Respiratory Pathology ( 10% )

Question 1

6. All of the following cause compressive atelectasis EXCEPT:

• a. Pneumothorax
• b. Asthma
• c. CCF
• d. Peritonitis
• e. Pleural effusion

Answer 1

Nick says b. Asthma

I think c. CCF

• Others all reduce volume of breathing (peritonitis) or can lead to collapse.*
• CCF would fill alveoli with fluid, so they could not collapse. Asthma can cause mucous plugging and obstruction.*

Question 2

20. With respect to atelectasis

• a. The mediastinum may shift away from the affected lung.
• b. Obstructive atelectasis is commonest after trauma.
• c. Compressive atelectasis is commonly encountered in patients with chronic obstructive airways disease.
• d. It is an irreversible disorder
• e. It can develop when there is loss of pulmonary surfactant.

Answer 2

a. The mediastinum may shift away from the affected lung.

This is listed as wrong, however this occurs in compression atelectasis

e. It can develop when there is loss of pulmonary surfactant.

Technically can refer to neonatal RDS (this was listed as right)

• b. Obstructive atelectasis is commonest after Mucus or exudate plugging
• c. Obstructive atelectasis is commonly encountered in patients with chronic obstructive airways disease.
• d. It is a reversible disorder.

Question 3

28. obstructive atelectasis

• a. the mediastinum moves away from lesion
• b. involves the reabsorption of air
• c. is caused by pleural fluid

Answer 3

b. involves the reabsorption of air

• a. the mediastinum moves towards the lesion
• c. is caused by mucous or exudative plugging

Question 4

36. Restrictive lung disease is characterized by

• a. Acute inflammation of alveolar interstitium
• b. Increased compliance
• c. Ground glass appearance on chest X-ray film
• d. Long term complication of mesothelioma
• e. Increased lung volume

Answer 4

c. Ground glass appearance on chest X-ray film

Question 5

2. squamous cell lung carcinoma

• a. has a 5 year survival rate of 60%
• b. is most commonly associated with smokers
• c. is commonest peripherally.
• d. is commonest in females.

Answer 5

b. is most commonly associated with smokers

• a. has a 5 year survival rate of 60%
• c. is commonest Hilum / central
• d. is commonest in Males

Question 6

7. Which is not true of bronchogenic cysts

• a. They may become dysplastic.
• b. They occasionally cause pneumothorax
• c. They have an epithelial layer
• d. They may contain mucous
• e. They are often associated with bronchioles

Answer 6

e. They are often associated with bronchioles

Bronchogenic cysts are congenital malformations of the bronchial tree (a type of bronchopulmonary foregut malformation). They can present as a mediastinal mass that may enlarge and cause local compression. It is also considered the commonest of foregut duplication cysts.

Question 7

9. Regarding bronchogenic carcinoma

• a. It most often arises around the hilum of the lung
• b. Distant spread occurs solely by lymphatic spread
• c. Metastasis are most common to the liver
• d. Small cell carcinoma is the most common type
• e. Surgical resection is often effective for small cell carcinoma

Answer 7

a. It most often arises around the hilum of the lung

Question 8

24. All of the following are neoplastic syndromes associated with lung cancer EXCEPT:

• a. Cushings syndrome
• b. Syndrome of inappropriate ADH secretion
• c. Hypocalcaemia.
• d. Carcinoid syndrome
• e. Hypertrophic osteoarthropathy

Answer 8

c. Hypercalcaemia.

Question 9

25. Which of the following is not a paraneoplastic syndrome associated with lung carcinoma?

• a. Ectopic ADH secretion
• b. Dermatomyositis
• c. Migratory thrombophlebitis
• d. Eaton-Lambert (myasthenic) syndrome
• e. Thrombocytosis

Answer 9

e. Thrombocytosis

Question 10

26. The features of bronchogenic carcinoma include

• a. The classification of “oat cell” tumour within the large cell type
• b. High initial response to chemotherapy for small cell type
• c. The strongest correlation with cigarette smoking in the adenocarcinoma type
• d. That 50% of small cell type occur in non-smokers
• e. Histological features identical in small cell carcinomas and squamous cell types

Answer 10

b. High initial response to chemotherapy for small cell type

• Small cell has a strong association with smoking*
  c. The strongest correlation with cigarette smoking in the squamous cell type

