Respiratory medicine 101. A 35-year-old woman who has been treated for asthma presents for review.

She helps with mucking out at a horse-riding stable over the weekends. She had been well until the past year or so, bit has since suffered recurrent chest infections, a dry cough and shortness of breath. There is no haemoptysis. Full blood count reveals a raised eosinophil count. Chest X-ray reveals evidence of pulmonary infiltration and some lobar consolidation and cavitation. What is the diagnosis that fits best with this clinical picture? Aspergilloma Allergic bronchopulmonary aspergillosis (ABPA) Asthma Tuberculosis Bronchiectasis

Your answer

This woman helps out at a stables and is likely to have been exposed to Aspergillus fumigatus. Diffuse X-ray changes, an asthmatic-type presentation originally, now bordering on bronchiectasis with frequent infections and peripheral blood eosinophilia point towards ABPA. Aspergilloma tends to become invasive, beginning in an old cavity, such as one left by TB infection, and you would not expect such severe X-ray changes in someone with asthma. Management involves oral prednisolone initially, and then later bronchodilators. The X-ray changes that appear long-term are in response to a type-2 hypersensitivity reaction.

102. A 16-year-old boy is brought to casualty after a fire in his parents' house. He inhaled a lot of smoke and has a hoarse voice, stridor and burned nasal hairs. Due to deterioration in his peak flow rate and arterial blood gases, he has been intubated, ventilated and transferred to the intensive care unit where his condition is now stable. In terms of investigation, what is the most important next step in assessing this boys condition? CT thorax Chest X-ray Bronchoscopy Your answer

Ventilationperfusion scan Echocardiography Inhalation of hot smoke can burn the upper airways and contributes significantly to deaths due to fires. Upper airway obstruction due to heat injury and mucosal swelling usually develops within 24 h of exposure, but stenosis due to scarring can develop later. A hoarse voice, stridor, severe conjunctivitis, burnt nasal hairs and falling peak flow all suggest significant upper airway damage. Bronchoscopy is then the best tool to establish whether there is significant oedema or mucosal ulceration obstructing the airways.

103. People with coal-workers pneumoconiosis are predisposed to developing which disease? Tuberculosis Carcinoma of the lung Progressive massive fibrosis Your answer Silicosis Heart failure Simple coal-workers pneumoconiosis causes no symptoms or physical signs, nor any important physiological abnormality. The danger associated with simple pneumoconiosis is that it is a predisposition to progressive massive fibrosis, a risk directly related to the profusion of simple pneumoconiosis on the X-ray. Progressive massive fibrosis may occur during working life or appear for the first time after (sometimes many years after) dust exposure ceases, even when there

is no apparent simple pneumoconiosis on the X-ray. Progressive massive fibrosis usually causes a mixture of restriction of lung volumes and, owing to associated emphysema, airflow obstruction. Ultimately, it may lead to cor pulmonale and death. However, the rate of progression is variable. In general, the earlier that progressive massive fibrosis develops in a persons life, the more rapidly it is progressive and thus the greater is the threat to health. A patient with progressive massive fibrosis may complain of shortness of breath and symptoms of cor pulmonale. An unusual, but pathognomonic symptom is melanoptysis the expectoration of the black contents of a cavitated lesion. Haemoptysis and finger clubbing suggest lung cancer and should not be attributed to pneumoconiosis. Abnormal signs in the chest, if present, relate to the presence of bullae, although sometimes lobar collapse can occur. Coal-workers pneumoconiosis is not associated with an increased risk of tuberculosis or lung cancer, although obviously these diseases can be seen in coal miners and should be suspected if an unusual progression of radiological changes occurs. The association between pneumoconiosis and emphysema has been controversial, but there is now clear evidence of a parallel association between dust exposure and two effects pneumoconiosis and airflow obstruction. The more dust that a miner has been exposed to, the greater are his risks of pneumoconiosis on the one hand, and productive cough, reduction in forced expiratory volume in 1 s (FEV1), and the presence of centriacinar emphysema on the other. Of course, the latter risks are also related to cigarette smoking, and the effect of dust exposure is additive.

104. You review a 72-year-old man with severe chronic obstructive pulmonary disease (COPD), who asks about the provision of oxygen therapy at home. In which of the following have randomised controlled trials shown that long-term oxygen therapy (LTOT) reduces mortality? Asthma Cor pulmonale caused by chronic airflow obstruction Cryptogenic fibrosing alveolitis Cystic fibrosis Pulmonary sarcoidosis

Your answer

Two controlled studies (in a mostly male population) indicated that life can be prolonged by the continuous delivery of 2 litres per minute of oxygen via nasal prongs to achieve saturations of greater than 90% for a large proportion of the day and night. Improvements in pulmonary artery hypertension were obtained in patients who wore oxygen for more

than 15 hours per day, but mortality was only improved in patients who wore oxygen for more than 19 hours per day. Long-term oxygen therapy (LTOT) should therefore be considered in patients with chronic obstructive pulmonary disease (COPD) and a forced expiratory volume 1 (FEV1) of less than 1.5 litres, an arterial partial pressure of oxygen (PaO2) of less than 7.3 kPa, and carboxyhaemoglobin of less than 3%. Although oxygen cylinders may be provided for intermittent use by patients for the relief of symptoms of breathlessness, they have no effect on prognosis.

105. A patient with tuberculosis was initially treated with streptomycin, later this was changed to a combination of isoniazid, rifampicin, pyrazinamide and ethambutol. He now complains of impaired visual acuity and loss of red/green colour discrimination. Which drug is responsible? Streptomycin Ethambutol Rifampicin Pyrazinamide Isoniazid

Your answer

The side-effects of ethambutol are largely confined to visual disturbances in the form of loss of acuity, colour blindness or restriction of visual fields. These toxic effects are more common where an excessive dosage is used or if the patients renal function is impaired. The earliest features of ocular toxicity are subjective and patients should be advised to discontinue therapy immediately if they develop deterioration in vision and to seek further advice promptly. Early discontinuation of the drug is almost always followed by recovery of eyesight. Patients who cannot understand warnings about visual side-effects should, if possible, be given an alternative drug. In particular, ethambutol should be used with caution in children until they are at least 5 years old and capable of reporting symptomatic visual changes accurately.

