Chest Radiology — MCQs

Chest Radiology Indian Medical PG Practice Questions and MCQs

Question 471: Inhalational anthrax is characterized by:

A. Consolidation and pleural effusion
B. Mediastinal widening and pleural effusion (Correct Answer)
C. Bilateral patchy opacities with pleural effusion
D. None of the options

Explanation: ***Mediastinal widening and pleural effusion*** - The spores of *Bacillus anthracis* are taken up by macrophages, transported to mediastinal lymph nodes, causing lymphadenitis and edema that appears as **mediastinal widening** on chest X-ray. - Hemorrhagic mediastinitis and subsequent vascular compromise lead to the development of hemorrhagic **pleural effusions**, which are characteristic of inhalational anthrax. *Consolidation and pleural effusion* - While pleural effusions are seen, lobar consolidation is more typical of bacterial pneumonias caused by common bacteria, not primarily inhalational anthrax initially. - The primary lung manifestation in anthrax is not parenchymal consolidation but rather hemorrhagic mediastinitis extending to the pleura. *Bilateral patchy opacities with pleural effusion* - Bilateral patchy opacities are more indicative of conditions like atypical pneumonia, viral pneumonia, or acute respiratory distress syndrome (ARDS), which are not the presenting radiographic signs of early inhalational anthrax. - Although advanced cases might show some parenchymal involvement, the hallmark features remain mediastinal and pleural. *None of the options* - This option is incorrect because mediastinal widening and pleural effusion are classic and well-documented radiological findings in inhalational anthrax.

Question 472: Cavitating pulmonary lesions can be seen in the following except:

A. Carcinoma of lung
B. Sarcoidosis (Correct Answer)
C. Tuberculosis
D. Wegener's granulomatosis

Explanation: ***Sarcoidosis*** - While sarcoidosis often presents with a variety of pulmonary manifestations like **nodules**, **hilar lymphadenopathy**, and **interstitial lung disease**, **cavitating lesions** are highly atypical and rare. - Cavitation in sarcoidosis, if it occurs, usually suggests **secondary infection** (such as aspergilloma in pre-existing cysts) or a different diagnosis altogether. - Sarcoidosis typically shows **non-caseating granulomas** without tissue necrosis, which explains the absence of cavitation. *Tuberculosis* - **Pulmonary tuberculosis**, particularly the post-primary or reactivation form, commonly manifests with **cavitating lesions**, especially in the **upper lobes**. - Cavitation is a hallmark of active disease due to **caseating necrosis** and facilitates the airborne spread of bacteria. *Carcinoma of lung* - **Squamous cell carcinoma** is the most common histological type of lung cancer to present with **cavitating lesions** (seen in 10-20% of cases). - Cavitation occurs due to **central necrosis** of the tumor mass. - Other types like adenocarcinoma can also cavitate, though less frequently. *Wegener's granulomatosis* - **Granulomatosis with polyangiitis (GPA)**, formerly known as Wegener's granulomatosis, classically presents with **multiple cavitating nodules** in the lungs. - This is part of the **necrotizing granulomatous vasculitis** affecting small and medium-sized vessels. - Cavitation is seen in 25-50% of pulmonary nodules in GPA.

Question 473: Which of the following is the current preferred first-line diagnostic test for pulmonary embolism?

A. Pulmonary angiography (PA).
B. CT pulmonary angiography (CTPA). (Correct Answer)
C. Ventilation-perfusion (V/Q) scan.
D. D-dimer assay.

Explanation: ***CT pulmonary angiography (CTPA)*** * **CT pulmonary angiography** is considered the **gold standard** for diagnosing pulmonary embolism due to its high resolution and ability to directly visualize emboli within the pulmonary arteries. * It provides direct visualization of the **pulmonary vasculature** and can detect both central and peripheral emboli, as well as alternative diagnoses. *Ventilation-perfusion (V/Q) scan* * A **V/Q scan** measures airflow and blood flow in the lungs and is used when CTPA is contraindicated (e.g., renal failure, contrast allergy), but it is generally less specific for PE. * It is considered **indeterminate** in a significant proportion of cases, especially in patients with pre-existing lung disease, limiting its definitive diagnostic capability. *Pulmonary angiography (PA)* * **Selective pulmonary angiography** was historically the gold standard but is now rarely performed due to its **invasive nature** and the availability of less invasive, yet highly accurate, alternatives like CTPA. * It involves direct catheterization of the pulmonary artery and injection of contrast, carrying risks like vessel injury and arrhythmia. *D-dimer assay* * A **D-dimer assay** is a blood test used to rule out pulmonary embolism in patients with a low pretest probability, but it is **not diagnostic** on its own. * Elevated D-dimer levels can indicate clot formation but are **non-specific** and can be raised in many other conditions (e.g., infection, inflammation, surgery, pregnancy).

