Pleural Diseases — MCQs
True statement regarding pathology of pneumocystis jiroveci pneumonia:
Pneumothorax could be a complication of what?
PA view of chest X-ray is given here. What is the diagnosis?
Which of the following are true/false about clinical features of Fat embolism syndrome? 1. Tachypnea 2. Systemic hypoxia may occur 3. Fat globules in urine are diagnostic 4. Manifests after several days of trauma 5. Petechiae in anterior chest wall
Mesothelioma is closely associated with which of the following?
A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?
A lung biopsy shows 'temporal heterogeneity' with fibroblastic foci. Which radiological pattern would best support usual interstitial pneumonia?
Which is NOT a feature of pleural effusion?
A chest X-ray shows bilateral lung infiltrates. What is the next best investigation?
A patient presented with complaints of dyspnoea. The shown X-ray is suggestive of:
Pleural Diseases Indian Medical PG Practice Questions and MCQs
Question 1: True statement regarding pathology of pneumocystis jiroveci pneumonia:
- A. Alveoli are filled with foamy exudates (Correct Answer)
- B. Interstitial pneumonitis with foamy vacuoles
- C. Necrotising hemorrhage
- D. Pleural effusion
Explanation: ***Alveoli are filled with foamy exudates*** - This is a hallmark pathological finding in **Pneumocystis jiroveci pneumonia (PJP)**, where the alveoli are filled with an **eosinophilic, foamy, or honeycomb-like material** composed of organisms and host proteins [1]. - This exudate is rich in **trophozoites and cysts** of *P. jiroveci*, which stain well with special stains like Gomori methenamine silver (GMS) [1]. *Interstitial pneumonitis with foamy vacuoles* - While PJP does cause **interstitial inflammation**, the characteristic "foamy vacuoles" are actually the **alveolar exudate**, not an isolated interstitial finding. - The interstitial changes typically involve **lymphoplasmacytic infiltration**, but the primary accumulation of organisms and debris is intra-alveolar. *Necrotising hemorrhage* - **Necrotizing hemorrhage** is not a typical pathological feature of PJP. - This finding is more commonly associated with severe bacterial pneumonias, fungal infections like **aspergillosis**, or vasculitic processes [1]. *Pleural effusion* - **Pleural effusion** is an infrequent finding in uncomplicated PJP, occurring in less than 5% of cases. - When present, it often suggests a co-infection or other underlying pathology, rather than being a characteristic feature of PJP itself. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 318-319.
Question 2: Pneumothorax could be a complication of what?
- A. Pneumococcal pneumonia
- B. Klebsiella pneumonia
- C. Staphylococcal pneumonia (Correct Answer)
- D. Viral pneumonia
Explanation: ***Staphylococcal pneumonia*** - *Staphylococcus aureus* is known for causing **necrotizing pneumonia**, forming abscesses and **cavitary lesions** that can rupture into the pleural space. - This rupture leads to a **bronchopleural fistula** and subsequent development of a **pneumothorax** [2]. *Pneumococcal pneumonia* - This is the most common cause of **community-acquired pneumonia** but typically causes **lobar consolidation** [1]. - It is rarely associated with necrotizing changes or significant pleural complications like pneumothorax, though **empyema** can occur [2]. *Klebsiella pneumonia* - Often causes severe, **necrotizing pneumonia**, particularly in debilitated or alcoholic individuals, but is more commonly associated with **abscess formation** within the lung parenchyma [3]. - While lung destruction can occur, pneumothorax is a less frequent direct complication compared to cavitary lesions seen in staphylococcal infections. *Viral pneumonia* - Typically causes **interstitial inflammation** and diffuse involvement of the lung parenchyma [4]. - It does not usually lead to significant tissue necrosis or cavitation that would predispose to a pneumothorax.
Question 3: PA view of chest X-ray is given here. What is the diagnosis?
