Interstitial Lung Diseases — MCQs
Sarcoidosis is least likely to be associated with:
Which finding best indicates poor prognosis in interstitial lung disease?
Lung biopsy: temporal heterogeneity with fibroblastic foci and honeycomb change. No granulomas or vasculitis. Diagnosis?
A 60-year male with dyspnea shows honeycombing on HRCT. Labs show positive ANA. Diagnosis?
Which of the following conditions is most commonly associated with eggshell calcifications?
Match the following columns A. Caplan syndrome B. Mesothelioma C. Silicosis D. Asbestosis 1. Pleural effusion without shift 2. Crazy Paving 3. Lower lobe involved 4. Described in coal workers
A lung biopsy shows 'temporal heterogeneity' with fibroblastic foci. Which radiological pattern would best support usual interstitial pneumonia?
A patient of Scleroderma presents with acute respiratory distress. Chest X-ray shows B/L reticular basilar shadows. What is the next line of investigation in this patient?
A chest X-ray shows bilateral lung infiltrates. What is the next best investigation?
A female patient with clinical symptoms of systemic sclerosis presents with shortness of breath and bilateral basal rales. Her chest X-ray showed reticular opacities in bilateral basal fields. What is the next best step?
Interstitial Lung Diseases Indian Medical PG Practice Questions and MCQs
Question 1: Sarcoidosis is least likely to be associated with:
- A. Pericardial effusion (Correct Answer)
- B. Uveitis
- C. Erythema nodosum
- D. Lymphadenopathy
Explanation: ### Pericardial effusion - While cardiac involvement in **sarcoidosis** can occur, leading to **cardiomyopathy** or **arrhythmias**, **pericardial effusions** are relatively rare [1]. - Less than 5% of patients with sarcoidosis develop pericardial effusions, making it the **least likely** among the given options [1]. ### Uveitis - **Uveitis** (inflammation of the uvea of the eye) is a common ocular manifestation of **sarcoidosis**, affecting 25-50% of patients [1]. - It can manifest as acute or chronic anterior uveitis, or posterior uveitis, and can lead to **vision impairment**. ### Erythema nodosum - **Erythema nodosum** is a common dermatological manifestation of **sarcoidosis**, particularly in acute forms like **Lofgren's syndrome** [1]. - It presents as **painful, tender red nodules** typically on the shins [1]. ### Lymphadenopathy - **Lymphadenopathy**, particularly **bilatéral mediastinal and hilar lymphadenopathy**, is a hallmark of **sarcoidosis** and is present in over 90% of cases [1]. - It is often one of the first findings on **chest X-ray** in pulmonary sarcoidosis [1].
Question 2: Which finding best indicates poor prognosis in interstitial lung disease?
- A. Honeycombing on HRCT (Correct Answer)
- B. Ground glass opacity
- C. Restrictive PFT pattern
- D. Clubbing
Explanation: ***Honeycombing on HRCT*** - **Honeycombing** on High-Resolution Computed Tomography (HRCT) indicates **irreversible fibrosis and architectural distortion** of the lung parenchyma, representing end-stage lung disease. - Its presence is a strong predictor of **worse prognosis and increased mortality** in various interstitial lung diseases, particularly **idiopathic pulmonary fibrosis (IPF)**. *Ground glass opacity* - **Ground glass opacity (GGO)** represents inflammation and early fibrosis, which can be **reversible** with treatment in some interstitial lung diseases. - While GGO indicates lung involvement, it does not necessarily signify irreversible damage or poor prognosis as definitively as honeycombing. *Restrictive PFT pattern* - A **restrictive pattern on pulmonary function tests (PFTs)** (reduced total lung capacity and vital capacity) is characteristic of all interstitial lung diseases. - While indicative of the disease, it is a **diagnostic hallmark rather than a specific prognostic indicator** for the severity of fibrosis or future outcome. *Clubbing* - **Clubbing** (thickening of the distal phalanges) is a common sign in many chronic lung diseases, including interstitial lung disease. - While its presence suggests chronic oxygen deprivation, it is a **non-specific finding** and does not directly correlate with disease progression or prognosis as strongly as imaging findings like honeycombing.
Question 3: Lung biopsy: temporal heterogeneity with fibroblastic foci and honeycomb change. No granulomas or vasculitis. Diagnosis?
