PA25.1-7 | Respiratory System — Graded Quiz

A 67-year-old alcoholic man is brought to the emergency department with high-grade fever, rigors, and rusty-brown sputum for 3 days. Chest X-ray shows complete consolidation of the right lower lobe with visible air bronchograms. He is treated with antibiotics and recovers. Two weeks later, repeat imaging shows complete resolution. Which stage of lobar pneumonia had the patient most likely entered at the time of presentation, given the gross appearance of rusty sputum and early hepatization?

A 72-year-old diabetic woman is admitted with confusion, productive cough, and a spiking fever. Her husband reports she frequently chokes while eating. Blood cultures grow mixed anaerobic organisms. CT chest reveals a thick-walled cavity with an air-fluid level in the posterior segment of the right upper lobe, surrounded by consolidated parenchyma. Which of the following best explains the predilection of aspiration lung abscess for this anatomical location?

A 55-year-old ex-smoker (40 pack-years, quit 5 years ago) presents with progressive exertional breathlessness and a barrel-shaped chest. Spirometry shows FEV1/FVC 0.58, FEV1 42% predicted, and TLC 130% predicted. HRCT shows bilateral paraseptal and centrilobular areas of low attenuation without walls, predominating in the upper zones. Which pathological mechanism best explains the upper-zone predominance of this disease pattern in relation to smoking?

A 29-year-old atopic woman with seasonal allergic rhinitis is brought to the emergency department during a severe asthma exacerbation. She has not responded to four doses of salbutamol. On examination, she has a respiratory rate of 34/min, SpO2 82%, and is using accessory muscles. She dies despite resuscitation. Autopsy reveals overdistended lungs with mucus plugs filling the airways. Microscopy of the bronchial wall would most characteristically show which combination of findings?

A 10-year-old child from a rural area presents with a 3-week history of low-grade fever, weight loss, and a positive Mantoux test (induration 18 mm). Chest X-ray shows a small calcified nodule in the right mid-zone with ipsilateral hilar enlargement. The child is otherwise well. This radiological complex represents the end result of which immunological process?

A 48-year-old man presents with progressive dyspnoea and a productive cough over 6 months. He has worked in a granite quarrying operation for 20 years without respiratory protection. HRCT shows bilateral upper-zone nodules, some coalescing to large masses, with 'eggshell calcification' of hilar lymph nodes. Lung function testing shows a restrictive pattern. He is also found to have a significantly elevated serum ACE level and an abnormal Mantoux reaction. Which of the following best explains why this patient is at markedly increased risk for pulmonary tuberculosis?

A 63-year-old male construction worker with a 35-pack-year smoking history presents with a 3-month history of haemoptysis, weight loss, and progressive breathlessness. CT shows a 4.5 cm central hilar mass with mediastinal lymphadenopathy and post-obstructive collapse of the right upper lobe. Bronchoscopic biopsy reveals large pleomorphic cells arranged in nests with abundant pink cytoplasm, no gland formation, and intercellular bridges on high-power examination. Which tumour type and its most likely immunohistochemical profile best match this biopsy?

A 58-year-old woman, a lifelong non-smoker who worked as a cook in a poorly ventilated kitchen for 30 years, presents with a 2.5 cm peripheral lung nodule discovered incidentally. CT-guided biopsy shows tumour cells growing along alveolar walls without stromal invasion, vascular involvement, or pleural involvement. The pathologist uses the term 'lepidic' pattern. Molecular testing reveals an EGFR exon 19 deletion. Which of the following best describes the expected biological behaviour and optimal therapeutic approach for this tumour?

A 61-year-old male shipyard worker presents with progressive dyspnoea, a dry cough, and bilateral basal fine crackles over 10 years. He reports no smoking history but worked with lagging materials for 25 years. CT thorax shows bilateral lower-zone ground-glass opacification and pleural plaques. Pulmonary function tests reveal FVC 58% predicted, FEV1/FVC 0.80, DLCO 45% predicted. He is now referred for evaluation of a right pleural effusion with a thick, shaggy pleural peel. Cytological examination of pleural fluid shows malignant mesothelial cells. Which gross feature of mesothelioma best explains why the lesion typically encases rather than invades the lung parenchyma?

A 50-year-old woman is diagnosed with primary pulmonary hypertension. She is incidentally found to have bilateral hilar lymphadenopathy and elevated serum ACE. Bronchoscopic biopsy of a peribronchial nodule shows non-caseating granulomas with Langhans-type giant cells and asteroid bodies. Ziehl-Neelsen stain is negative, and cultures are sterile. Her spirometry shows a restrictive pattern. Which occupational exposure would most specifically explain this combination of findings if present in her history?

A 68-year-old man with a 45 pack-year history presents with haemoptysis, weight loss, and a central right-sided mass on CXR with associated right upper lobe collapse. Bronchoscopic biopsy shows a tumour with small dark cells, nuclear moulding, a very high mitotic rate, and 'salt-and-pepper' chromatin. Immunohistochemistry shows synaptophysin+, CD56+, and a Ki-67 index of 85%. Serum sodium is 122 mmol/L despite normal fluid intake. What is the most likely paraneoplastic mechanism responsible for his hyponatraemia?

A pathology museum exhibit displays a gross specimen: a lung lobe showing a cavity approximately 6 cm in diameter in the upper zone, with a thick, irregular fibrotic wall lined by yellowish caseous material. Adjacent parenchyma shows multiple grey-white nodules at various stages of healing and fibrosis. Satellite lesions are visible extending toward the pleura, and one nodule appears to have ruptured into the pleural space. A Year-2 student examining this specimen concludes it is secondary (post-primary) tuberculosis. Which combination of features most supports this conclusion versus a lung abscess?