A 20-year-old woman presents for a follow-up visit with her physician. She has a history of cystic fibrosis and is currently under treatment. She has recently been struggling with recurrent bouts of cough and foul-smelling, mucopurulent sputum over the past year. Each episode lasts for about a week or so and then subsides. She does not have a fever or chills during these episodes. She has been hospitalized several times for pneumonia as a child and continues to struggle with diarrhea. Physically she appears to be underweight and in distress. Auscultation reveals reduced breath sounds on the lower lung fields with prominent rhonchi. Which of the following infectious agents is most likely associated with the recurrent symptoms this patient is experiencing?
Q2
A 51-year-old woman is brought to the emergency department because of an aggressive cough with copious amounts of thick, foamy, yellow-green sputum. She says she has had this cough for about 11 years with exacerbations similar to her presentation today. She also reports that her cough is worse in the morning. She was evaluated multiple times in the past because of recurrent bouts of bronchitis that have required treatment with antibiotics. She is a non-smoker. On physical examination, the blood pressure is 125/78 mm Hg, pulse rate is 80/min, respiratory rate is 16/min, and temperature is 36.7°C (98.0°F). Chest auscultation reveals crackles and wheezing over the right middle lobe and the rest of her physical examinations are normal. The chest X-ray shows irregular opacities in the right middle lobe and diffuse airway thickening. Based on this history and physical examination, which of the following is the most likely diagnosis?
Q3
A 9-year-old boy with cystic fibrosis (CF) presents to the clinic with fever, increased sputum production, and cough. The vital signs include: temperature 38.0°C (100.4°F), blood pressure 126/74 mm Hg, heart rate 103/min, and respiratory rate 22/min. His physical examination is significant for short stature, thin body frame, decreased breath sounds bilateral, and a 2/6 holosystolic murmur heard best on the upper right sternal border. His pulmonary function tests are at his baseline, and his sputum cultures reveal Pseudomonas aeruginosa. What is the best treatment option for this patient?
Q4
A 72-year-old man is brought to the emergency department after an episode of hemoptysis. He has a chronic cough that is productive of copious sputum. Six years ago, he had a stroke that left him with difficulty swallowing. He smoked one pack of cigarettes daily for 40 years, but quit 2 years ago. His respirations are 25/min and labored. Physical examination shows digital clubbing. An x-ray of the chest shows tram track opacities in the lower lung fields. Which of the following is the most likely diagnosis?
Q5
A 61-year-old man presents with gradually increasing shortness of breath. For the last 2 years, he has had a productive cough on most days. Past medical history is significant for hypertension and a recent admission to the hospital for pneumonia. He uses a triamcinolone inhaler and uses an albuterol inhaler as a rescue inhaler. He also takes lisinopril and a multivitamin daily. He has smoked a pack a day for the last 32 years and has no intention to quit now. Today, his blood pressure is 142/97 mm Hg, heart rate is 97/min, respiratory rate is 22/min, and temperature is 37.4°C (99.3°F). On physical exam, he has tachypnea and has some difficulty finishing his sentences. His heart has a regular rate and rhythm. Auscultation of his lungs reveals wheezing and rhonchi that improves after a deep cough. Fremitus is absent. Pulmonary function tests show FEV1/FVC of 55% with no change in FEV1 after albuterol treatment. Which of the following is the most likely pathology associated with this patient's disease?
Q6
A 1-year-old infant is brought to the emergency department by his parents because of fever and rapid breathing for the past 2 days. He had a mild seizure on the way to the emergency department and developed altered sensorium. His mother states that the patient has had recurrent respiratory infections since birth. He was delivered vaginally at term and without complications. He is up to date on his vaccines and has met all developmental milestones. His temperature is 37.0°C (98.6°F), pulse rate is 200/min, and respirations are 50/min. He is lethargic, irritable, and crying excessively. Physical examination is notable for a small head, an elongated face, broad nose, low set ears, and cleft palate. Cardiopulmonary exam is remarkable for a parasternal thrill, grade IV pansystolic murmur, and crackles over both lung bases. Laboratory studies show hypocalcemia and lymphopenia. Blood cultures are drawn and broad-spectrum antibiotics are started, and the child is admitted to the pediatric intensive care unit. The intensivist suspects a genetic abnormality and a fluorescence in situ hybridization (FISH) analysis is ordered which shows 22q11.2 deletion. Despite maximal therapy, the infant succumbs to his illness. The parents of the child request an autopsy. Which of the following findings is the most likely to be present on autopsy?