106. Leukotriene-receptor antagonists (LTRAs) may be used as add-on therapy in the treatment of asthma. Which of the following statements best describes how and when they should be used? LTRAs should be used as initial therapy in adults They are an ideal add-in for those patients using excessive prn salbutamol

LTRAs are usually not of therapeutic value in patients with aspirinintolerant asthma and should be avoided in this group LTRAs should be add-in therapy when patients are poorly controlled on dual therapy with high-dose inhaled corticosteroids and a long-acting 2agonist LTRAs may elicit a delayed response in terms of symptom improvement, and it is necessary to continue treatment for at least 6 months

Your answer

LTRAs such as montelukast are given orally and are effective in a subpopulation of asthma patients. A 4-week treatment trial to determine symptomatic response to the therapeutic class is normally recommended. Patients who are aspirin-intolerant appear to derive particular benefit from this therapy. LTRAs act by inhibiting the cysteinyl leukotriene receptor and partially inhibiting the inflammatory cascade associated with asthma. They should be considered as add-in therapy for those patients who are poorly controlled on high-dose inhaled steroid and inhaled long-acting 2-agonists.

107. A 43-year-old woman is referred by her general practitioner with a productive cough and inspiratory crackles at the left base. Which of the following is considered to be a core adverse prognostic factor? Respiratory rate of 28/minute Blood pressure of 98/65 mmHg Serum urea concentration of 7.1 mmol/l Oxygen saturation of 92% on room air Bilateral changes on chest radiograph

Your answer

Core clinical adverse prognostic factors are given by the abbreviation CURB: Confusion (new onset) with a Mini-Mental Test score < 8; Urea > 7.0 mmol/l; Respiratory rate > 30/minute; Blood pressure systolic < 90 mmHg or diastolic < 60 mmHg. If any core clinical factors are present then the patient is at increased risk of death and should not be sent home (British Thoracic Society Guidelines, December 2001). 108. A 64-year-old man is brought to the Accident and Emergency Department by his wife with drowsiness and confusion. He has a history of COPD and attends the chest clinic. He had been commenced on antibiotics by his general practitioner 2 days earlier for an exacerbation of his COPD. Which of the following blood gases (on 2 litres O2/min) fit best with this mans condition? pH 7.14 pa(CO2) 7.3 pa(O2) 9.1 bicarbonate 14 pH 7.24 pa(CO2) 9.3 pa(O2) 8.1 bicarbonate 34

Your answer

pH 7.38 pa(CO2) 8.3 pa(O2) 8.1 bicarbonate 38 pH 7.38 pa(CO2) 5.3 pa(O2) 8.1 bicarbonate 30 pH 7.54 pa(CO2) 3.3 pa(O2) 9.1 bicarbonate 24 This patient has acute on chronic respiratory acidosis. Respiratory acidosis will have a + raised pa(CO2) and H concentration. The elevation of the bicarbonate reflects renal buffering from his chronic respiratory failure. In acute respiratory acidosis every 1 kPa rise in CO2 produces 6 nmol/l of hydrogen ion and a 1 mmol/l increase in bicarbonate, whereas when chronic, the increase in hydrogen ions per kPa rise in carbon dioxide falls to about 2.5 nmol/l. In this question B is the best response as it best encapsulates the clinical data provided.

109. A 50-year-old woman is admitted with a dry cough, shortness of breath and a 2-week history of intermittent fevers. She had had flu-like symptoms at the beginning of her illness. On examination she has right-sided crepitations and a chest X-ray shows patchy shadowing at her right lower lobe, with an air bronchogram. Her white cell count and CRP are raised. She is started on antibiotics for community-acquired pneumonia and after 2 days of clinically improving, she is discharged. You see her in clinic 3 months later, when she tells you she is no better. Her chest X-ray shows left upper lobe consolidation. What is the most likely cause of this? Recurrent bacterial pneumonia Eosinophilic pneumonia Cryptogenic organising pneumonia Your answer Lymphangioleiomyomatosis Pulmonary alveolar proteinosis Cryptogenic organising pneumonia is a non-specific inflammatory pulmonary process, with buds of granulation tissue forming in the distal air spaces. Organising pneumonia may result from a number of causes, including connective tissue disease, infection and drugs, but if there is no obvious cause it is called cryptogenic. It causes non-specific symptoms of fever, dry cough,

malaise, anorexia and weight loss. It is associated with raised a WCC and Creactive protein (CRP) levels. The chest X-ray can show consolidation, nodules or thickened septal lines. The consolidation typically occurs in different places at different times. CT findings are characteristic with multiple patchy alveolar opacities, which often spontaneously migrate. The diagnosis may be made from CT alone, or from transbronchial or open lung biopsy. Treatment is with steroids. Relapse is common with further consolidation and may need treatment with increased steroid doses. Recurrent lobar bacterial infection is unusual in an immunocompetent adult, and eosinophilic pneumonia gives flitting peripheral chest X-ray shadows. Lymphangioleiomyomatosis is a rare disease affecting women of child-bearing age, who have abnormal proliferation of atypical smooth muscle cells throughout their lungs and airways. CT shows multiple small cysts. Pulmonary alveolar proteinosis is a rare defect where the alveoli become filled with proteinaceous material that cannot be cleared. CT shows airspace shadowing.

110. A patient with cystic fibrosis presents with a severe bronchopneumonia. What is the most likely pathogen? Streptococcus pyogenes Streptococcus pneumoniae Pseudomonas aeruginosa Your answer Klebsiella pneumoniae An atypical Mycobacteria sp

Pseudomonas aeruginosa is the commonest colonising organism in patients with cystic fibrosis after the age of 10 years, with a reported prevalence varying between 40 and 80%. Enhanced adherence to the airways of patients with cystic fibrosis promotes colonisation, but prior antibiotic treatment may play a part. No particular phage type predominates, but siblings with cystic fibrosis often carry

the same type, and environmental sources have been identified in cystic fibrosis centres, dentistry equipment, hydrotherapy pools and nebulisers. After some months or years of colonisation, pseudomonas produces mucoid alginate as a protective biofilm and the organisms live in mucoid microcolonies. This mucoid variant is associated with a worse prognosis and greater antibiotic resistance. Most colonising types of Pseudomonas aeruginosa are sensitive to antibiotics at first, but over the years and in association with antibiotic treatment, multiple resistance to most antibiotics (except colistin (eg Colomycin)) develops.

