** and dilated lymphatics (lymphangiectasia) rather than uniform alveolar filling [2]. * **D. Pulmonary Embolus:** This typically leads to **pulmonary infarction** or hyemorrhage. Histology would show alveolar spaces filled with erythrocytes (red blood cells) and evidence of ischemic necrosis of the alveolar walls. **NEET-PG High-Yield Pearls:** * **Heart Failure Cells:** In chronic passive congestion (CHF), look for hemosiderin-laden macrophages in the alveoli. * **Transudate vs. Exudate:** Transudates (CHF) have low protein and low LDH; Exudates (Pneumonia/Malignancy) have high protein and high LDH (Light’s Criteria). * **Gross Appearance:** Lungs in pulmonary edema are heavy, boggy, and subcrepitant; frothy blood-tinged fluid exudes from the cut surface. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 536-538. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, pp. 124-126.

Question 195: Which of the following statements is FALSE regarding malignant mesothelioma?

A. It is the most common tumor of the pleura.
B. It is more common in males.
C. The serpentine type of asbestos is more commonly associated with it than the amphibole type. (Correct Answer)
D. Vimentin cell marker is positive.

Explanation: ### Explanation **1. Why Option C is the Correct (False) Statement:** The relationship between asbestos and mesothelioma depends on the fiber type. **Amphibole fibers** (straight, stiff, and brittle) are significantly more carcinogenic than **serpentine fibers** (curly and flexible). Amphiboles can penetrate deep into the lungs and reach the visceral pleura, where they persist for decades. While the serpentine type (chrysotile) is more commonly used in industry, it is the **amphibole type (specifically crocidolite)** that is most strongly associated with the development of malignant mesothelioma. **2. Analysis of Other Options:** * **Option A (True):** Malignant mesothelioma is the most common **primary** tumor of the pleura [1]. (Note: Secondary/metastatic tumors are more common overall, but among primary pleural tumors, mesothelioma leads). * **Option B (True):** It is more common in males (ratio approx. 3:1), primarily due to occupational exposure in industries like shipbuilding, construction, and insulation. * **Option D (True):** Mesothelioma cells typically show positivity for **Vimentin**, Calretinin, Cytokeratin 5/6, and WT1 [2]. These markers are crucial for differentiating it from adenocarcinoma (which is usually CEA and MOC-31 positive). **3. High-Yield Clinical Pearls for NEET-PG:** * **Latent Period:** There is a long lag period of **25–40 years** between exposure and tumor development. * **Smoking Link:** Unlike bronchogenic carcinoma, smoking **does not** increase the risk of developing mesothelioma [1]. * **Morphology:** It can present as three types: Epithelioid (most common), Sarcomatoid, or Biphasic [2]. * **Psammoma Bodies:** These may be seen in the epithelioid variant. * **Electron Microscopy:** Characterized by **long, slender microvilli** (unlike the short, blunt microvilli of adenocarcinoma). **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 221-222. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, p. 731.

Question 196: What is the most common site of metastasis for carcinoma of the bronchus?

A. Liver and bones (Correct Answer)
B. Prostate
C. Kidney
D. Breast

Explanation: **Explanation:** Carcinoma of the bronchus (Lung Cancer) is notorious for early and widespread hematogenous dissemination. The correct answer is **Liver and bones** because these are the most frequent sites of distant spread. [1] **Why Liver and Bones are correct:** Lung cancer cells enter the pulmonary veins, reach the left heart, and are distributed via the systemic circulation. * **Liver:** The most common site of visceral metastasis. [1], [4] * **Bones:** Frequently involved (especially vertebrae, ribs, and pelvis), often presenting as osteolytic lesions. [2] * **Adrenals:** Though not listed as a primary option here, the **adrenal glands** are classically the most common site of "silent" metastasis in lung cancer (involved in >50% of cases at autopsy). [1] * **Brain:** Another major site, particularly for Small Cell Lung Cancer (SCLC) and Adenocarcinoma. [1], [3] **Why the other options are incorrect:** * **Prostate:** Lung cancer rarely metastasizes to the prostate. Conversely, prostate cancer typically metastasizes *to* the bone (osteoblastic). * **Kidney:** While the kidney can be a site of secondary spread, it is significantly less common than the liver, bones, or adrenals. * **Breast:** Metastasis to the breast from the lung is extremely rare. The breast is more commonly a primary site that metastasizes *to* the lungs. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site overall:** Adrenal glands (often asymptomatic). [1] * **Most common visceral site:** Liver. [1] * **Bone lesions:** Typically **osteolytic** (except for Small Cell, which can occasionally be blastic). * **Pancoast Tumor:** A superior sulcus tumor that often involves the brachial plexus and cervical sympathetic chain (Horner’s Syndrome). [4] * **Sentinel finding:** In any male smoker presenting with new-onset seizure or focal neurological deficits, always rule out metastatic lung cancer to the brain. [3] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 724-725. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 671-672. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 337-338. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 334-335.