Q7
In which of the following pathological states would the oxygen content of the trachea resemble the oxygen content in the affected alveoli?
Q8
A 47-year-old woman presents to her physician for difficulty swallowing. She states that she intentionally delayed seeing a physician for this issue. She says her primary issue with swallowing is that her mouth always feels dry so she has difficulty chewing food to the point that it can be swallowed. On physical examination, her oral mucosa appears dry. Both of her eyes also appear dry. Several enlarged lymph nodes are palpated. Which of the following patterns of reactive lymphadenitis is most commonly associated with this patient’s presentation?
Q9
A 31 year-old African-American female presents with painful shin nodules, uveitis, and calcified hilar lymph nodes. A transbronchial biopsy of the lung would most likely show which of the following histologies?
Q10
A 68-year-old male smoker dies suddenly in a car accident. He had smoked 2 packs per day for 40 years. His past medical history is notable for a frequent, very productive cough, recurrent respiratory infections and occasional wheezing. He had no other medical problems. At autopsy, which of the following is most likely to be found in this patient?
Bronchiectasis US Medical PG Practice Questions and MCQs
Question 1: A 20-year-old woman presents for a follow-up visit with her physician. She has a history of cystic fibrosis and is currently under treatment. She has recently been struggling with recurrent bouts of cough and foul-smelling, mucopurulent sputum over the past year. Each episode lasts for about a week or so and then subsides. She does not have a fever or chills during these episodes. She has been hospitalized several times for pneumonia as a child and continues to struggle with diarrhea. Physically she appears to be underweight and in distress. Auscultation reveals reduced breath sounds on the lower lung fields with prominent rhonchi. Which of the following infectious agents is most likely associated with the recurrent symptoms this patient is experiencing?
A. Mycobacterium avium
B. Pseudomonas (Correct Answer)
C. Histoplasma
D. Pneumococcus
E. Listeria
Explanation: ***Pseudomonas***
- **Pseudomonas aeruginosa** is a common and opportunistic pathogen in patients with **cystic fibrosis** due to altered mucus secretion and impaired mucociliary clearance.
- Recurrent cough, foul-smelling, and **mucopurulent sputum** are classic symptoms of **Pseudomonas** lung infections in CF patients, often leading to chronic colonization and bronchiectasis.
*Mycobacterium avium*
- While *Mycobacterium avium complex* (MAC) can infect patients with cystic fibrosis, it typically causes a **more indolent and chronic lung disease** rather than recurrent, self-limiting bouts of cough and sputum.
- MAC infections are often associated with **nodular or cavitary lesions** on imaging and may require prolonged multidrug therapy.
*Histoplasmosis*
- **Histoplasmosis** is a fungal infection endemic to certain geographic regions (e.g., Ohio and Mississippi River valleys) and is acquired by inhaling spores.
- It's **not a typical or recurrent pathogen** in cystic fibrosis patients in the way bacterial infections are, and its presentation often includes fever, chills, and disseminated disease in immunocompromised individuals.
*Pneumococcus*
- *Streptococcus pneumoniae* (**Pneumococcus**) is a common cause of **acute bacterial pneumonia** in the general population, including young children.
- While CF patients can get pneumococcal infections, the pattern of **recurrent bouts of foul-smelling mucopurulent sputum** without fever and the chronic nature of the lung disease point away from typical acute pneumococcal infection and more towards a chronic colonizer like *Pseudomonas*.