111. What is the most common cause of haemoptysis? Infective exacerbation of COPD Pulmonary infarction Tuberculosis Goodpastures syndrome Bronchial carcinoma Your answer

The most common cause of haemoptysis is acute infection, in exacerbation of COPD in particular. But other causes should be excluded while investigating. Bronchial carcinoma, pulmonary infarction and tuberculosis are common causes. Massive haemoptysis of more than 200 ml of blood is present in cases of bronchiectasis and tuberculosis. Pulmonary haemosiderosis, Goodpastures syndrome, microscopic polyangiitis, and trauma are some of the rarer causes worth remembering.

112. A 28-year-old black nurse develops painful nodules on the shin of both legs. She has low grade fever and has lost 5 kg in the two months prior to her presentation. Her chest Xray shows bilateral hilar lymphadenopathy. The MOST likely outcome of this patients illness is? Complete remission after appropriate course of steroid and cytotoxic drugs Complete remission without any specific treatment Complete initial remission soon interrupted by increasing relapses Diffuse reticulo-nodular changes in the lung and progressive shortness of breath Generalised lymphadenopathy and progressive wasting in 510 years Your answer

Acute sarcoidosis includes the complex of erythema nodosum and X-ray findings of bilateral hilar adenopathy, often accompanied by joint symptoms, including arthritis at the ankles, knees, wrists, or elbows. Spontaneous remission occurs in nearly two-thirds of patients with acute sarcoidosis, while 1030% develop a chronic course. Remissions often occur within the first six months after diagnosis. NSAIDs are very useful for musculoskeletal symptom control.

113. The parents (both cystic fibrosis gene carriers) of a child with cystic fibrosis (CF) come to see you for advice after reading about CF on the Internet. Which of the following bits of information from their Internet printout is correct? The gene defect is a mutation on chromosome 6 There is evidence of pulmonary disease at birth <50% of patients survive to adulthood Burkholderia cepacia is a significant pathogen Probability of a further child being affected is 50%

Your answer

The gene defect in cystic fibrosis is a mutation on the long arm of chromosome 7. Pulmonary disease develops within the first few months. The 80% survival curve for the 1990s approaches 30 years. Burkholderia cepacia is seen in severe lung disease and is often associated with a rapid deterioration. Pneumothorax is seen in up to 5% of patients over 10 years of age and approximately 50% recur. The probability of a child born to two carriers being affected is 25% as CF is an autosomal recessive condition. 114. A 45-year-old woman visits the surgery with her 15-year-old son who has recently been diagnosed with asthma. She has studied the pathology of asthma and has a number of questions as to potential causative factors. Which of the following responses best describes the pathology of asthma? Asthma predominantly occurs due to airway hyporesponsiveness Asthma predominantly occurs due to airway hyperresponsiveness Asthma predominantly occurs due to airflow limitation Asthma predominantly occurs due to airway inflammation Asthma occurs due to a combination of airway hyperresponsiveness, airflow limitation and airway inflammation

Your answer

Asthma is characterised by airflow limitation that is usually reversible spontaneously or with treatment, although later on in the disease there may be an irreversible component to airflow limitation. There is also airway hyperresponsiveness to a wide range of external stimuli. A predominantly eosinophilic pattern of inflammation occurs, with associated plasma exudates, oedema, mucus-plug formation, bronchial smooth muscle hypertrophy and long-term epithelial damage. In many Western countries the prevalence of asthma is

increasing, particularly during the second decade of life, where it may affect up to 1015% of the population.

115. A 68-year-old man who has a long history of smoking presents to the Emergency Department with worsening shortness of breath. His general health has deteriorated over the past few months and recently he has been prescribed a salbutamol inhaler by his GP for cough and wheezing, particularly on exercise and at night. On examination in the Emergency Department he is lip pursing and has considerable wheeze on auscultation of the chest. He is pyrexial at 37.8C and has purulent sputum. He can only manage a peak flow of 150 l/min. Arterial blood gas sampling reveals a pa(O2) of 7.2 kPa. Which of the following would be the most appropriate choice for antibiotic therapy in this man? Clarithromycin 500 mg po bd Penicillin V 500 mg po qds Metronidazole 500 mg po tds Cefotaxime 1 g iv tds Ciprofloxacin 500 mg po bd Your answer

This man has an exacerbation of chronic pulmonary disease (COPD). The most common causative pathogens are Haemophilus influenzae and Moraxella catarrhalis. The most appropriate antibiotic therefore would be a macrolide such as clarithromycin. It should be noted however that in patients taking theophyllines, concomitant use of macrolides might increase serum aminophylline levels. Other important acute treatment in this case would be repeated nebulisation with salbutamol and ipratropium 46 hourly, oxygen therapy, and oral steroids. Non-invasive ventilation may be considered where the pH is 7.3 or less and the patient is not improving after 4 h of medical therapy.

116. A 60-year-old patient was referred with a 1-year history of persistent cough productive of mucopurulent sputum throughout the year. He has been treated by his GP for recurrent chest infections. What is the most likely diagnosis? Fibrosing alveolitis Carcinoma of the lung Sarcoidosis Bronchiectasis Allergic asthma

Your answer

Bronchiectasis should be suspected when there is a history of persistent cough productive of mucopurulent or purulent sputum throughout the year. Patients have frequently been treated for recurrent chest infections and labelled as bronchitic, often despite the absence

of a history of smoking. Patients may produce mucoid sputum early in their disease, developing purulent sputum when they suffer an exacerbation associated with a viral upper respiratory tract infection. Such exacerbations may be associated with pleuritic chest pain, haemoptysis, fever and sometimes wheeze. Those presenting as adults often recall a chesty cough or wheezy bronchitis associated with upper respiratory tract infections in childhood, followed by complete resolution of symptoms in their teens and early adult life before the symptoms return after a viral trigger. Upper respiratory tract symptoms such as postnasal drip are common, and in about 30% of cases there is a history of chronic sinusitis. Patients with bronchiectasis also suffer from undue tiredness, which many find more troublesome than the productive cough.