Question 11

45. Regarding malignant mesothelioma

• a. It is asbestos related in more than 90% of cases.
• b. It has been found to contain adenovirus DNA sequence
• c. Smoking increases the risk of developing mesothelioma.
• d. 50% of patients die within 6 months of diagnosis
• e. can contain epithelioid and sarcomatoid cells

Answer 11

e. can contain epithelioid and sarcomatoid cells

• a. It is asbestos related in 90% of cases.
• b. It has been found to contain adenovirus DNA sequence
• c. asbestos increases the risk of developing mesothelioma.
• d. 50% of patients die within 6 months of diagnosis

Question 12

15. Comparing the pulmonary oedema of CCF with ARDS, a defining characteristic of ARDS is:

• a. Spontaneous resolution within 48 hours
• b. Formation of hyaline membranes
• c. A deficiency of surfactant
• d. A distinct lobar pattern of consolidation
• e. High pulmonary wedge pressures

Answer 12

b. Formation of hyaline membranes

Question 13

37. ARDS is associated with all of the following EXCEPT:

• a. Interstitial fibrosis
• b. Pulmonary vein obstruction
• c. Hypoxaemia responsive to oxygen therapy
• d. Radiation injury
• e. DKA

Answer 13

c. Hypoxaemia responsive to oxygen therapy

Is associated with oxygen toxicity

Question 14

39. Pulmonary oedema

• a. Contains a protein rich fluid in the alveolar spaces
• b. Fluid accumulates especially in the dependent apical regions of the lower lobe
• c. In a chronic state, can result in interstitial fibrosis
• d. Is not associated with ARDS
• e. Can result from increased hydrostatic pressure such as in the nephritic syndrome

Answer 14

​c. In a chronic state, can result in interstitial fibrosis

• a. Contains a protein poor fluid in the alveolar spaces (a transudate)
• b. Fluid accumulates especially in the dependent basal regions of the lower lobe
• d. IS associated with ARDS (I assume they mean that ARDS is similar to pulmonary oedema)
• e. Can result from increased hydrostatic pressure such as in volume overload, CHF, LV failure
  
  • ​Nephritic syndrome causes a low oncotic pressure

Question 15

1. The type of emphysema associated with smoking is

• a. Panacinar
• b. Centriacinar
• c. Distal acinar
• d. Irregular
• e. None of the above

Answer 15

b. Centriacinar

• Aka the more proximal regions are destroyed*
• Panacinar is seen in a1 antitrypsin deficiency*

Question 16

5. Chronic bronchitis is characterized by

• a. Smooth muscle hypertrophy
• b. Leukocyte infiltration
• c. Mucous gland hypertrophy
• d. Increased size of goblet cells

Answer 16

c. Mucous gland hypertrophy

• Pathogenesis
  
  • Chronic irritation of airways by inhaled substances (usually tobacco smoke)
  • Bronchial epithelial metaplasia from columnar to squamous
  • Mucus gland hypertrophy and goblet cell metaplasia allow for hypersecretion
    
    • Stimulated by histamine
  • Chronic infl -> fibrosis (cf emphysema which has minimal or no fibrosis)
  • Inhaled irritants impair ciliary function and therefore mucus clearance
  • Infections play a significant role in maintaining the disease state

Question 17

8. Chronic bronchitis major morphological change involves

• a. Leukocyte infiltration
• b. Decreased goblet cell number
• c. Smooth muscle hypertrophy
• d. Increased mucosal gland depth (REID index)
• e. Monocyte infiltration

Answer 17

d. Increased mucosal gland depth (REID index)

Mucosal gland hypertrophy and goblet cell metaplasia

Emphysema is characterised by a neutrophil infiltrate

Question 18

10. In emphysema

• a. A deficiency of alpha 1 antitryptin is protective
• b. Centriacinar destruction leads to obstructive overinflation
• c. The protease-antiprotease mechanism is the most plausible explanation of the disease
• d. Smokers have an increased number of macrophages in the bronchi
• e. Elastase activity is unaffected by oxygen free radicals

Answer 18

c. The protease-antiprotease mechanism is the most plausible explanation of the disease

• emphysema is characterised by a neutrophil infiltrate*
• Oxygen free radicals degrade elastin*
• Centriacinar destruction leads to overinflation due to loss of usual elastic tissues*

Question 19

11. In chronic bronchitis

• a. The hallmark is hypersecretion of mucous in the large airways
• b. There is a marked increase in goblet cells in the main bronchi
• c. Infection is a primary cause
• d. Cigarette smoke stimulates alveolar leukocytes
• e. Dysplasia of the epithelium leads to emphysema