*Listeria*
- *Listeria monocytogenes* is primarily a cause of **foodborne illness**, leading to gastroenteritis, meningitis, or sepsis, particularly in immunocompromised individuals, pregnant women, and neonates.
- It is **not a common respiratory pathogen**, and its presentation does not align with the described recurrent pulmonary symptoms in a cystic fibrosis patient.
Question 2: A 51-year-old woman is brought to the emergency department because of an aggressive cough with copious amounts of thick, foamy, yellow-green sputum. She says she has had this cough for about 11 years with exacerbations similar to her presentation today. She also reports that her cough is worse in the morning. She was evaluated multiple times in the past because of recurrent bouts of bronchitis that have required treatment with antibiotics. She is a non-smoker. On physical examination, the blood pressure is 125/78 mm Hg, pulse rate is 80/min, respiratory rate is 16/min, and temperature is 36.7°C (98.0°F). Chest auscultation reveals crackles and wheezing over the right middle lobe and the rest of her physical examinations are normal. The chest X-ray shows irregular opacities in the right middle lobe and diffuse airway thickening. Based on this history and physical examination, which of the following is the most likely diagnosis?
A. Bronchiectasis (Correct Answer)
B. Tuberculosis
C. Chronic bronchitis
D. Chronic obstructive pulmonary disease
E. Alpha-1-antitrypsin deficiency
Explanation: ***Correct: Bronchiectasis***
- The classic presentation of **chronic cough with copious, purulent sputum** (thick, foamy, yellow-green) lasting 11 years is pathognomonic for bronchiectasis
- **Recurrent respiratory infections** requiring multiple antibiotic courses indicate permanent airway damage with impaired mucus clearance
- **Morning cough** reflects postural drainage of secretions that accumulated overnight in dilated bronchi
- **Non-smoker status** with chronic symptoms points to structural lung disease rather than smoking-related conditions
- Chest X-ray findings of **irregular opacities in right middle lobe and diffuse airway thickening** are characteristic of bronchiectasis (permanent dilation and thickening of airways)
- Right middle lobe is a common location for bronchiectasis due to anatomical drainage issues
*Incorrect: Tuberculosis*
- While TB can cause chronic cough and lung lesions, the **copious, foamy, purulent sputum** production is not typical of TB
- TB typically presents with **constitutional symptoms** (fever, night sweats, weight loss), which are absent here
- Chest X-ray in TB classically shows **apical infiltrates, cavitation, or granulomas**, not diffuse airway thickening
- The 11-year history with stable exacerbations would be unusual for untreated TB
*Incorrect: Chronic bronchitis*
- Chronic bronchitis requires **productive cough for ≥3 months per year for ≥2 consecutive years**, but is **strongly associated with smoking**
- This patient is a **non-smoker**, making chronic bronchitis unlikely
- The imaging finding of **diffuse airway thickening** suggests permanent structural changes (bronchiectasis) rather than simple mucosal inflammation
- Chronic bronchitis doesn't typically cause localized findings in one lobe
*Incorrect: Chronic obstructive pulmonary disease*
- COPD is characterized by **irreversible airflow limitation** and is almost exclusively seen in **smokers** or those with significant environmental exposure
- This **non-smoking patient** lacks the primary risk factor for COPD
- The dominant clinical features of **copious purulent sputum and airway thickening** are more consistent with bronchiectasis than the emphysema or chronic bronchitis components of COPD
- Physical exam would typically show **hyperinflation, decreased breath sounds, and prolonged expiration** in COPD, not localized crackles
*Incorrect: Alpha-1-antitrypsin deficiency*
- This genetic condition causes **early-onset emphysema** (typically age 30-40s) in non-smokers and may cause liver disease
- While it can present without smoking history, the predominant feature is **lower lobe-predominant emphysema**, not bronchiectasis
- The clinical picture of **copious purulent sputum, recurrent infections, and airway thickening** is inconsistent with primary alpha-1-antitrypsin deficiency
- This condition would show **hyperinflation and reduced lung markings** on imaging, not airway thickening
Question 3: A 9-year-old boy with cystic fibrosis (CF) presents to the clinic with fever, increased sputum production, and cough. The vital signs include: temperature 38.0°C (100.4°F), blood pressure 126/74 mm Hg, heart rate 103/min, and respiratory rate 22/min. His physical examination is significant for short stature, thin body frame, decreased breath sounds bilateral, and a 2/6 holosystolic murmur heard best on the upper right sternal border. His pulmonary function tests are at his baseline, and his sputum cultures reveal Pseudomonas aeruginosa. What is the best treatment option for this patient?