117. A 56-year-old man with confirmed squamous cell carcinoma of the right upper lobe of the lung has a normal FEV1 and normal serum biochemistry. Which one of the following investigations is most appropriate to assess operability? Bone scan Chest CT scan Differential perfusion lung scan Measurement of total lung capacity Sputum cytology

Your answer

A chest CT scan is the best method for staging squamous cell carcinoma of the lung. This would indicate the extent of involvement and surgical approach. Five-year survival rates are > 75% in stage I disease (nodes 0, tumour confined within visceral pleura) and 55% in stage II disease, which includes resection in patients with ipsilateral peribronchial or hilar node involvement. Sputum cytology is irrelevant, as the diagnosis has already been established. Measurement of total lung capacity and differential perfusion lung scans is not helpful in staging. A bone scan is not required as there is no clinical, haematological or biochemical evidence of tumour spread to bony sites.

118. A 49-year-old woman with ulcerative colitis becomes breathless and develops a dry cough. Her pulmonary function tests reveal mild gas trapping and reduced expiratory flow rates at low lung volumes. Which of the following pulmonary complications of ulcerative colitis is the most likely explanation? Bronchiolitis Your answer Interstitial lung disease

Pulmonary infiltrates with eosinophilia (PIE Syndrome) Bronchiectasis Cryptogenic organising pneumonia (COP) All the above may be seen in the context of inflammatory bowel disease but the low flow rates at low lung volumes is suggestive of a small airway (ie bronchiolar) problem. In combination with gas transfer the diagnosis is bronchiolitis. Expiratory thoracic HRCT classically reveals a mosaic pattern compatible with gas trapping.

119. A 48-year-old woman presented with increasing shortness of breath. She also reported that her abdominal girth had increased over the past few months but put this down to good living. On examination her GP noticed a right-sided pleural effusion and a very large mass in her right pelvis. Signs of ascites were also present. CA-125, hCG, CEA and a-fetoprotein were unremarkable. A few weeks later a large ovarian fibroma was removed. Some 6 months later she remains well. Whichdiagnosis best fits with this picture? Ovarian carcinomatosis Heart failure Cirrhosis Meiges syndrome Rheumatoid arthritis

Your answer

This syndrome is characterised by the presence of a benign ovarian fibroma, associated with ascites and a right-sided pleural effusion. The average age at presentation is 48 years. Meiges syndrome is associated with 0.004% of ovarian tumours. The aetiology of the pleural effusion is thought to be related to the size of fibroma, leading to accumulated peritoneal ascites that flows into the pleural cavity via the lymphatics or via abdominal pleural communication (via the foramen of Bochdalek). Removal of the ovarian mass is associated with resolution of the ascites and pleural effusion and an excellent prognosis.

120. A 43-year-old woman has a pleural effusion and evidence of fibrosis on CXR. She has noticed a facial rash on sun exposure that has worsened over the past few months. Which is the most likely diagnosis? Systemic lupus erythematosus Adenocarcinoma lung Wegener's granulomatosis Progressive massive fibrosis Actinomycosis Your answer

Direct pulmonary involvement in systemic lupus erythematosus (SLE) occurs in 30% (pleuropericarditis, atelectasis, pneumonitis, raised hemidiaphragms and pulmonary fibrosis). Autoimmune screen with antinuclear antibody (ANA) and anti-dsDNA antibodies may be useful in confirmation of the diagnosis. The other stems are all associated with cavitating lung lesions. Wegener's granulomatosis is a necrotising vasculitis characterised by granulomas in the upper and lower respiratory tracts and a focal glomerulonephritis. Progressive massive fibrosis is a complicated coal workers pneumoconiosis where pulmonary nodules coalesce and cavitate. Actinomycosis is a chronic granulomatous disorder produced by a Gram-positive anaerobe. Any lung cancer may cavitate if it outgrows its blood supply but it is typically squamous cell carcinoma, which cavitates.

121. A 40-year-old man presents to the emergency department with difficulty breathing and swallowing. Examination is normal. Chest X-ray shows an enlarged upper mediastinum, so you arrange a CT scan, which is performed the next day. This shows an enlarged thymus gland. What would you do next? Arrange a fine-needle aspirate of the thymus Arrange a biopsy of the thymus Refer to the surgeons for thymus excision Your answer Refer to the oncologists for radiotherapy Await the results of antibody testing prior to making a decision This man has a thymoma, which is a tumour of epithelial origin arising in the thymus. Between 30 and 40% of patients with a thymoma have myasthenia

gravis, and will have positive antiacetylcholine-receptor antibodies. The myasthenia often does not improve after the thymus is removed. Awaiting the results of antibody testing does not alter the management, which is thymectomy (20% of patients with myasthenia gravis have a thymoma). Thymomas contained within the thymic capsule tend to be benign, but those that have extended beyond it are generally malignant. Biopsy or FNA can breech the capsule and hence increase the risk of thymoma tumour seeding and should be avoided. Postoperative radiotherapy is indicated for those malignant or incompletely excised thymomas.

122. A 48-year-old man with hepatitis B is admitted via his GP with a history of breathlessness. He has signs of chronic liver disease and does not want to stay in hospital. His INR is 2.8 and his chest radiograph appears normal. The nurses comment that his oxygen saturation drops from 98% to 91% on room air every time he gets up to leave. What is the most likely diagnosis? Small pneumothorax Aspiration pneumonia Pulmonary embolus Hepatopulmonary syndrome Your answer Viral pneumonitis Hepatic disease can result in right-to-left shunting, secondary to intrapulmonary vasodilatation mainly in the lower lobes. This is similar to pulmonary arteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia, where the PAVMs are located mostly in the lower lobes. As a result, there is increased blood flow through the lower lobes when the patient moves from the supine to the erect posture. The end result of this is that deoxygenated blood enters the left side without going through the lungs, with consequent desaturation in the erect posture. This phenomenon is called orthodeoxia.

123. A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting 2-agonists (salmeterol), oral leukotriene-receptor antagonists and inhaled short-acting 2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy? Oral steroids Antibiotics Switch to nebuliser Oral cromoglycate Oral theophylline Your answer Theophylline is indicated in step 4 in the treatment of chronic asthma when symptoms are still not controlled. Theophylline improves lung function and symptoms; however, side-effects can occur more commonly.