- A. DIP
- B. NSIP
- C. UIP (Correct Answer)
- D. COP
Explanation: ***UIP (Usual Interstitial Pneumonia)*** - The presence of **temporal heterogeneity**, **fibroblastic foci**, and **honeycomb change** are the classic histologic hallmarks of UIP [1]. - The absence of granulomas or vasculitis further supports UIP, as these findings point away from other interstitial lung diseases [1]. *DIP (Desquamative Interstitial Pneumonia)* - DIP is characterized by the accumulation of **macrophages in alveolar spaces**, often associated with smoking [2]. - It lacks the **temporal heterogeneity** and widespread **fibroblastic foci** and **honeycomb change** seen in UIP [2]. *NSIP (Nonspecific Interstitial Pneumonia)* - NSIP typically shows **temporal homogeneity**, meaning all areas of the lung are affected to a similar degree, unlike the heterogeneity seen here [1]. - Histologically, it can present with either a **cellular pattern** (inflammation) or a **fibrotic pattern** (fibrosis), but it generally lacks prominent **fibroblastic foci** and extensive **honeycombing**, which are key features of UIP [1]. *COP (Cryptogenic Organizing Pneumonia)* - COP (also known as BOOP) is characterized by **intraluminal buds of granulation tissue** (**Masson bodies**) within the small airways and alveolar ducts [1]. - It does not exhibit the **temporal heterogeneity**, **fibroblastic foci**, or widespread **honeycomb change** characteristic of UIP [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 693-695. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 702-703.
Question 4: A 60-year male with dyspnea shows honeycombing on HRCT. Labs show positive ANA. Diagnosis?
- A. COP
- B. Sarcoidosis
- C. UIP (Correct Answer)
- D. NSIP
Explanation: UIP - **Honeycombing** on HRCT is a hallmark finding of **Usual Interstitial Pneumonia (UIP)**, which is the most common pattern of **Idiopathic Pulmonary Fibrosis (IPF)** [1]. - While a **positive ANA** can be associated with various connective tissue diseases, it is not specific and in the context of isolated honeycombing, UIP remains the most likely pattern; mildly positive ANA is not uncommon in IPF cases [1]. *COP* - **Cryptogenic Organizing Pneumonia (COP)** typically presents with **peribronchial consolidation** and **ground-glass opacities** on HRCT, rather than widespread honeycombing. - While patient symptoms can overlap, the characteristic HRCT findings for COP are different from those described. *Sarcoidosis* - **Sarcoidosis** is characterized by **non-caseating granulomas** and typically presents with **lymphadenopathy**, **nodules**, or **reticulonodular opacities** on HRCT, not primarily honeycombing. - A positive ANA is not a typical serological marker for sarcoidosis. *NSIP* - **Nonspecific Interstitial Pneumonia (NSIP)** primarily shows **ground-glass opacities** and **reticular abnormalities** with less prominent or absent honeycombing compared to UIP. - NSIP is also more likely to show uniform inflammation and fibrosis without the patchy, peripheral predilection of UIP.
Question 5: Which of the following conditions is most commonly associated with eggshell calcifications?
- A. Sarcoidosis
- B. Silicosis (Correct Answer)
- C. Aspergillosis
- D. Pulmonary artery hypertension
Explanation: **Silicosis** - **Eggshell calcifications** in hilar lymph nodes are a **pathognomonic finding** for silicosis. - This condition is caused by the inhalation of **silica dust**, leading to fibrotic changes in the lungs. *Sarcoidosis* - Characterized by **non-caseating granulomas** and can cause hilar lymphadenopathy, but typically does not manifest as eggshell calcifications. - More commonly associated with **bilateral hilar lymphadenopathy** that is symmetric and often resolves spontaneously. *Aspergillosis* - Primarily a **fungal infection** that can cause various lung manifestations, including aspergillomas and invasive aspergillosis. - Does not typically lead to **eggshell calcifications** of the lymph nodes. *Pulmonary artery hypertension* - Involves **elevated pressures in the pulmonary arteries** and is not associated with calcifications of lymph nodes. - Often manifests with **right heart enlargement** and specific vascular changes on imaging.