A. Dornase alfa 2.5 mg as a single-use
B. Oral cephalexin for 14 days
C. Inhaled tobramycin for 28 days (Correct Answer)
D. Minocycline for 28 days
E. Sulfamethoxazole and trimethoprim for 14 days
Explanation: ***Inhaled tobramycin for 28 days***
- This patient presents with a **mild pulmonary exacerbation** of **cystic fibrosis (CF)**, characterized by fever, increased sputum production, and the isolation of **Pseudomonas aeruginosa** from sputum cultures.
- The **pulmonary function tests (PFTs) at baseline** indicate this is a **mild exacerbation** that can be managed in the **outpatient setting**.
- **Inhaled tobramycin** is the appropriate first-line treatment for **mild-to-moderate exacerbations** and for **chronic suppressive therapy** of **Pseudomonas aeruginosa** infections in CF patients.
- It is effective in improving lung function, reducing bacterial load, and decreasing exacerbation frequency with minimal systemic toxicity.
- More severe exacerbations (significant PFT decline, respiratory distress) would require **IV antipseudomonal antibiotics**.
*Dornase alfa 2.5 mg as a single-use*
- **Dornase alfa** (DNase) is a mucolytic agent used in CF to reduce sputum viscosity and improve airway clearance by breaking down extracellular DNA in mucus.
- While beneficial for **chronic airway clearance therapy**, it is not an antibiotic and does not directly treat the **bacterial infection** causing the current exacerbation.
*Oral cephalexin for 14 days*
- **Cephalexin** is a first-generation cephalosporin that primarily targets **gram-positive bacteria** (such as Staphylococcus aureus) and some **gram-negative bacteria**.
- It is **completely ineffective against Pseudomonas aeruginosa**, which is intrinsically resistant to first-generation cephalosporins.
*Minocycline for 28 days*
- **Minocycline** is a **tetracycline antibiotic** with activity against many bacteria, including some **atypical pathogens** and **Staphylococcus aureus**.
- However, it is **not effective against Pseudomonas aeruginosa**, which is intrinsically resistant to tetracyclines and is a common and aggressive pathogen in CF patients.
*Sulfamethoxazole and trimethoprim for 14 days*
- **Sulfamethoxazole and trimethoprim** (TMP-SMX, Bactrim) is an antibiotic combination effective against various bacteria, including some **gram-negative organisms** and **Staphylococcus aureus**.
- It does **not provide adequate coverage for Pseudomonas aeruginosa**, making it an inappropriate choice for this patient's documented infection.
Question 4: A 72-year-old man is brought to the emergency department after an episode of hemoptysis. He has a chronic cough that is productive of copious sputum. Six years ago, he had a stroke that left him with difficulty swallowing. He smoked one pack of cigarettes daily for 40 years, but quit 2 years ago. His respirations are 25/min and labored. Physical examination shows digital clubbing. An x-ray of the chest shows tram track opacities in the lower lung fields. Which of the following is the most likely diagnosis?
A. Aspiration pneumonia
B. Bronchiectasis (Correct Answer)
C. Emphysema
D. Lung cancer
E. Chronic bronchitis
Explanation: ***Bronchiectasis***
- The combination of **chronic cough with copious sputum**, **hemoptysis**, **digital clubbing**, and **tram track opacities** on chest x-ray is highly characteristic of bronchiectasis.
- The patient's history of difficulty swallowing following a stroke suggests a risk factor for recurrent aspirations leading to chronic infection and airway damage characteristic of bronchiectasis.