- A. Right Pneumothorax with left tracheal shift (Correct Answer)
- B. Left Pneumothorax with right tracheal shift
- C. Left Pneumothorax with left tracheal shift
- D. Right Pneumothorax with right tracheal shift
Explanation: ***Right Pneumothorax with left tracheal shift*** - The image shows a large **radiolucency (black area) on the right side** of the chest, indicative of **air in the pleural space**, consistent with a **right-sided pneumothorax**. - The **trachea is shifted towards the left** (away from the pneumothorax), which is the **expected finding** in pneumothorax due to increased pressure in the right pleural space pushing mediastinal structures to the contralateral side. - In pneumothorax, the trachea and mediastinum shift **away from** the affected side due to the pressure effect of air accumulation in the pleural cavity. - This **contralateral tracheal deviation** is a classic radiological sign of pneumothorax and helps confirm the diagnosis. *Right Pneumothorax with right tracheal shift* - While the **right pneumothorax** is correctly identified, the tracheal shift direction is incorrect. - In pneumothorax, the trachea shifts **away from** the affected side (contralateral), not toward it (ipsilateral). - **Ipsilateral tracheal shift** would suggest volume loss (atelectasis) or lung collapse, not pneumothorax alone. *Left Pneumothorax with right tracheal shift* - The pneumothorax is clearly on the **right side**, not the left. - The radiolucency and absent lung markings are visible on the right hemithorax. - A left pneumothorax would show these findings on the left side. *Left Pneumothorax with left tracheal shift* - There is **no pneumothorax on the left side** of the chest. - The left lung shows normal vascular markings and no evidence of pleural air. - This combination would be medically implausible as it suggests pneumothorax with ipsilateral shift.
Question 4: Which of the following are true/false about clinical features of Fat embolism syndrome? 1. Tachypnea 2. Systemic hypoxia may occur 3. Fat globules in urine are diagnostic 4. Manifests after several days of trauma 5. Petechiae in anterior chest wall
- A. 1, 3, 4, 5 true & 2 false
- B. 1, 2, 3, 5 true & 4 false
- C. All are true (Correct Answer)
- D. 2, 4 false & 1, 3, 5 true
Explanation: ***All are true*** - **Tachypnea** (1), **systemic hypoxia** (2) [2], **fat globules in urine** (3) [2], **petechiae in the anterior chest wall** (5) [1], and manifestation **after several days of trauma** (4) [1] are all recognized clinical features or associated findings of **Fat Embolism Syndrome (FES)**. - The classic triad of FES includes **respiratory insufficiency**, **neurological symptoms**, and **petechial rash**, which frequently emerge 24-72 hours post-injury [1]. *1, 3, 4, 5 true & 2 false* - This option incorrectly states that systemic hypoxia is false. **Systemic hypoxia** is a common and serious manifestation of **Fat Embolism Syndrome**, often resulting from pulmonary microvascular obstruction [2]. - While other points are correct, the misidentification of hypoxia as false makes this option incorrect. *1, 2, 3, 5 true & 4 false* - This option incorrectly states that FES does not manifest after several days of trauma. **Fat Embolism Syndrome** typically has a delayed onset, occurring **12-72 hours (several days)** after the initial injury [1], [2]. - The delayed presentation is a key diagnostic characteristic distinguishing it from immediate post-traumatic complications. *2, 4 false & 1, 3, 5 true* - This option is extensively incorrect as it falsely identifies both **systemic hypoxia** and the **delayed manifestation** as false. - **Systemic hypoxia** is a hallmark of pulmonary involvement in FES [2], and **delayed onset** is a crucial diagnostic criterion.
Question 5: Mesothelioma is closely associated with which of the following?