124. You are asked to see a newly diagnosed asthmatic woman who is eight weeks pregnant. She is not on any treatment at the moment. Her PEFR diary shows wide diurnal variations and she also gives a past history of eczema. Which of the following is true? Short-acting 2-agonists are contraindicated during the first trimester Inhaled steroids are associated with major congenital deformities A leukotriene-receptor antagonist is the first-line treatment

Theophyllines are safe during pregnancy Steroid tablets are teratogenic

Your answer

In general, the medicines used for asthma are safe during pregnancy. Leukotriene-receptor antagonists are not the first-line treatment during pregnancy. However, they may be continued in women who have demonstrated significant improvement in asthma control with these agents prior to pregnancy. 125. Which one of the following conditions is rarely associated with pulmonary infiltrates and peripheral eosinophilia? Allergic bronchopulmonary aspergillosis Lefflers syndrome Churg-Strauss syndrome Sulphonamide therapy Fibrosing alveolitis

Your answer

Eosinophilic lung diseases are a heterogeneous group of disorders which are characterised by the presence of pulmonary symptoms or an abnormal chest X-ray accompanied by inflammatory cell infiltrate in the airways and/or lung parenchyma which contain a large number of eosinophils. Many of these disorders are associated with peripheral eosinophilia. The following list is just an example: Drugs and toxins (nitrofurantoin, L-tryptophan, sulphonamides) Helminthic infection (Lefflers syndrome, larva migran) Acute and chronic eosinophilic pneumonia (primary) Churg-Strauss syndrome Allergic bronchopulmonary aspergillosis Hypereosinophilic syndrome

126. Which one of the following features is MOST characteristic of small cell bronchial carcinoma? History of prior asbestos exposure is usually obtained Hyponatraemia

Your

answer Known as small cell because the cancer cell origin is from small lymphocytes It has a relatively better prognosis when compared with other bronchial cancers Surgery is often the only defined treatment Small cell (oat cell) bronchial carcinoma is frequently associated with ectopic hormone production. The syndrome of inappropriate anti-diuretic hormone secretion (SIADH) causes hyponatraemia. By the time the diagnosis has been made the tumour is usually disseminated, so that surgery is seldom considered. Unlike mesothelioma a history of asbestos exposure is seldom obtained. The prognosis is very poor and survival beyond two years is exceptional.

127. A 70-year-old man with chronic obstructive pulmonary disease and bronchiectasis had a sputum sample sent from clinic because he had been more breathless for 6 months and was coughing purulent sputum. The result has shown the presence of Mycobacterium malmoense. What does this mean? He should have further sputum samples sent for culture He needs admitting to hospital and isolating in a side room Public health authorities should be informed to begin contact tracing He should be started on triple-drug antituberculous therapy He should be started on quadruple-drug antituberculous therapy Mycobacterium malmoense is a non-tuberculous mycobacterium and an environmental low-grade pathogen in humans. This organism most commonly causes pulmonary infection in middle-aged and older adults with pre-existing lung disease or immunodeficiency. M. malmoense can also cause local invasion from a skin lesion. It causes non-specific symptoms, such as malaise and weight loss, or chest disease not progressing as expected. Chest X-ray appearances can be indistinguishable from those seen in patients with Mycobacterium Your answer

tuberculosis infection, with upper zone fibrosis and cavitation. A single isolate from a non-sterile site may not be significant and may represent contamination. More than two isolates from a non-sterile site are required to establish disease. There is a low-risk of cross-infection, so there is no need to isolate patients or notify public health authorities. There are BTS guidelines on the treatment of each of the different non-tuberculous mycobacteria, but this is with either two or three antituberculous drugs (see Subcommittee of the Joint Tuberculosis Committee of the British Thoracic Society 2000. Management of opportunistic mycobacterial infections. Thorax,55(3),21018).

128. A 48-year-old mechanic presented to the clinic complaining of increasing shortness of breath over the last 3 months, but with no symptoms of cough. There was no recent history of chest trauma. He smokes 2025 cigarettes per day and two cans of beer every day. His brother recently died of stomach cancer and he was quite concerned about his problem. Clinically, he had a large pleural effusion on his left side, which was confirmed on X-ray. On aspiration, a white fluid came out and there was no clear supernatant after centrifugation. Co-cholesterol crystals were detected. What is the probable cause of the effusion? Lymphoma Tuberculosis Metastatic stomach carcinoma Lymphangioleomyomatosis Yellow-nail syndrome Your answer

This effusion is chylous fluid, classically described as a milky, opalescent fluid that contains fat globules. It is differentiated from empyema because the latter yields a clear supernatant on centrifugation. Pseudochyle is a fluid that has a high lipid content, as cholesterol, and is typically seen in patients with tuberculosis. The commonest cause of a chylothorax is trauma or a malignancy. The malignancy is usually a lymphoma. Although metastatic lung deposits may cause chylothorax, it is not so common. Other causes of chylothorax are a congenital absence of thoracic ducts, filariasis, tuberculous mediastinal lymphadenitis, lymphangioleiomyomatosis, yellow-nail syndrome and left subclavian venous thrombosis.

129.A 26-year-old patient admitted with suspected pneumonia and an abnormal chest Xray mentions to the attending physician that he has an azygous lobe. Where would you visualize the azygous lobe on an anterior-posterior chest X-ray? Right upper zone Your answer

Right middle zone Right lower zone Left upper zone Left lower zone An azygous lobe is seen in about 0.5% of routine chest X-rays and is a normal variant. It is seen as a reverse comma sign behind the medial end of the right clavicle.

130. Which of the following statements applies to the peak expiratory flow rate? It is a less sensitive parameter for assessing improvement to therapy in patients with acute bronchial asthma It measures small-airway resistance It is more related to age than height Less than 50% of normal is an indication for aminophylline therapy in those with acute asthma It is effort-dependent PEFR is a sensitive measurement of small-airway obstruction, although the maximal midexpiratory flow rate is more changed in mild disease. The ease of performing the PEFR at the bedside has made it more relevant in clinical practice. It is more related to height than age, and is effort-independent if the proper technique is used. Your answer

131. A 64-year-old cigarette smoker presents with increasing breathlessness. Examination confirms basal crackles in the absence of finger clubbing. His CXR shows widespread pleural plaques with additional reticular shadowing at the bases. Lung function tests confirm mild restriction with a low TLCO. Which of the following is likely to be true? Inhaled steroids may prevent disease progression Open lung biopsy is mandatory to establish a histological diagnosis Oral corticosteroids should lead to a significant improvement in lung function The condition is slowly progressive The most likely diagnosis is extrinsic allergic alveolitis Pulmonary asbestosis usually affects men with a history of heavy asbestos exposure. It presents with progressive breathlessness and is resistant to treatment with Your answer

immunosuppressive therapy. The changes typically affect the lower lobes and CT scanning can be useful in detecting disease. Biopsy is not mandatory as the diagnosis can be made on clinical and radiological grounds. The only advice is to avoid further exposure and to stop smoking (>50 risk of lung cancer if a smoker and asbestos exposure compared to exposure to neither). Clubbing occurs in 43% cases of asbestosis.