*Aspiration pneumonia*
- While the patient has a risk factor for aspiration due to difficulty swallowing, aspiration pneumonia typically presents as an acute infection with fever and infiltrates, rather than chronic symptoms and specific radiographic findings like **tram track opacities** and **digital clubbing**.
- Aspiration pneumonia may lead to bronchiectasis if chronic, but it is not the most definitive diagnosis given the full constellation of findings described.
*Emphysema*
- Emphysema is a form of COPD characterized by destruction of alveolar walls and presents with **dyspnea**, **barrel chest**, and often a history of smoking, but does not typically cause **hemoptysis** or **tram track opacities**.
- Chest x-rays in emphysema usually show **hyperinflation** and **flattened diaphragms**, not specific airway dilation.
*Lung cancer*
- While **hemoptysis** and **chronic cough** can be symptoms of lung cancer, and the patient has a significant smoking history, lung cancer does not typically cause **copious sputum** or **tram track opacities**.
- Although digital clubbing can occur with lung cancer as a paraneoplastic syndrome, the presence of **tram track opacities** is pathognomonic for bronchiectasis and points strongly to this diagnosis.
*Chronic bronchitis*
- Chronic bronchitis is defined by a **chronic productive cough** for at least three months in two consecutive years and is associated with smoking.
- However, it does not typically cause **hemoptysis**, **digital clubbing**, or the specific **tram track opacities** seen on x-ray, which indicate bronchial wall thickening and dilation.
Question 5: A 61-year-old man presents with gradually increasing shortness of breath. For the last 2 years, he has had a productive cough on most days. Past medical history is significant for hypertension and a recent admission to the hospital for pneumonia. He uses a triamcinolone inhaler and uses an albuterol inhaler as a rescue inhaler. He also takes lisinopril and a multivitamin daily. He has smoked a pack a day for the last 32 years and has no intention to quit now. Today, his blood pressure is 142/97 mm Hg, heart rate is 97/min, respiratory rate is 22/min, and temperature is 37.4°C (99.3°F). On physical exam, he has tachypnea and has some difficulty finishing his sentences. His heart has a regular rate and rhythm. Auscultation of his lungs reveals wheezing and rhonchi that improves after a deep cough. Fremitus is absent. Pulmonary function tests show FEV1/FVC of 55% with no change in FEV1 after albuterol treatment. Which of the following is the most likely pathology associated with this patient's disease?
A. Airway hypersensitivity
B. Chronic granulomatous inflammation with bilateral hilar lymphadenopathy
C. Consolidation and red hepatization
D. Inflamed bronchus with hypertrophy and hyperplasia of mucous glands (Correct Answer)
E. Permanent bronchial dilation
Explanation: ***Inflamed bronchus with hypertrophy and hyperplasia of mucous glands***
- The patient's history of a **productive cough for 2 years**, a **32-pack-year smoking history**, and **irreversible obstructive lung disease** (FEV1/FVC of 55% with no change after albuterol) are classic signs of **chronic bronchitis**.
- The defining pathological feature of chronic bronchitis involves **inflammation of the large airways**, leading to **mucous gland hypertrophy** and **hyperplasia**, resulting in excessive mucus production and airway obstruction.
*Airway hypersensitivity*
- **Airway hypersensitivity** is characteristic of **asthma**, where triggers cause sudden bronchoconstriction, which is typically **reversible** with bronchodilators.
- The patient's FEV1/FVC ratio **did not improve with albuterol**, indicating an irreversible obstruction not typical of hypersensitivity alone.
*Chronic granulomatous inflammation with bilateral hilar lymphadenopathy*
- This description is characteristic of **sarcoidosis**, a systemic inflammatory disease.
- While sarcoidosis can cause respiratory symptoms, it does not fit the typical presentation of **chronic productive cough** in a heavy smoker, and the classic PFT findings for sarcoidosis are **restrictive**, not obstructive.
*Consolidation and red hepatization*
- **Consolidation** and **red hepatization** are pathological features seen in the acute phase of **lobar pneumonia**, reflecting alveolar inflammation and exudation.
