Figure 44.1. Posteroanterior chest x-ray for Question 9.

QUESTION 10–14. For each of the five following statements (10–14), indicate whether it pertains to patients with asthma, chronic obstructive pulmonary disease (COPD), neither, or both.

    A. Asthma

    B. COPD

    C. Neither

    D. Both

10. Disease severity correlates directly with the reduction in the forced expired volume in 1 sec (FEV₁).

    A. Asthma

    B. COPD

    C. Neither

    D. Both

11. Leukotriene receptor antagonists such as montelukast (Singulair) are indicated in patients with mild or moderate disease.

    A. Asthma

    B. COPD

    C. Neither

    D. Both

12. Inhaled anticholinergic bronchodilators are appropriate first-line therapy.

    A. Asthma

    B. COPD

    C. Neither

    D. Both

13. Alpha-1-antitrypsin augmentation therapy may improve lung function (increase FEV₁) in some patients.

    A. Asthma

    B. COPD

    C. Neither

    D. Both

14. Antibiotics are generally indicated for exacerbations of the disease when the patient reports cough and discolored sputum.

    A. Asthma

    B. COPD

    C. Neither

    D. Both

QUESTION 15–19. For each of the five following phrases or statements (15–19), indicate whether it pertains to patients with sarcoidosis, idiopathic pulmonary fibrosis, neither, or both.

    A. Sarcoidosis

    B. Idiopathic pulmonary fibrosis

    C. Neither

    D. Both

15. Rarely seen in children

    A. Sarcoidosis

    B. Idiopathic pulmonary fibrosis

    C. Neither

    D. Both

16. May be a cause of chronic airflow obstruction on pulmonary function testing

    A. Sarcoidosis

    B. Idiopathic pulmonary fibrosis

    C. Neither

    D. Both

17. Associated with an increased risk of lung cancer

    A. Sarcoidosis

    B. Idiopathic pulmonary fibrosis

    C. Neither

    D. Both

18. Predominantly involves the lower lung zones

    A. Sarcoidosis

    B. Idiopathic pulmonary fibrosis

    C. Neither

    D. Both

19. A definitive infectious pathogen has been identified as the cause

    A. Sarcoidosis

    B. Idiopathic pulmonary fibrosis

    C. Neither

    D. Both

QUESTION 20–24. INH treatment for latent tuberculous infection (INH 300 mg daily for 9 months) should be given to which of the following patients?

20. A 21-year-old healthcare worker with a PPD skin test reaction of 12 mm of induration. His chest x-ray is normal. His skin test reaction last year had 10 mm of induration.

    A. Yes

    B. No

21. A 45-year-old former intravenous drug abuser known to be human immunodeficiency virus (HIV) positive has a clear chest x-ray, and the PPD skin test shows 5 mm of induration. Prior skin tests are reported as “equivocal.”

    A. Yes

    B. No

22. A 74-year-old man with no known tuberculosis exposure and a clear chest x-ray has a PPD skin test showing 5 mm of induration. The patient does not recall any previous tuberculin skin tests. Repeat testing 1 week later now shows 15 mm of induration.

    A. Yes

    B. No

23. A 53-year-old woman with no known medical illnesses and a clear chest x-ray has a PPD skin test reaction with 8 mm of induration. She has never before had skin testing but has been tested now because her husband has just had active tuberculosis diagnosed after a 6-month illness.

    A. Yes

    B. No

24. A 26-year-old homeless man has a PPD skin test demonstrating 15 mm of induration. He has no symptoms, but his chest x-ray shows nonhomogeneous opacities with some nodularity in the left upper lobe.

    A. Yes

    B. No

ANSWERS

1. D. An elderly woman admitted to a nursing home has a positive PPD skin test and an abnormal chest x-ray with evidence of “a localized, poorly defined area of opacity in the right upper lobe posteriorly.” This description is suspicious for reactivation tuberculosis with a tuberculous pneumonia in the right upper lobe. The anatomic location is typical for reactivation tuberculosis, which most often begins in the posterior and apical segments of the upper lobes or in the superior segment of the lower lobes. A pneumonia localized to the anterior segment of the upper lobe is unlikely to be tuberculosis.

    What is surprising in the brief description of her condition—and what may cause some doubt about the correct answer—is that she is asymptomatic, free of cough, sputum production, fever, or weight loss. Do not let this observation dissuade you from the possibility that she has active pulmonary tuberculosis. In its early stages, active tuberculosis may be asymptomatic. Nor should it be reassuring to those around her that she has no cough. She may develop a cough any day, and the risk of contagion is real, especially in a nursing home residence where she will likely be in contact with a vulnerable population of people, many with chronic illness.

    With active tuberculosis as a possibility, your proper management plan is to attempt diagnosis (such as with analysis of sputum induced by inhalation of nebulized hypertonic saline or with bronchoscopy with bronchoalveolar lavage) and, while awaiting the results of sputum acid-fast stain and culture, initiate therapy for presumed active tuberculosis (answer D). The patient will also need to be kept in respiratory isolation until either three sputum samples have returned negative for acid-fast bacilli on smear or until she has completed 2 weeks of antimycobacterial therapy. A three-drug regimen of antituberculous medications, such as offered in answer D, is appropriate if she is a patient at low risk for primary drug-resistant tuberculosis.