Question 6: Match the following columns A. Caplan syndrome B. Mesothelioma C. Silicosis D. Asbestosis 1. Pleural effusion without shift 2. Crazy Paving 3. Lower lobe involved 4. Described in coal workers
- A. A4-B1-C3-D2 (Correct Answer)
- B. A4-B1-C3-D3
- C. A2-B1-C4-D3
- D. A4-B3-C1-D2
Explanation: ***A4-B1-C2-D3*** - **Caplan syndrome** is a rare lung condition characterized by the development of discrete **rheumatoid nodules** (0.5 to 5.0 cm in diameter) in the lungs of individuals with **rheumatoid arthritis** who also have a history of exposure to coal dust, thus it is described in **coal workers (A4)** [3], [4]. - **Mesothelioma** is an aggressive cancer arising from the lining of the lungs and abdomen, with hallmark features of **pleural effusion** without a mediastinal shift due to pleural encasement. It is strongly associated with **asbestos exposure (B1)** [2]. - **Silicosis** is a form of pneumoconiosis caused by the inhalation of crystalline silica. It characteristically causes fibrosis in the **upper and mid lung zones** [1]. The **"crazy paving" pattern** can be seen when silicosis is complicated by secondary **pulmonary alveolar proteinosis (PAP)**, making C2 the correct association. - **Asbestosis** is a chronic lung disease caused by inhaling asbestos fibers. It typically causes fibrosis in the **lower lobes** of the lungs, as asbestos fibers tend to accumulate in these areas due to gravity and ventilation patterns **(D3)** [1]. *A2-B1-C4-D3* - This option incorrectly associates "crazy paving" with asbestosis (D2 interpretation error) and incorrectly describes silicosis as primarily described in coal workers (C4), while silicosis is specifically due to silica exposure, not coal dust (though coal workers can develop silicosis from silica in coal mines). *A4-B3-C1-D2* - This option incorrectly states that mesothelioma primarily causes lower lobe involvement (B3), whereas its defining feature is pleural effusion without shift. - It also misidentifies pleural effusion without shift as a feature of silicosis (C1) and crazy paving as characteristic of asbestosis (D2). *A4-B1-C3-D3* - This option has a fundamental error: both silicosis (C) and asbestosis (D) are matched to feature 3 (lower lobe), which is impossible in a matching question. - Medically, silicosis affects **upper lobes**, not lower lobes, making this matching incorrect [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 698-699. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 339-340. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 331-332. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 333-334.
Question 7: A lung biopsy shows 'temporal heterogeneity' with fibroblastic foci. Which radiological pattern would best support usual interstitial pneumonia?
- A. Peripheral and basal honeycombing (Correct Answer)
- B. Peribronchovascular nodules
- C. Central ground glass opacities
- D. Upper lobe nodules
Explanation: ***Peripheral and basal honeycombing*** - The combination of **temporal heterogeneity** and **fibroblastic foci** on biopsy is pathognomonic for usual interstitial pneumonia (UIP). - Radiologically, UIP is characterized by **peripheral, basal, reticular opacities** with **honeycombing**, often accompanied by **traction bronchiectasis**. *Peribronchovascular nodules* - This pattern is more commonly seen in **sarcoidosis**, a granulomatous disease, rather than UIP. - Sarcoidosis involves lymphocytic inflammation and non-caseating granulomas, which is distinct from the fibrotic process of UIP. *Central ground glass opacities* - While ground-glass opacities can be seen in various interstitial lung diseases, a **central distribution** is less typical for UIP. - More commonly associated with **acute interstitial pneumonia** or **non-specific interstitial pneumonia (NSIP)**. *Upper lobe nodules* - **Upper lobe predominance** with nodules is characteristic of conditions like **silicosis**, **coal workers' pneumoconiosis**, or **hypersensitivity pneumonitis**. - UIP typically involves the **lower lobes** and presents as reticular opacities and honeycombing rather than discrete nodules.
Question 8: A patient of Scleroderma presents with acute respiratory distress. Chest X-ray shows B/L reticular basilar shadows. What is the next line of investigation in this patient?
- A. High resolution CT to characterize the lung parenchyma. (Correct Answer)
- B. Pulmonary function tests to assess lung function.
- C. Contrast-enhanced CT scan for vascular assessment.
- D. Echocardiography to evaluate cardiac complications.