- The patient had a recent admission for pneumonia, but his current chronic symptoms and PFT results point to an underlying **obstructive lung disease (chronic bronchitis)**, not acute pneumonia.
*Permanent bronchial dilation*
- **Permanent bronchial dilation** is known as **bronchiectasis**, which results from chronic inflammation and infection leading to destruction of the bronchial walls.
- While chronic bronchitis can sometimes lead to bronchiectasis, the primary and most direct pathological finding for the symptoms described (chronic productive cough in a smoker with irreversible obstruction) is the **inflammation and mucous gland changes** within the bronchi.
Question 6: A 1-year-old infant is brought to the emergency department by his parents because of fever and rapid breathing for the past 2 days. He had a mild seizure on the way to the emergency department and developed altered sensorium. His mother states that the patient has had recurrent respiratory infections since birth. He was delivered vaginally at term and without complications. He is up to date on his vaccines and has met all developmental milestones. His temperature is 37.0°C (98.6°F), pulse rate is 200/min, and respirations are 50/min. He is lethargic, irritable, and crying excessively. Physical examination is notable for a small head, an elongated face, broad nose, low set ears, and cleft palate. Cardiopulmonary exam is remarkable for a parasternal thrill, grade IV pansystolic murmur, and crackles over both lung bases. Laboratory studies show hypocalcemia and lymphopenia. Blood cultures are drawn and broad-spectrum antibiotics are started, and the child is admitted to the pediatric intensive care unit. The intensivist suspects a genetic abnormality and a fluorescence in situ hybridization (FISH) analysis is ordered which shows 22q11.2 deletion. Despite maximal therapy, the infant succumbs to his illness. The parents of the child request an autopsy. Which of the following findings is the most likely to be present on autopsy?
A. Aplastic thymus (Correct Answer)
B. Hypercellular bone marrow
C. Accessory spleen
D. Hypertrophy of Hassall's corpuscles
E. Absent follicles in the lymph nodes
Explanation: ***Aplastic thymus***
- This infant's presentation with 22q11.2 deletion, recurrent respiratory infections, hypocalcemia, and congenital heart disease (parasternal thrill, pansystolic murmur) is classic for **DiGeorge syndrome**.
- **DiGeorge syndrome** is characterized by thymic aplasia or hypoplasia, leading to **T-cell immunodeficiency**, and parathyroid hypoplasia, resulting in **hypocalcemia**.
*Hypercellular bone marrow*
- **Hypercellular bone marrow** indicates increased hematopoietic activity and is not a characteristic finding in DiGeorge syndrome.
- In immunodeficiency states like DiGeorge, the bone marrow itself is often normal or may show lymphoid depletion.
*Accessory spleen*
- **Accessory spleen** is a common congenital anomaly and is not specifically associated with DiGeorge syndrome or its immunodeficiency.
- While it can occur in individuals with DiGeorge syndrome, it is not a direct pathological consequence of the 22q11.2 deletion.
*Hypertrophy of Hassall's corpuscles*
- **Hassall's corpuscles** are found in the medulla of the thymus, and their hypertrophy would indicate an active or hyperplastic thymus, which is contrary to the **thymic aplasia/hypoplasia** seen in DiGeorge syndrome.
- In DiGeorge syndrome, the thymus is either absent or severely underdeveloped.
*Absent follicles in the lymph nodes*
- **Absent follicles in the lymph nodes** would indicate a B-cell deficiency, as follicles are primarily composed of B lymphocytes.
- DiGeorge syndrome primarily affects **T-cell development** due to thymic abnormalities, not B-cell development or lymph node follicular formation directly.
Question 7: In which of the following pathological states would the oxygen content of the trachea resemble the oxygen content in the affected alveoli?
A. Emphysema
B. Exercise
C. Pulmonary embolism (Correct Answer)
D. Pulmonary fibrosis
E. Foreign body obstruction distal to the trachea
Explanation: ***Pulmonary embolism***
- A pulmonary embolism blocks **blood flow** to a portion of the lung, creating **dead space ventilation** (high V/Q ratio).