Question 474: All are radiological features of mitral stenosis except:

A. Straight left border of heart
B. Lifting of left bronchus
C. Pulmonary hemosiderosis
D. Oligemia of upper lung fields (Correct Answer)

Explanation: ***Oligemia of upper lung fields*** - This is **NOT a feature of mitral stenosis** and is therefore the correct answer to this EXCEPT question. - Mitral stenosis causes **cephalization of pulmonary blood flow** (also called upper lobe blood diversion), which means **increased vascularity** in the upper lung fields, not oligemia (decreased blood flow). - Due to pulmonary venous hypertension, there is redistribution of blood flow from the lower lobes to the upper lobes, making the upper lobe vessels appear **more prominent**, not oligemic. - **Oligemia** (reduced blood flow) is the opposite of what occurs in mitral stenosis. *Straight left border of heart* - This is a **characteristic feature** of mitral stenosis. - Results from enlargement of the **left atrial appendage**, which straightens the normally concave left heart border. - Creates a distinctive silhouette on PA chest X-ray due to left atrial pressure overload. *Pulmonary hemosiderosis* - This is a **feature of chronic severe mitral stenosis**. - Occurs due to recurrent microhemorrhages from chronically congested pulmonary capillaries. - Hemosiderin-laden macrophages (heart failure cells) accumulate in the alveoli. - May present as fine reticulonodular opacities on chest X-ray. *Lifting of left bronchus* - This is a **classic feature** of mitral stenosis with significant left atrial enlargement. - The enlarged left atrium pushes the **left main bronchus** upward, best seen on lateral chest X-ray. - The angle between the main bronchi increases (normally 60-70°, may exceed 90° in severe cases).

Question 475: 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 476: Best diagnostic aid for bronchiectasis is

A. Bronchoscopy
B. X-ray
C. Bronchography
D. CT scan (Correct Answer)

Explanation: ***CT scan*** - **High-resolution computed tomography (HRCT)** is considered the **gold standard** for diagnosing bronchiectasis due to its ability to visualize airway dilation and wall thickening with high detail. - CT scans can accurately identify the characteristic **"signet ring" sign** (dilated bronchus adjacent to a pulmonary artery) and **lack of bronchial tapering**. *Bronchoscopy* - While useful for evaluating the airways for obstruction, performing biopsies, or obtaining samples for microbiology, **bronchoscopy** is not the primary diagnostic tool for bronchiectasis itself. - It may be indicated in cases where the cause of bronchiectasis is unclear or to rule out endobronchial lesions. *X-ray* - A **chest X-ray** can show non-specific findings such as increased bronchial markings or cystic shadows, but it is **not sensitive or specific enough** to reliably diagnose bronchiectasis. - **Early or mild cases** of bronchiectasis are often missed on a plain chest X-ray. *Bronchography* - **Bronchography**, an older technique involving the injection of contrast material into the airways, was once used for diagnosing bronchiectasis but has largely been **replaced by HRCT**. - It is an **invasive procedure** with potential complications and poorer resolution compared to modern CT imaging.

Question 477: A 70-year-old male presented with complaints of breathlessness and exhibited abnormal bronchial breath sounds on examination. What is the most probable diagnosis based on the provided X-ray image?

A. Pulmonary TB
B. Metastasis (Correct Answer)
C. Bronchogenic carcinoma
D. Sarcoidosis

Explanation: ***Metastasis*** - The provided X-ray image shows a **large, well-defined mass** in the upper right lung field, which could represent a **pulmonary metastasis** from an occult primary tumor or a primary lung malignancy. - The **well-circumscribed borders** and **smooth margins** are more suggestive of a metastatic deposit than a primary bronchogenic carcinoma, which typically has more irregular borders. - The clinical presentation with breathlessness and bronchial breath sounds indicates a significant space-occupying lesion causing local compression effects. - **Note:** Without history of a known primary malignancy, distinguishing metastasis from primary lung cancer requires clinical correlation, CT imaging, and histopathology. *Bronchogenic carcinoma* - **Bronchogenic carcinoma** is indeed a close differential, especially in a 70-year-old male (common demographic for lung cancer). - Primary lung cancers typically present with **irregular margins**, **speculation**, **pleural tethering**, or associated features like **hilar lymphadenopathy** or **obstructive pneumonitis**. - The relatively **smooth, well-defined borders** of this mass make a metastatic lesion slightly more likely on imaging alone, though clinical history is essential for definitive differentiation. *Pulmonary TB* - **Pulmonary tuberculosis** typically presents with upper lobe infiltrates, cavitation, fibrotic changes, or miliary patterns. - A solitary, large, well-circumscribed mass is **not characteristic** of typical TB presentations. - While TB can cause breathlessness, the radiographic appearance does not support this diagnosis. *Sarcoidosis* - **Sarcoidosis** characteristically shows **bilateral hilar lymphadenopathy** with or without interstitial infiltrates or multiple small nodules. - The presence of a **solitary, unilateral, large mass** is inconsistent with typical sarcoidosis imaging patterns. - The radiographic features clearly point away from this diagnosis.