132. A 23-year-old smoker of 30 cigarettes per day presents with rapidly increasing shortness of breath, cough and haemoptysis over the past month following a chest infection. His chest X-ray demonstrates diffuse alveolar infiltrates. Blood testing indicates raised urea and creatinine levels, with positive anti-GBM antibodies. Urine analysis reveals haematuria and proteinuria. Pulmonary transfer factor is elevated. What diagnosis best fits this clinical picture? Wegeners granulomatosis Goodpastures syndrome Drug-induced renopulmonary disease Systemic lupus erythematosus Idiopathic glomerulonephritis

Your answer

The picture of renal and pulmonary symptoms with evidence of glomerulonephritis and intrapulmonary haemorrhage is particularly suggestive of Goodpastures syndrome, especially with the positive anti-GBM antibodies. The condition has a male:female ratio of 6:1, accounts for 5% of cases of rapidly progressive glomerulonephritis and 80% of patients are HLA-BR2 positive. Management is with prednisolone and cyclophosphamide, dialysis support where necessary and plasma-exchange therapy in centres where it is offered.

133. A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting 2-agonists (salmeterol) and inhaled shortacting 2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy? Antibiotics Salbutamol nebuliser Oral steroids Oral cromoglycate Oral leukotriene-receptor antagonists

Your answer

Occasional-relief bronchodilators are indicated in step 1 in the treatment of chronic asthma, if relief is only needed once daily and if there are no night-time symptoms or there is no

impaired lung function. Regular inhaled corticosteroids are added in step 2. Regular inhaled long-acting 2-agonists (salmeterol) are added in step 3. Oral leukotriene-receptor antagonists can also be added in step 3 if the asthma is still not controlled.

134. A 37-year-old man who speaks little English comes to the TB clinic. His notes are missing but he is able to tell you that he has been on treatment for almost 1 year. What is the most likely reason he has been treated for this length of time? Pulmonary TB Lymph-node TB TB meningitis Bony TB Pleural TB

Your answer

In the UK, all fully sensitive TB is treated for 6 months except for TB affecting the central nervous system, which is treated for 12 months. Multi-drug resistant TB (MDRTB) will require longer courses of treatment, usually with a combination of less commonly used anti-TB drugs.

135. A 40-year-old AfroCaribbean woman presents to clinic following an insurance medical examination, where she was found to have bilateral hilar lymphadenopathy on her chest radiograph. Her CT scan confirms hilar lymphadenopathy and comments on nodularity in the lung fields. What would you do next? Arrange a trans-bronchial, lymph node needle aspiration Arrange a lung biopsy Commence oral prednisolone Send sputum samples to microbiology Observe and repeat her chest X-ray in 3 months Your answer

This woman has typical features of pulmonary and lymph node sarcoid. If the history and radiology is typical, the diagnosis of sarcoidosis can be confidently made and there is no need to proceed to tissue biopsy. If there were atypical features and tissue biopsy was required, either trans-bronchial or open lung biopsy is preferable. Trans-bronchial, lymph node aspiration is useful for assessing metastatic spread to lymph nodes, but is not a good test for nonmalignant conditions. In the absence of symptoms, she does not need steroid treatment. She does not need sputum sending for culture as there is no suspicion of tuberculosis. She can be followed up and observed radiologically at regular intervals. Some 50% of patients with stage 2 sarcoidosis, ie hilar lymphadenopathy and parenchymal infiltrate, recover spontaneously in 2 years.

136. A 40-year-old nurse, who is a UK-born Caucasian, comes to clinic. She has been coughing for the last 3 months, has a cavity on her chest radiograph and Mycobacterium tuberculosis has been grown from her sputum. HIV testing is negative. Antibiotic sensitivities are awaited. Which of the following antibiotic regimes would be optimal? Rifampicin, isoniazid Rifampicin, isoniazid, pyrazinamide Rifampicin, isoniazid, pyrazinamide and ethambutol Rifampicin, isoniazid, pyrazinamide, ethambutol and ciprofloxacin Rifampicin, isoniazid, pyrazinamide, ethambutol, ciprofloxacin, streptomycin For the initial empiric treatment of tuberculosis (TB), patients are started on a 4-drug regimen; isoniazid, rifampicin, pyrazinamide, and either ethambutol or streptomycin. Once the isolate is known to be fully susceptible, ethambutol (or streptomycin if used as a fourth drug) can be discontinued. After 2 months of therapy (for a fully susceptible isolate), pyrazinamide can be stopped. Isoniazid

Your answer

plus rifampicin are continued as daily or intermittent therapy for 4 or more months. Therapy must be extended if the patient has cavitary disease or remains culture positive after 2 months of treatment. Treatment regimes are different in the case of HIV related TB, where immunocompromise and also the issue of drug interactions becomes important; this requires close specialist management. Extra-pulmonary TB (e.g. bone, CNS) requires a longer duration of treatment, usually 9-12 months. The emerging problem of drug-resistant TB also requires individual management by a specialist team, as patterns of drug resistance vary.

137. A 34-year-old woman, who is a non-smoker, is found to have moderate hypoxaemia on blood gases with a pa(O2) of 7.9 kPa. Lung function tests confirm normal lung volumes but a reduced TLCO at 45% of predicted. The most likely cause for this is: Pulmonary AV malformation Acute asthma Emphysema Goodpastures syndrome Polycythaemia Your answer

Pulmonary AV malformations cause right to left shunts so reducing TLCO values and provoking hypoxaemia. Emphysema also causes reduced TLCO but is usually associated with an elevated residual volume and would be unusual in a young non-smoker. Polycythaemia and pulmonary haemorrhage syndromes usually cause elevation of TLCO. During acute asthma lung volumes will be decreased, particularly FEV1.