- In the affected alveoli, **no blood perfusion** means no oxygen extraction occurs, so the alveolar oxygen content remains **high and similar to tracheal/inspired air**.
- This is the classic physiological state where ventilation continues but perfusion is absent, preventing gas exchange.
*Foreign body obstruction distal to the trachea*
- A complete obstruction **prevents fresh air** from reaching the affected alveoli.
- The trapped gas undergoes **resorption atelectasis**: oxygen is absorbed into capillary blood, CO2 diffuses in, and alveolar gas equilibrates with **venous blood** composition.
- Alveolar oxygen content becomes **very low**, not similar to tracheal air.
*Emphysema*
- Emphysema involves destruction of **alveolar walls** and enlargement of airspaces with impaired gas exchange.
- While V/Q mismatch occurs, oxygen is still extracted by perfusing blood.
- Alveolar oxygen content is **lower than tracheal air** due to ongoing (though inefficient) gas exchange.
*Exercise*
- During exercise, **oxygen consumption increases** dramatically with enhanced cardiac output and oxygen extraction.
- Alveolar oxygen content is **significantly lower** than tracheal air due to increased oxygen uptake by blood.
*Pulmonary fibrosis*
- Pulmonary fibrosis causes **thickening of the alveolar-capillary membrane**, impairing oxygen diffusion.
- Despite diffusion limitation, blood still perfuses the alveoli and extracts oxygen.
- Alveolar oxygen content is **lower than tracheal air**, though the A-a gradient is increased.
Question 8: A 47-year-old woman presents to her physician for difficulty swallowing. She states that she intentionally delayed seeing a physician for this issue. She says her primary issue with swallowing is that her mouth always feels dry so she has difficulty chewing food to the point that it can be swallowed. On physical examination, her oral mucosa appears dry. Both of her eyes also appear dry. Several enlarged lymph nodes are palpated. Which of the following patterns of reactive lymphadenitis is most commonly associated with this patient’s presentation?
A. Sinus hyperplasia
B. Follicular hyperplasia (Correct Answer)
C. Diffuse hyperplasia
D. Mixed B and T cell hyperplasia
E. Paracortical hyperplasia
Explanation: ***Follicular hyperplasia***
- The patient's symptoms of **dry mouth (xerostomia)** and **dry eyes (xerophthalmia)** strongly suggest **Sjögren syndrome**. This autoimmune disease selectively affects **exocrine glands**, particularly the salivary and lacrimal glands.
- Lymphoid hyperplasia, especially **follicular hyperplasia**, is a common feature in Sjögren syndrome due to chronic B-cell activation, which is linked to a higher risk of developing **MALT lymphoma**.
*Sinus hyperplasia*
- **Sinus hyperplasia**, also known as **reticular hyperplasia**, is characterized by an increase in the number and size of macrophages within the subcapsular and medullary sinuses of lymph nodes.
- It is typically associated with **lymph nodes draining a site of malignancy** or conditions involving histiocytic proliferation.
*Diffuse hyperplasia*
- **Diffuse hyperplasia** involves a generalized expansion of all lymphoid components within the lymph node, without a predominance of any specific area.
- This pattern is less specific and can be seen in various **chronic inflammatory conditions** or reactive processes, but it is not the most characteristic pattern for Sjögren syndrome.
*Mixed B and T cell hyperplasia*
- While both B and T cells are involved in immune responses, **mixed B and T cell hyperplasia** refers to the expansion of both populations in a less defined pattern than follicular or paracortical types.
- Conditions like **toxoplasmosis** can present with mixed hyperplasia, but it is not the classic pattern seen in Sjögren syndrome.
*Paracortical hyperplasia*
- **Paracortical hyperplasia** involves the expansion of the paracortical areas of the lymph node, which are rich in T-lymphocytes.
- This pattern is typically seen in response to **viral infections** (e.g., infectious mononucleosis) or certain drug reactions, where T-cell activation is a prominent feature.