Question 478: The following are direct signs of lung collapse seen on a chest X-ray, which one of the following is NOT a direct sign?

A. Crowding of the vessels
B. Loss of aeration
C. Mediastinal shift (Correct Answer)
D. Displacement of the fissure

Explanation: ***Mediastinal shift*** - While mediastinal shift can occur with lung collapse, it is an **indirect sign** caused by the volume loss in the affected hemithorax, pulling the mediastinum towards the collapsed lung. - Direct signs refer to changes observed *within* the collapsed lung tissue itself, such as increased density or displaced structures, whereas mediastinal shift is a secondary effect. *Crowding of the vessels* - This is a **direct sign** of lung collapse, as the pulmonary vessels become compacted due to the loss of lung volume. - The vessels appear closer together and more prominent in the area of collapse. *Loss of aeration* - This is a **direct sign** of lung collapse, as air is expelled or resorbed from the affected lung tissue, leading to increased opacity. - The collapsed lung appears denser and whiter on the X-ray compared to normally aerated lung. *Displacement of the fissure* - This is a **direct sign** of lung collapse, as the interlobar fissures are pulled towards the collapsed lobe due to volume loss. - The displacement of the fissure indicates the location and extent of the collapse.

Question 479: Ring sign with dilated bronchi on CXR is a feature of

A. Asthma
B. Bronchiolitis
C. Candidiasis
D. Bronchiectasis (Correct Answer)

Explanation: ***Bronchiectasis*** - The "ring sign" on a Chest X-Ray (CXR) is characteristic of **bronchiectasis**, representing the cross-sectional view of a **dilated bronchus**. - **Bronchial wall thickening** and dilation create this appearance, often accompanied by **"tram lines"** (parallel lines corresponding to longitudinal views of dilated bronchi). *Asthma* - CXR in asthma is often normal but may show signs of **hyperinflation** or **bronchial wall thickening** in severe cases. - It does not typically present with the "ring sign" of permanently dilated bronchi. *Bronchiolitis* - This condition primarily affects the **small airways (bronchioles)** and is common in infants. - CXR findings typically include **hyperinflation**, **peribronchial thickening**, and **atelectasis**, but not dilated bronchi forming ring signs. *Candidiasis* - Pulmonary candidiasis is a fungal infection that can cause various CXR findings like **infiltrates**, **nodules**, or **cavities**. - It does not typically lead to bronchial dilation or the characteristic "ring sign" seen in bronchiectasis.

Question 480: Kerley-B lines are seen when pulmonary venous pressure is what?

A. 5 mmHg
B. 10 mmHg
C. 20 mmHg (Correct Answer)
D. 40 mmHg

Explanation: ***20 mmHg*** - **Kerley B lines** indicate **interstitial edema** due to elevated **pulmonary venous pressure**, typically occurring when pressure exceeds 18-20 mmHg. - This level of pressure signifies early fluid transudation into the **interstitium**, making these lines visible on chest X-ray. *5 mmHg* - A pulmonary venous pressure of 5 mmHg is considered **normal** or within a healthy range. - At this pressure, there would be **no fluid transudation** into the interstitium, hence no Kerley B lines. *10 mmHg* - A pressure of 10 mmHg is still within the **normal or borderline normal range** for pulmonary venous pressure. - It is **insufficient** to cause the significant interstitial edema required for the formation of Kerley B lines. *40 mmHg* - A pulmonary venous pressure of 40 mmHg indicates **severe pulmonary edema**, often leading to **alveolar edema**. - At this high pressure, there would likely be diffuse, widespread opacities and **"bat wing" appearance**, not just isolated Kerley B lines.

Practice by Chapter

Normal Chest Radiographic Anatomy

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Radiographic Signs in Chest Imaging

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Pulmonary Infections

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Chronic Obstructive Pulmonary Disease

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Interstitial Lung Diseases

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Pulmonary Neoplasms

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Pleural Diseases

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Mediastinal Pathology

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Congenital and Developmental Chest Anomalies

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Pulmonary Vascular Diseases

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Chest Trauma Imaging

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Post-Surgical Chest Imaging

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