Question 197: In lobar pneumonia, the presence of fibrinosuppurative exudate with disintegration of red cells is seen in which stage?

A. Congestion
B. Red hepatization
C. Grey hepatization (Correct Answer)
D. Resolution

Explanation: **Explanation:** Lobar pneumonia typically progresses through four distinct pathological stages. Understanding the evolution of the alveolar exudate is key to identifying the correct stage [1]. **1. Why Grey Hepatization is correct:** During the **Grey Hepatization** stage (typically days 5–8), the lung becomes dry, firm, and greyish-brown [2]. Microscopically, the congestion seen in previous stages disappears. The alveoli are filled with a dense **fibrinosuppurative exudate** (fibrin and neutrophils). Crucially, the red blood cells (RBCs) that were present during the red hepatization stage undergo **disintegration (lysis)** [1], and the extravasated hemoglobin is cleared, leading to the characteristic change in color from red to grey. **2. Analysis of Incorrect Options:** * **Congestion (Stage 1):** Characterized by heavy, boggy, and red lungs. Histology shows vascular engorgement, intra-alveolar fluid with few neutrophils, and numerous bacteria [1]. * **Red Hepatization (Stage 2):** The lung resembles the consistency of the liver. Alveoli are packed with **intact RBCs**, fibrin, and neutrophils [1]. The presence of intact RBCs gives it the "red" appearance. * **Resolution (Stage 4):** The exudate undergoes enzymatic digestion by macrophages. The debris is either coughed up or resorbed, restoring the normal alveolar architecture [1]. **High-Yield NEET-PG Pearls:** * **Causative Agent:** *Streptococcus pneumoniae* is the most common cause of lobar pneumonia. * **Hepatization:** This term refers to the lung acquiring a liver-like consistency due to the filling of air spaces with exudate [1]. * **Key Differentiator:** The transition from Red to Grey hepatization is defined by the **lysis of RBCs** and the persistence of fibrin [1]. * **Complications:** Look for terms like *Carnification* (organization of exudate into fibrous tissue) and *Empyema* (pus in the pleural cavity). **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 711-712. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 317-318.

Question 198: Which of the following is NOT a feature of asbestosis?

A. Pleural cancer
B. Lung carcinoma
C. Pleural effusion
D. Atelectasis (Correct Answer)

Explanation: **Explanation:** Asbestosis is a chronic interstitial lung disease caused by the inhalation of asbestos fibers. The correct answer is **Atelectasis**, as it is not a primary or characteristic feature of asbestos exposure. While "Rounded Atelectasis" can occasionally occur secondary to pleural thickening, generalized atelectasis is not a hallmark of the disease process itself. **Why the other options are incorrect:** * **Pleural Cancer (Mesothelioma):** Asbestos is the most significant risk factor for malignant mesothelioma [1]. It typically occurs after a long latent period (25–40 years). * **Lung Carcinoma:** This is actually the **most common** malignancy associated with asbestos exposure [1]. The risk is synergistically increased (up to 55-fold) in individuals who also smoke. * **Pleural Effusion:** Benign asbestos pleural effusion (BAPE) is often the earliest clinical manifestation of asbestos exposure, occurring within 10–20 years of contact [1]. **Clinical Pearls for NEET-PG:** 1. **Golden-Brown Rods:** Asbestos bodies (Ferruginous bodies) are fibers coated with iron-containing protein, appearing as beaded/dumbell-shaped structures under light microscopy [1]. 2. **Pleural Plaques:** These are the most common manifestation of asbestos exposure; they are well-circumscribed plaques of dense collagen, most often found on the anterior and posterolateral aspects of the parietal pleura and over the diaphragm [1]. 3. **Lower Lobe Predominance:** Unlike silicosis and coal worker's pneumoconiosis (which affect upper lobes), asbestosis primarily involves the **lower lobes** and subpleural regions [1]. 4. **Prussian Blue Stain:** This stain is used to highlight the iron coating of asbestos bodies. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 698-699.

Question 199: Which of the following is a neuroendocrine lesion of the lung?