Question 9: A 31 year-old African-American female presents with painful shin nodules, uveitis, and calcified hilar lymph nodes. A transbronchial biopsy of the lung would most likely show which of the following histologies?
A. Golden-brown fusiform rods
B. Inflammation, fibrosis and cyst formation that is most prominent in subpleural regions
C. Non-caseating granulomas (Correct Answer)
D. Silica particles (birefringent) surrounded by collagen
E. Patchy interstitial lymphoid infiltrate into walls of alveolar units
Explanation: ***Non-caseating granulomas***
- The constellation of **erythema nodosum** (painful shin nodules), **uveitis**, and **hilar lymphadenopathy** in an African-American female is highly characteristic of **sarcoidosis**.
- **Sarcoidosis** is pathologically defined by the presence of **non-caseating granulomas** in affected tissues, which would be visible on a transbronchial biopsy.
*Golden-brown fusiform rods*
- These are **ferruginous bodies**, characteristic of **asbestosis**, which is not supported by the patient's presentation.
- Asbestosis would typically involve a history of **asbestos exposure** and present with **pleural plaques** or **interstitial fibrosis**.
*Inflammation, fibrosis and cyst formation that is most prominent in subpleural regions*
- This description is more indicative of **pulmonary Langerhans cell histiocytosis**, a rare disease usually associated with **smoking**.
- It does not align with the patient's specific systemic manifestations like uveitis or erythema nodosum.
*Silica particles (birefringent) surrounded by collagen*
- This describes the histological findings of **silicosis**, an occupational lung disease resulting from exposure to **silica dust**.
- Silicosis is not typically associated with uveitis or erythema nodosum.
*Patchy interstitial lymphoid infiltrate into walls of alveolar units*
- This pattern can be seen in various interstitial lung diseases, but it is not specific for sarcoidosis.
- It could be found in conditions like **lymphoid interstitial pneumonia**, which does not fit the overall clinical picture.
Question 10: A 68-year-old male smoker dies suddenly in a car accident. He had smoked 2 packs per day for 40 years. His past medical history is notable for a frequent, very productive cough, recurrent respiratory infections and occasional wheezing. He had no other medical problems. At autopsy, which of the following is most likely to be found in this patient?
A. Increased number and activity of goblet cells (Correct Answer)
B. Ferruginous bodies
C. Mucous gland atrophy
D. Interstitial fibrosis of the lung
E. Pleural plaques
Explanation: ***Increased number and activity of goblet cells***
- The patient's history of a **productive cough**, **recurrent respiratory infections**, and **wheezing** in a chronic smoker strongly indicates **chronic bronchitis**.
- **Chronic bronchitis** is pathologically characterized by **hypertrophy of mucous glands** and an **increase in goblet cell number and activity**, leading to excessive mucus production.
*Ferruginous bodies*
- **Ferruginous bodies** are typically found in **asbestosis**, a lung disease caused by asbestos exposure.
- While asbestos exposure can cause respiratory symptoms, the sudden death and clinical picture without specific exposure history do not point to asbestosis as the primary diagnosis.
*Mucous gland atrophy*
- **Mucous gland atrophy** is generally not associated with chronic smoking and the symptoms described.
- In conditions like chronic bronchitis, there is actually **hypertrophy** and **hyperplasia** of the mucous glands, leading to increased mucus production.
*Interstitial fibrosis of the lung*
- **Interstitial fibrosis** is characteristic of conditions like **idiopathic pulmonary fibrosis** or other **interstitial lung diseases**.
- While smoking is a risk factor for some forms of fibrosis, the predominant symptoms of a productive cough and recurrent infections are more indicative of chronic bronchitis rather than diffuse interstitial fibrosis.
*Pleural plaques*
- **Pleural plaques** are **fibrous thickenings of the pleura**, almost exclusively associated with **asbestos exposure**.
- They are usually asymptomatic and do not directly explain the productive cough, recurrent infections, and wheezing presented in this patient's history.
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