Explanation: ***High resolution CT*** - A **high-resolution CT (HRCT) scan** is the gold standard for evaluating **interstitial lung disease (ILD)**, which is commonly seen in **scleroderma** and presents with basilar reticular shadows on chest X-ray. - HRCT provides detailed images of the lung parenchyma, allowing for accurate characterization of the **fibrotic changes** and extent of ILD. *Pulmonary function tests to assess lung function.* - **Pulmonary function tests (PFTs)** provide functional information about lung capacity and gas exchange but do not offer detailed anatomical imaging of the lung parenchyma. - While essential for monitoring disease progression and severity, PFTs are not the primary diagnostic tool to further characterize the **reticular basilar shadows** seen on X-ray in an acute setting. *Contrast-enhanced CT scan for vascular assessment.* - A **contrast-enhanced CT scan** is primarily used to assess **vascular structures** or rule out conditions like **pulmonary embolism**, which is not directly indicated by the description of bilateral reticular basilar shadows. - The primary concern here is **interstitial lung disease**, which is best evaluated by **HRCT** without contrast. *Echocardiography to evaluate cardiac complications.* - **Echocardiography** is used to assess cardiac function and look for complications like **pulmonary hypertension** or **myocardial fibrosis**, which can occur in scleroderma. - However, it does not directly evaluate the **lung parenchyma** or the cause of the reticular basilar shadows.
Question 9: A chest X-ray shows bilateral lung infiltrates. What is the next best investigation?
- A. Sputum examination
- B. CT (Correct Answer)
- C. Bronchoscopy
- D. Echocardiography
Explanation: ***CT*** - A **CT scan (preferably HRCT)** provides a more detailed view of the lung parenchyma, allowing for better characterization of the infiltrates (e.g., location, pattern, presence of nodules, ground-glass opacities, or consolidation). - This detailed imagery is crucial for narrowing down the differential diagnosis and guiding further diagnostic or therapeutic interventions. - **CT is the best next investigation** for characterizing bilateral lung infiltrates seen on chest X-ray. *Sputum examination* - While important for identifying infectious causes, **sputum examination** is often only productive in certain types of pneumonia or infections and might not directly clarify the morphology or distribution of the infiltrates as a CT scan would. - It might be a subsequent step once the nature of the infiltrate is better understood through imaging. *Bronchoscopy* - **Bronchoscopy** is an invasive procedure generally reserved for cases where less invasive methods have failed to yield a diagnosis or when specific findings from imaging (like a CT scan) suggest the need for direct visualization, lavage, or biopsy. - It's not typically the immediate next step after identifying bilateral infiltrates on a chest X-ray. *Echocardiography* - **Echocardiography** is useful for evaluating cardiac causes of bilateral infiltrates (such as pulmonary edema from heart failure). - However, it does not directly visualize or characterize the lung parenchymal infiltrates themselves, making CT more valuable as the next investigation.
Question 10: A female patient with clinical symptoms of systemic sclerosis presents with shortness of breath and bilateral basal rales. Her chest X-ray showed reticular opacities in bilateral basal fields. What is the next best step?
- A. Do 2D echocardiography
- B. Do Pulmonary Function Test
- C. Do CECT
- D. Do HRCT (Correct Answer)
Explanation: ***Do HRCT*** - **High-resolution computed tomography (HRCT)** is the gold standard for evaluating **interstitial lung disease (ILD)**, a common and serious complication of systemic sclerosis, characterized by **reticular opacities** seen on chest X-ray. - HRCT provides detailed images of the lung parenchyma, allowing for accurate characterization of ILD patterns (e.g., usual interstitial pneumonia and non-specific interstitial pneumonia) and assessment of disease extent and severity, which is crucial for determining prognosis and guiding treatment. *2D echocardiography* - This test is primarily used to assess **cardiac function** and evaluate for conditions like **pulmonary hypertension** or **congestive heart failure**, which can cause shortness of breath. - While pulmonary hypertension can be associated with systemic sclerosis, the **reticular opacities** and **basal rales** on chest X-ray strongly point towards a primary lung parenchymal pathology, making HRCT a more direct and immediate diagnostic step for the observed lung findings. *Do Pulmonary Function Test* - **Pulmonary function tests (PFTs)** measure lung volumes, airflow, and gas exchange and are essential for quantifying the extent of lung impairment in conditions like ILD. - While PFTs are crucial for monitoring disease progression and response to therapy, they do not provide the detailed anatomical information needed for the initial diagnosis and characterization of the **interstitial lung changes** suggested by the chest X-ray, which is better served by HRCT. *Do CECT* - **Contrast-enhanced computed tomography (CECT)** is primarily used to evaluate for **vascular abnormalities**, **masses**, or **lymphadenopathy** within the chest. - While it can provide some information about lung parenchyma, **contrast** is not typically necessary or beneficial for the initial assessment of **interstitial lung disease (ILD)** and may even pose risks if the patient has renal impairment, making HRCT a more appropriate choice for this specific clinical presentation.
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