Answer 19

a. The hallmark is hypersecretion of mucous in the large airways

• b. There is metaplasia in goblet cells in the main bronchi -> mucous hypersecretion
• c. Infection is a complication and secondary cause of further damage
• d. Cigarette smoke stimulates alveolar leukocytes (this occurs in emphysema)
• e. Dysplasia of the epithelium leads to emphysema - seperate but often connected disease processes

Question 20

12. In bronchial asthma

• a. Extrinsic asthma is initiated by diverse non-immune mechanisms
• b. Sub-epithelial vagal receptors in respiratory mucosa are insensitive to irritants
• c. IgG plays a role
• d. Bronchial wall smooth muscle is atrophic
• e. Primary mediators include eosinophilic and neutrophilic chemotactic factors

Answer 20

e. Primary mediators include eosinophilic and neutrophilic chemotactic factors

Question 21

14. Regarding anatomical types of emphysema:

• a. Panacinar is more common than centriacinar
• b. Centriacinar is not common in smokers
• c. Paraseptal emphysema is associated with alpha-1 antitrypsin deficiency
• d. Spontaneous penumothorax is common in panacinar type
• e. Distal portion of acinus is predominantly involved in paraseptal emphysema

Answer 21

e. Distal portion of acinus is predominantly involved in paraseptal emphysema

• Centriacinar is common in smokers, and more common than panacinar*
• Panacinar is associated with a1AT deficiency*
• PTX common in paraseptal / distal acinar*

Question 22

22. Regarding emphysema

• a. The usual age of onset is 40-50 years.
• b. Copious sputum production is common.
• c. Cor pulmonale is a common feature.
• d. Airways resistance may be normal
• e. CXR usually shows a large heart.

Answer 22

d. Airways resistance may be normal

• a. The usual age of onset is 40-50 years in Chronic bronchitis.
  
  • ​Emphysema is later (50-70)
• b. Copious sputum production is Uncommon
• c. Cor pulmonale is an Uncommon feature
• e. CXR usually shows a large heart in Chronic bronchitis due to cor pulmonale

Question 23

19. The following is not an obstructive airways disease

• a. Emphysema
• b. Pneumonia
• c. Asthma
• d. Bronchitis
• e. Bronchiectasis

Answer 23

b. Pneumonia

Question 24

40. Characteristic histologic findings of asthma include:

• a. Thinning of the basement membrane of the bronchial epithelium
• b. Oedema and an inflammatory infiltrate in the bronchial walls with a prominence of plasma cells
• c. An increase in size of the submucosal glands
• d. Atrophy of the bronchial wall muscle
• e. Undistended lungs because of occlusion of bronchioles

Answer 24

c. An increase in size of the submucosal glands

Morphology of asthma

• Bronchial smooth muscle and submucosal gland hypertrophy
• Thickening of the basement membrane of bronchial epithelium
• Subepithelial fibrosis
• Oedema and an infiltrate of eosinophils and mast cells in the bronchial walls
• Curshmann spirals

Question 25

41. Regarding the pathogenesis of COPD: * a. Macrophage elastase function is inhibited by alpha1-antitrypsin * b. Cigarette smoking activates the classic complement pathway * c. Microbiologic infections initiate the changes. * d. Smokers have decreased numbers of neutrophils in their alveoli * e. Chronic bronchitis is up to 10 times more common in heavy smokers

Answer 25

a. Macrophage elastase function is inhibited by alpha1-antitrypsin e. Chronic bronchitis is up to 10 times more common in heavy smokers * Probably one of these two - a) fits with the protease/antiprotease theory. e) - I wouldnt be surpirsed if the ratio was higher.* * b. Cigarette smoking activates the *alternative* complement pathway * c. Microbiologic infections initiate the changes. * *Thought to be due to protease-antiprotease imbalance* * *Infection -\> bronchiectasis* * d. Smokers have decreased numbers of *?macrophages* in their alveoli

Question 26

43. emphysema * a. is defined clinically as persistent cough with sputum production for at least three months in at least two consecutive years. * b. is defined morphologically as the abnormal enlargement of air spaces proximal to the terminal bronchioles. * c. is a restrictive lung disease. * d. has airway dilation and scarring as its major pathological change. * e. develops earlier in smokers with an alpha 1 antitrypsin deficiency

Answer 26

**e. develops earlier in smokers with an alpha 1 antitrypsin deficiency** * *Chronic brochitis* is defined clinically as persistent cough with sputum production for at least three months in at least two consecutive years. * b. is defined morphologically as the abnormal enlargement of air spaces *distal* to the terminal bronchioles. * c. is a *obstructive* lung disease * *Bronchiectasis* has airway dilation and scarring as its major pathological change.