A. Carcinoid (Correct Answer)
B. Benign tumourlets
C. Bronchoalveolar carcinoma
D. Hemangioma

Explanation: **Explanation:** The lung contains a population of specialized cells known as **Kulchitsky cells** (bronchial mucosal APUD cells), which are part of the diffuse neuroendocrine system. Tumors arising from these cells are classified as neuroendocrine lesions. [1] **1. Why Carcinoid is Correct:** Bronchial carcinoids are malignant neuroendocrine tumors. They are characterized by the expression of neuroendocrine markers such as **Chromogranin, Synaptophysin, and CD56**. On electron microscopy, they show pathognomonic **dense-core neurosecretory granules**. They are classified into Typical (low grade) and Atypical (intermediate grade) based on mitotic count and necrosis. [1] **2. Analysis of Incorrect Options:** * **Benign tumourlets (Option B):** While these are neuroendocrine in origin (small clusters of hyperplastic neuroendocrine cells), they are generally considered **reactive proliferations** rather than true neoplastic lesions. Note: In some classifications, they are grouped under neuroendocrine proliferations, but Carcinoid is the definitive "lesion/tumor" usually tested. * **Bronchoalveolar carcinoma (Option C):** Now reclassified as **Adenocarcinoma in situ (AIS)**, this is a subtype of non-small cell lung cancer (NSCLC) arising from Type II pneumocytes or Clara cells, not neuroendocrine cells. [3] * **Hemangioma (Option D):** This is a benign **vascular tumor** arising from endothelial cells. **High-Yield Clinical Pearls for NEET-PG:** * **Spectrum of Neuroendocrine Tumors:** Typical Carcinoid → Atypical Carcinoid → Large Cell Neuroendocrine Carcinoma → Small Cell Carcinoma (most aggressive). [2] * **Histology:** Carcinoids show a "salt and pepper" chromatin pattern and an organoid/nesting growth pattern. [1] * **Carcinoid Syndrome:** Rare in lung carcinoids (seen in <10%) unless there are extensive liver metastases. * **Location:** Most carcinoids are central/perihilar and present with hemoptysis or persistent cough. [1] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 725-727. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 337-338. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 335-336.

Question 200: Which is not an inflammatory stage in pneumonia?

A. Organisation (Correct Answer)
B. Congestion
C. Resolution
D. Hepatisation

Explanation: In lobar pneumonia, the lung undergoes a classic sequence of pathological changes [1], [2]. The correct answer is **Organisation** because it represents a **complication** or a failure of the normal inflammatory process, rather than a standard stage of acute inflammation [4]. ### Why "Organisation" is the Correct Answer: In a typical case of pneumonia, the exudate is eventually removed by enzymatic digestion and macrophage activity (Resolution) [2]. **Organisation** occurs when the intra-alveolar exudate is not resorbed but is instead replaced by **fibroblasts and connective tissue**, leading to permanent scarring (Masson bodies) [4]. This is considered a pathological sequela, not a stage of the acute inflammatory cycle. ### Explanation of Incorrect Options (The 4 Stages of Pneumonia): 1. **Congestion (Day 1-2):** The initial vascular response. Lungs are heavy, boggy, and red. Histology shows vascular engorgement and intra-alveolar fluid with few bacteria [1], [2]. 2. **Hepatisation (Red: Day 3-4; Grey: Day 5-7):** * **Red:** Massive confluent exudation of RBCs, neutrophils, and fibrin. The lung consistency resembles the liver [1], [2]. * **Grey:** RBCs disintegrate, but fibrin persists. The lung appears dry and grey-brown [1], [2]. 3. **Resolution (Day 8 onwards):** The final stage of the inflammatory process where enzymes (from neutrophils) digest the exudate, which is then coughed up or resorbed by macrophages, restoring normal lung architecture [2], [3]. ### High-Yield Clinical Pearls for NEET-PG: * **Most common cause of Lobar Pneumonia:** *Streptococcus pneumoniae* [3]. * **Masson Bodies:** These are polypoid plugs of loose connective tissue seen in Organising Pneumonia. * **Carnification:** A gross term used when the lung tissue becomes tough and flesh-like due to the process of organisation. * **Key distinction:** Resolution = Restoration of architecture; Organisation = Fibrosis/Scarring [4]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 317-318. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 711-712. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, p. 715. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 194-195.

Practice by Chapter

Congenital Anomalies

Practice Questions

Atelectasis and Acute Lung Injury

Practice Questions

Obstructive Pulmonary Diseases

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Restrictive Pulmonary Diseases

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Lung Infections

Practice Questions

Pulmonary Vascular Diseases

Practice Questions

Lung Tumors

Practice Questions

Pleural Diseases

Practice Questions

Interstitial Lung Diseases

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Occupational Lung Diseases

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