138. A 67-year-old man who suffers from recurrent ventricular tachycardia has been taking amiodarone 200 mg daily for 5 years, as well as phenytoin for epilepsy and NSAIDs for arthritis. Over the past few months he has suffered progressive shortness of breath on exercise. Lung function testing reveals a restrictive picture and his chest X-ray is suggestive of diffuse lung fibrosis. Which diagnosis best fits this clinical picture? Phenytoin-induced lung fibrosis NSAID-induced lung fibrosis Amiodarone-induced lung fibrosis Cardiac failure

Your answer

Cryptogenic fibrosing alveolitis Amiodarone may be related to diffuse lung fibrosis. NSAIDs may cause asthma or pulmonary eosinophilia, phenytoin is also characteristically related to pulmonary eosinophilia. Other drugs related to lung fibrosis include nitrofurantoin, hexamethonium and a number of cytotoxic agents. Corticosteroids may be of value in some patients, but withdrawal of the amiodarone, if possible, is advised. In this case, other therapies such as an implantable defibrillator may be considered.

139. Which of the following statements applies to patients with cystic fibrosis (CF)? Neonatal screening for CF results in a better survival rate and reduced decline in lung function Allergic bronchopulmonary aspergillosis is a recognised complication, Your found in 15% of adult CF patients answer The controlled intake of high-calorie food is the first line of management for patients with CF-related diabetes Reduced body mass index is an absolute contraindication for heartlung transplantation A correlation exists between genotype and the severity of the disease The commonest mutation in patients with cystic fibrosis (CF) is the Delta-F508 mutation. There is no correlation between genotype, the range of manifestations, the age of symptoms and the survival rate in CF. Neonatal screening allows the early implementation of prophylactic therapeutic measures. Prospective and retrospective studies have demonstrated that neonates detected by screening have a better nutritional status than those who were discovered by symptoms. The age of acquisition of Pseudomonas aeruginosa and the decline in lung function were found to be comparable in the two groups. The increased age of survival for CF patients is associated with increased complications, such as diabetes mellitus, acquisition of multiple bacteria in their respiratory flora, osteoporosis and liver disease. Diabetes is now seen in almost 10% of patients over the age of 20 years, the main manifestations being weight loss, repeated respiratory infections and decline in lung function. The treatment of choice is subcutaneous insulin therapy. Calorie intake should not be restricted in CF patients who are prone to malnutrition due to their pancreatic insufficiency. The increasing incidence of allergic bronchopulmonary aspergillosis (ABPA) is a recognised phenomenon. ABPA is encountered in 1 in 6 adult CF patients. Manifestations of ABPA include asthma symptoms, flitting opacities on the chest radiograph, increased eosinophil count, and hyperreactivity to the skin-prick test and increased specific plasma IgE. The main treatment is high-dose corticosteroids initially, with a smaller maintenance dose. The duration of treatment ranges from few months to few years. Anti-fungal agents are of no proven benefit. Heartlung transplantation is offered to patients who exhibit a rapid decline in lung function despite optimal treatment, and to patients with respiratory failure. Moderately reduced body mass index (BMI) is an

indication for transplantation. A severe reduction in BMI is a relative contraindication to transplantation, this is because it is associated with a reduced survival but not an absolute one.

140. Which of the following interventions is most likely to improve the FEV1 and prognosis of a cigarette smoker with spirometric evidence of moderate COPD? Tobacco-smoking cessation Frequent use of antibiotics for acute bacterial exacerbations of chronic bronchitis Daily use of salmeterol to improve FEV1 Long-term oxygen therapy at 2 l/min Daily use of ipratropium bromide to improve FEV1 There is no treatment that has been shown to significantly slow or alter the progression of COPD except smoking cessation. The single best thing patients with COPD can do for themselves is to stop smoking. All other treatments are largely for symptom relief. Chronic obstructive pulmonary disease is a common chronic respiratory illness. It is steadily progressive and carries a large burden of mortality and morbidity. It causes about 30,500 deaths per year in the UK. The morbidity burden this raises for the NHS is huge. Of all emergency medical admissions, 25% are due to acute respiratory infections and COPD exacerbations comprise over half this total. The cost in hospital care for these patients is about 500 million. Housing changes and alterations add to the social costs of this disease. COPD is caused by tobacco smoking, heavy exposure to occupational dusts and chemicals, air pollution, cannabis smoking (which is now being recognised) and a1-antitrypsin deficiency. Your answer

141. A 29-year-old woman noticed shortness of breath and a dry cough while jogging last winter. She now wakes up twice a week at 4 oclock in the morning with a troublesome cough. What is the most likely cause? Cardiac insufficiency Mycoplasma pneumonia

Asthma Your answer Bronchiectasis Extrinsic allergic alveolitis The symptoms of asthma are non-specific: shortness of breath, wheezing, chest tightness and cough. These are manifestations of airway narrowing (which is usually variable in severity over short periods, but can be persistent) and of airway hyperresponsiveness. Asthma as the cause of these symptoms is suggested by the variability in their severity and distinguished by their periodicity (such as daily, weekly, monthly, or seasonal), their provocation by specific (such as allergen) and non-specific stimuli and their reversibility with bronchodilators or corticosteroids. Patients with asthma can be categorised, at any one time, by whether their symptoms are intermittent or persistent, and by the severity of their symptoms and underlying airway narrowing measured by lung function tests (even those with mild asthma can develop severe asthma):

Mild, intermittent asthma symptoms occur less than weekly, with normal or near-normal lung function between episodes. Mild persistent asthma symptoms occur more than weekly but less than daily, with normal or near-normal lung function between episodes. Moderate persistent asthma symptoms occur daily, with mild to moderate variable airflow limitation. Severe persistent asthma symptoms occur daily and interfere with normal activities. There is frequent nocturnal waking and moderate to severe variable airflow limitation. Severe asthma severe distressing symptoms prevent sleep. Severe airflow limitation responds poorly to inhaled bronchodilators and can be life-threatening.

142. A morbidly obese 36 year-old man presents for review. His main reason for attendance is that his wife is concerned about his loud snoring and the fact that he stops breathing during the night for periods of up to 810 seconds, followed by coughing, snoring and arousal. Recently he has become hypertensive and is also on treatment for impotence. His 24-h urinary free cortisol level is normal. Which diagnosis best fits this picture?