Question 27

44. Regarding asthma * a. The inflammatory infiltrate of bronchial walls is predominantly neutrophils * b. Hypertrophy of bronchial wall muscle reflects prolonged bronchoconstriction * c. It is triggered by IgG response * d. Sympathetic stimulation provokes bronchoconstriction * e. Bacteria are the most common provokers of an acute attack

Answer 27

**b. Hypertrophy of bronchial wall muscle reflects prolonged bronchoconstriction** * a. The inflammatory infiltrate of bronchial walls is predominantly *eosinophils* * c. It is triggered by *IgE* response * d. *Parasympathetic (vagal)* stimulation provokes bronchoconstriction * e. *Allergens* are the most common provokers of an acute attack

Question 28

3. Intrinsic asthma: * a. Decreases vagal afferent responsiveness. * b. Is associated with atopy. * c. is commonly triggered by viral infections * d. IgE levels are often elevated. * e. The airway is not hyperreactive.

Answer 28

Intrinsic = non-atopic **c. is commonly triggered by viral infections** * a. *increased* vagal afferent responsiveness. * b. Is *not* associated with atopy. * d. IgE levels are often elevated *in Atopic* * e. The airway *_is_* hyperreactive.

Question 29

29. Asthma shows all EXCEPT * a. Thinning of basement membrane. * b. Submucosal gland hypertrophy * c. Hypertrophy of smooth muscle * d. Charcot Leyden crystals * e. Cushmann’s spirals

Answer 29

a. *Thickening* of basement membrane.

Question 30

30. Regarding the use of steroids in Asthma * a. They inhibit cytokines * b. Cause bronchodilation * c. Given nocte because of diurnal variation

Answer 30

**a. They inhibit cytokines** *Do not have a direct action on smooth muscle - hence the time taken for them to work acutely, and often just used prophylactically*

Question 31

31. The most common type of emphysema associated with cigarette smoking is * a. Centrilobular * b. Panacinar * c. Paraseptal * d. Irregular * e. Compensatory

Answer 31

**a. Centrilobular**

Question 32

33. Chronic bronchitis * a. Is twenty times more common in heavy smokers * b. Is present in any patient with persistent cough with sputum production for at least two months in three consecutive years * c. Is characterized by early functional respiratory impairment * d. Can progress to cor pulmonale and cardiac failure * e. Is a disease of the large airways

Answer 32

**d. Can progress to cor pulmonale and cardiac failure** *Can be diagnosed by 3 months of cough in 2 consective years*

Question 33

34. Regarding emphysema * a. The commonest type is panacinar form * b. In centrilobular form, the distal alveoli are spared * c. In panacinar form, the upper lobes of the lungs are mainly affected * d. In centrilobular form, the lower lobes of the lungs are mainly affected * e. There is no association between cigarette smoking and emphysema

Answer 33

**b. In centrilobular form, the distal alveoli are spared** * Centrlobular is more common, mainly affects the upper lobes, and associated with smoking* * Panacinar is associated wtih a1AT deficiency, and is less common*

Question 34

35. Features of atopic asthma include all of the following EXCEPT: * a. IgE production by beta-cells * b. Induction of TH1 cells. * c. Release of IL-4 and IL-5 * d. Growth of mast cells * e. Activation of eosinophils

Answer 34

b. Induction of *TH2* cells.

Question 35

4. Lobar pneumonia * a. Is more common in the young and the elderly * b. Involves morphological changes of red to grey hepatisation * c. Not usually associated with a productive cough * d. Is associated with immunosuppression * e. Rarely caused by streptococcus

Answer 35

b. Involves morphological changes of red to grey hepatisation

Question 36

13. In bacterial pneumonia * a. Patchy consolidation of the lung is the dominant feature of bronchopneumonia * b. A lobar distribution is a function of anatomical variations * c. Klebsiella pneumonia is a common virulent agent * d. Alveolar clearance of bacteria is achieved by lymphocytes * e. The nasopharynx is inconsequential in defending the lung against infection