    The other proposed options for her management are not appropriate. “Watchful waiting,” as in answer A, puts both the patient and those around her at risk. It might be an appropriate course if an old chest x-ray from a year or two previously had been identical, indicating that the right upper lobe abnormality was a chronic radiographic finding, but not in the absence of such information.

    Until you are certain that this patient does not have active pulmonary tuberculosis, it would be inappropriate to treat with a single antituberculous medication for latent tuberculous infection (answer B). Doing so might induce an INH-resistant strain of Mycobacterium tuberculosis. Besides, the indication for chemoprophylaxis in this elderly woman with a positive PPD skin test is unclear. We will discuss these indications further in a subsequent portion of the Board Simulation exercise (Questions 20–24).

    Identification of M. tuberculosis by traditional culture techniques can take up to 6–8 weeks. Waiting several weeks without initiating antituberculous therapy (answer C) again places the patient at risk for worsening disease and those around her at risk for acquiring tuberculous infection. Finally, immediate treatment with a two-drug regimen (answer E) is wrong because (1) it fails to obtain a diagnostic sample for culture and sensitivity testing; (2) it employs an old-fashioned treatment regimen that requires 18 months of therapy; and (3) it does not address the possibility of infection with a primary INH-resistant strain of tuberculosis.

    2. E. You may have difficulty choosing the correct answer to this question because all of the options strike you as correct. You know that the pulmonary disease of cystic fibrosis is bronchiectasis (answer A) and that chronic sinusitis and nasal polyps are common in cystic fibrosis (answer B). (As a general rule, if you identify a child with nasal polyps, think cystic fibrosis rather than asthma and allergies, because nasal polyps rarely complicate allergies and asthma until later in life.) You are aware that diffuse bronchiectasis can cause both airflow obstruction (due to airway narrowing and intraluminal secretions) and restriction (due to destruction of lung tissue, consolidation due to infection and inflammation, and atelectasis) as in answer C. You recall that men with cystic fibrosis generally have azoospermia due to bilateral absence of the vas deferens (answer D). And of course, Pseudomonas commonly infects the bronchiectatic airways in cystic fibrosis (as well as in bronchiectasis of other causes). But wait—answer E specifically refers to systemic Pseudomonas infections, and in fact, Pseudomonas bacteremia or disseminated Pseudomonas infection involving skin, kidneys, liver, and so forth, is unheard of in cystic fibrosis. You know this fact; the challenge in this question is simply careful reading of the potential choices offered!

    3. A. The term asbestosis is sometimes loosely and inappropriately used to describe any thoracic manifestation that results from extensive asbestos fiber inhalation. In fact, the term should be reserved to describe specifically the diffuse interstitial inflammation and fibrosis that results from many years (decades) of intense asbestos exposure. The radiographic appearance typically involves a pattern of interstitial opacities (linear and nodular shadows) predominantly in the lower lung zones bilaterally. Calcification, if present, involves pleural surfaces. The description offered as answer A, “fibrocalcific parenchymal disease, predominantly involving the upper zones of the lung,” does not evoke asbestosis. It is rather a description of chronic granulomatous lung disease, such as tuberculosis. A sample chest x-ray with this pattern is seen in Figure 44.2. It shows bilateral upper lobe scarring, calcified nodules in the right upper lobe, and cephalad retraction of the hila in a patient with treated reactivation tuberculosis.

    The other choices—pleural plaques, mesothelioma, benign pleural effusions, and bronchogenic carcinoma—are indeed all potential consequences of chronic asbestos fiber inhalation. Perhaps least well known is answer D, benign pleural effusions. Benign exudative effusions, often bloody and often bilateral, may develop with a latency period of ≥10 years after asbestos inhalation, a relatively short latency period compared to other asbestos-related diseases. Because mesothelioma often manifests as a unilateral pleural effusion, the challenge for the clinician in a patient with unilateral pleural effusion and a history of asbestos exposure is to exclude malignancy as the cause.

    The radiographic images of asbestos-related pleural plaques and of mesothelioma can be distinctive. Figure 44.3 is the posteroanterior chest x-ray of a patient with asbestos-related pleural plaques. It shows multiple bilateral nodular opacities, and one’s immediate response to the image may well be to think of metastatic lung nodules. However, many of the opacities are pleural-based, and at least one (on the lateral margin of the left lung) is not spherical but rather is shaped like a bluff or plateau with its long diameter paralleling the pleural surface, a clue to its pleural origin. Adjacent and more medial to this plaque is a round-appearing nodule. It too is a pleural plaque, not located in the substance of the lung but along the pleural surface. It is located along an anterior or posterior portion of the pleura and when seen en face gives a rounded appearance. The pleural location of these asbestos-related plaques is best visualized on the transverse image of a chest CT scan, as seen in Figure 44.4 (in a chest CT image from a different patient). Although not illustrated by these images, pleural plaques may become calcified. They are not precancerous lesions and do not evolve into mesothelioma.

    Figure 44.5 is the posteroanterior chest x-ray of a patient with mesothelioma. There is a large right pleural effusion. In addition, one sees distinctive lobulated opacities along the upper portion of the lateral pleural surface of the right lung. These opacities may represent loculated pleural fluid, but their nodularity suggests more mass-like tissue invasion along the chest wall. We are likely visualizing both tumor mass growing along the pleural surface as well as associated malignant pleural effusion. Mesothelioma is the disease manifestation related to asbestos fiber inhalation that may develop with relatively minor exposure, such as a summer or two spent working closely with asbestos in a shipyard 20 years earlier.

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