- A. Silicosis
- B. Anthracosis
- C. Byssinosis
- D. Asbestosis (Correct Answer)
Explanation: ***Asbestosis*** - Mesothelioma is a rare but aggressive cancer of the **pleura** or **peritoneum**, and its strongest known etiological link is with **asbestos exposure**. - Asbestos fibers can become lodged in the lungs and pleural lining, leading to chronic inflammation, DNA damage, and eventually oncogenic transformation. *Silicosis* - **Silicosis** is a lung disease caused by inhaling **crystalline silica dust**, primarily affecting miners, construction workers, and foundry workers. - While it can lead to pulmonary fibrosis and an increased risk of tuberculosis and lung cancer, it is not directly associated with mesothelioma. *Anthracosis* - **Anthracosis** is often seen in coal miners and urban dwellers due to the inhalation of **carbon dust**, leading to the accumulation of pigment in the lungs. - This condition is generally benign but can contribute to the development of **coal worker's pneumoconiosis**, which is distinct from mesothelioma. *Byssinosis* - **Byssinosis** is an occupational lung disease caused by the inhalation of **cotton dust** or other textile dusts, typically affecting textile workers. - Symptoms include chest tightness and shortness of breath, particularly after beginning work after a break, and it is unrelated to mesothelioma.
Question 6: A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?
- A. Lateral view Chest X-ray
- B. USG (Correct Answer)
- C. Erect Chest X-ray PA view
- D. Lateral decubitus view
Explanation: ***USG*** - **Ultrasound** is the **best first-line investigation** for detecting **pleural effusions** in children due to its **non-invasive nature**, lack of radiation exposure, and ability to detect even small effusions (as little as 5-10 mL). - It can effectively differentiate between pleural fluid and other pathologies (e.g., consolidation, masses) and guide aspiration if needed. - **Real-time bedside availability** makes it ideal for pediatric patients. *Lateral view Chest X-ray* - A lateral Chest X-ray only detects pleural effusion if the fluid volume is at least **75-100 mL**, which might miss smaller effusions. - While it can provide additional information about the lungs and mediastinum, it is not as sensitive as ultrasound for detecting small effusions. *Erect Chest X-ray PA view* - An erect Chest X-ray PA view requires a minimum of **200-300 mL of fluid** to blunt the **costophrenic angle**, potentially missing smaller effusions. - It involves **ionizing radiation**, a concern in pediatric patients, and is less sensitive than ultrasound for early detection. *Lateral decubitus view* - A lateral decubitus view is useful for confirming the presence of **free-flowing pleural fluid** and differentiating it from loculated effusions, typically after an initial effusion is suspected. - While sensitive for detecting small effusions (as little as **50 mL**), it is typically performed as a secondary investigation and involves radiation exposure, unlike ultrasound.
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: Which is NOT a feature of pleural effusion?
- A. Horizontal fluid level
- B. Low lung volume
- C. Muffled heart sound (Correct Answer)
- D. Decreased chest movements
Explanation: ***Muffled heart sound*** - This is **NOT a feature of pleural effusion** and is the correct answer to this negation question. - Muffled heart sounds are characteristic of **pericardial effusion** or **cardiac tamponade**, where fluid accumulates in the pericardial sac around the heart itself. - Pleural effusion involves fluid in the pleural space surrounding the lungs, not the heart. - While massive pleural effusions can displace mediastinal structures, they do not typically cause muffled heart sounds. *Horizontal fluid level* - This **IS a feature** when air is also present in the pleural space (**hydropneumothorax**). - In **simple pleural effusion** (fluid only), the fluid typically forms a **meniscus-shaped curve** with blunting of the costophrenic angles on upright chest X-ray, not a horizontal level. - However, when both air and fluid are present, a distinct horizontal air-fluid level is visible on upright imaging. - Since the question asks about pleural effusion broadly, and effusions can be associated with air (empyema with gas-forming organisms, post-thoracentesis), this can be considered a radiological feature in certain contexts. *Low lung volume* - This **IS a feature** of pleural effusion. - The accumulating pleural fluid causes **compression atelectasis** of the adjacent lung parenchyma. - This results in **reduced functional lung volume** on the affected side, visible on chest imaging. *Decreased chest movements* - This **IS a feature** of pleural effusion. - Fluid in the pleural space restricts normal lung expansion and chest wall movement. - On physical examination, there are **diminished respiratory excursions** on the affected side. - This is one of the classic clinical signs of pleural effusion.
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 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.
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