Answer 36

**a. Patchy consolidation of the lung is the dominant feature of bronchopneumonia** * b. A lobar distribution is a function of anatomical variations * *?it just happens that it involves a lobe - can occur in anyone, does not need anatomical variation* * c. Klebsiella pneumonia is a *uncommon* virulent agent * d. Alveolar clearance of bacteria is achieved by *macrophages* * e. The nasopharynx is *important* in defending the lung against infection

Question 37

16. Bacterial pneumonia: * a. May be predisposed to by immotile cilia syndromes (eg. Kartageners) * b. Is characterized by an acute (neutrophilic) suppurative exudates within alveolar spaces and airways * c. Is a frequent cause of death in hospitalized patients * d. May be complicated by organisation * e. All of the above

Answer 37

**e. All of the above**

Question 38

18. Regarding pulmonary infections: * a. Respiratory tract infections are more frequent than infection of any other organ * b. Patchy consolidation is uncommon with bronchopneumonia. * c. Lobar pneumonia is more frequent than bronchopneumonia. * d. Haematogenous secondary seeding of lungs does not occur. * e. Commonest infectious agents are H. influenzae and K. pneumoniae.

Answer 38

**a. Respiratory tract infections are more frequent than infection of any other organ** * b. Patchy consolidation is *the defining feature* of bronchopneumonia. * c. Lobar pneumonia is *less* frequent than bronchopneumonia. * d. Haematogenous secondary seeding of lungs *can rarely* occur. * e. Commonest infectious agents are H. influenzae and *S. pneuoniae*

Question 39

21. Regarding lung abscesses: * a. Aspiration most commonly results in abscesses in the left lung. * b. Anaerobic organisms are the exclusive isolates in 60% of cases. * c. A central area of liquefactive necrosis develops * d. Infected emboli from bacterial endocarditis typically affect the right lung * e. Secondary empyema occurs in 50% of cases

Answer 39

**b. Anaerobic organisms are the exclusive isolates in 60% of cases.** **????Commonly mixed** * a. Aspiration most commonly results in abscesses in the *right* lung. * c. A central area of liquefactive necrosis develops * ????

Question 40

7. In lobar pneumonia: * a. It is more common in the young and elderly * b. Get a change from red to grey hepatisation * c. Not usually associated with a productive cough * d. Rarely caused by streptococcus * e. Associated with immunosuppression

Answer 40

b. Get a change from red to grey hepatisation

Question 41

32. In regards to bacterial pneumonia * a. A predominantly interstitial pattern of inflammation is seen in some paediatric patients * b. Most lobar pneumonias are caused by pneumococci which enter the lung haematogenously. * c. Congestion predominates in the first 72 hours. * d. Complications are more common with bronchopneumonias * e. Organization of exudates into a fibrotic scar tissue is not a complication.

Answer 41

**a. A predominantly interstitial pattern of inflammation is seen in some paediatric patients** * b. Most lobar pneumonias are caused by pneumococci which enter the lung *Via airways* * c. Congestion predominates in the first *(less than* 72 hours) * d. Complications are *less* common with bronchopneumonias * e. Organization of exudates into a fibrotic scar tissue _is_ a complication.

Question 42

38. In the lungs * a. Bacterial invasion evokes exudative liquification * b. Bronchopneumonia is commonly caused by Chlamydia organisms. * c. 90-95% of lobar pneumonias are caused by Streptococcus pneumoniae. * d. grey hepatisation is the first stage of the inflammatory response. * e. bronchopneumonia shows characteristic radiological appearance of radio-opaque well circumscribed lobe.

Answer 42

**c. 90-95% of lobar pneumonias are caused by Streptococcus pneumoniae.** *This is the answer given, but as per Nick:* **Doubtful af** * a. Bacterial invasion evokes exudative liquification * ??abscesses * b. Bronchopneumonia is *not* commonly caused by Chlamydia organisms. * d. grey hepatisation is the *third* stage of the inflammatory response. * First is congestion * Second Red hepatisation * Fourth is resolution by repair or scar * e. *lobar* pneumonia shows characteristic radiological appearance of radio-opaque well circumscribed lobe.

Question 43

42. Regarding bacterial pneumonia * a. Lobar pneumonia is most often caused by staphylococci * b. Coliform bacteria are unlikely to cause bronchopneumonia * c. Particles larger than 10mm are deposited in terminal airways of alveoli * d. Lobar distribution is an indication of the virulence of the organism * e. During resolution, the transudate is digested by enzymes

Answer 43

d. Lobar distribution is an indication of the virulence of the organism