Cushings disease Obstructive sleep apnoea Simple snoring Simple obesity Essential hypertension

Your answer

Symptoms of sleep apnoea include memory impairment, daytime somnolence, grossly disrupted sleep pattern, decreased libido and systemic hypertension. Further investigation should involve thyroid function testing to rule out hypothyroidism, and assessment of the uvula and tonsils to rule out mechanical obstruction that might be amenable to ENT surgery. Diagnosis of sleep apnoea is made via overnight oximetry. The mainstay of management is weight loss, with the addition of overnight CPAP (continuous positive airway pressure).

143. A 30-year-old woman presents with shortness of breath. This began gradually, around 2.5 years ago, but now she is breathless on climbing a flight of stairs. There is no past history of note. On examination the JVP is raised, carotid pulse volume is reduced and there is evidence of right ventricular hypertrophy. There are right-sided murmurs on cardiac auscultation. Her chest X-ray shows pulmonary artery enlargement, ECG shows right axis deviation and right ventricular hypertrophy. Arterial blood gases reveal hypoxia and hypercapnia, a lung perfusion scan is normal. Cardiac catheterisation reveals that rightsided pressures are markedly raised. Which diagnosis best fits with this clinical picture? Chronic thromboembolic disease Right ventricular failure Primary pulmonary hypertension (PPH) Cryptogenic fibrosing alveolitis Asthma

Your answer

The perfusion scan is not suggestive of chronic thromboembolic disease, which makes primary pulmonary hypertension the most likely diagnosis. Plexogenic pulmonary arteriopathy is found in 3060% of sufferers and characterised by medial hypertrophy and concentric laminar intimal fibrosis. The gene for PPH has now been mapped to chromosome 2, and mutations in the bone morphogenic protein receptor have been identified in some patients. Intravenous epoprostenol (prostacyclin) and oxygen therapy has been shown to improve quality of life in sufferers. Recently, phosphodiesterase (PDE)5 inhibitors have also been shown to have some therapeutic advantage. Unfortunately, several studies report a mean survival of only 2.5 years from diagnosis, with right ventricular failure and sudden death the main causes of mortality.

144. An elderly gentleman with a history of atrial fibrillation and cardiac failure presents to the chest clinic with increasing effort breathlessness. A CXR shows bilateral upper lobe fibrosis. Which of the following is the most likely diagnosis? Asbestosis Bronchopneumonia Multiple pulmonary emboli Sarcoidosis Your answer Worsening cardiac failure With upper lobe fibrosis there are five main causes you should think of: TB, extrinsic allergic alveolitis, sarcoidosis, ankylosing spondylitis and ABPA. Asbestosis causes lower zone shadowing.

145. You are asked to see a 57-year-old smoker, who complains of shortness of breath some 7 days after a total hip replacement. On examination he is obese and has a swollen left leg, and he is visibly short of breath. There appears to be increased prominence of vascular markings at the right hilum on chest X-ray. His calculated alveolararterial (Aa) gradient is 4.5 kPa. Which of the following fits best with his diagnosis?

Postoperative pneumonia Pulmonary embolus Your answer Hyperventilation syndrome Atelectasis Pneumothorax

The alveolararterial (Aa) gradient is affected primarily by V/Q mismatch and shunting. This situation occurs in pulmonary embolism and in pneumonia and given the clinical history and findings, pulmonary embolus is the most likely diagnosis here. The alveolararterial (Aa) gradient is calculated with the following equation pA(O2) (pa(O2) + pa(CO2)/0.8) pA(O2) = alveolar oxygen. Calculated by: (100 7) % inspired O2 eg for 21% O2, the pA(O2) would be 20 kPa pa(O2) and pa(CO2) are arterial O2 and CO2 levels. This illustrates how the normal alveolararterial (Aa) gradient also varies according to level of inspired oxygen. This means that if you use a nomogram for calculating the alveolararterial (Aa) gradient, you must make sure you are looking at the correct slope line for the patients inspired oxygen.

146. A 30-year-old man from the Russia is seen in the emergency department. He was diagnosed with pulmonary tuberculosis 4 months ago in Russia and is taking rifampicin and isoniazid. He comes because of a productive cough, fevers, weight loss and malaise. What would you like to do next? Send a sputum sample and arrange to see him in out-patients Admit him to hospital, send a sputum sample and start him on amoxicillin Admit him to hospital, send a sputum sample and start him on pyrazinamide Admit him to hospital, send a sputum sample and start him on amoxicillin and pyrazinamide

Admit him to hospital, send a sputum sample and add pyrazinamide, amikacin and ethambutol

Your answer

The concern with this man is one of multidrug-resistant tuberculosis. He is failing on his current regime and has clinical features of active tuberculosis. Treatment failure is usually due to poor compliance, which can lead to the development of drug resistance. Other risk factors for resistant disease are: previous anti-TB treatment, HIV infection and contact with drug-resistant TB. Although he may have a superimposed simple bacterial infection, this should not deter from investigating and treating him for TB, as most of the antibiotics used for TB will cover the usual bacterial chest pathogens. A single drug should never be added to a failing TB regime. Add two or three, ideally ones to which the organism is known to be sensitive and which the patient has not previously taken. Send sputum for culture and polymerase chain reaction (PCR) testing before starting further treatment. If he has confirmed multidrug-resistant TB, ensure he is on five or more drugs to which the organism is likely to be susceptible.

147. A 42-year-old patient was diagnosed with mediastinal tuberculosis 3 weeks ago and commenced on treatment. He presents with worsening breathlessness and stridor. His chest X-ray shows mediastinal lymph nodes compressing the carina area, whilst he is distressed he is alert and orientated and maintaining his oxygenation. What is the next step in the investigation and/or management? Urgent computed tomography (CT) scan Tracheostomy Hydrocortisone Ethambutol Broad spectrum antibiotics Your answer

The CT scan is the most appropriate investigation. On enhanced CT scans, nodes larger than 2 cm in diameter invariably show central areas of low attenuation and peripheral rim enhancement. Enhanced walls are usually irregular in thickness. CT scan is useful prior to commencing steroid therapy, a) to confirm the degree of airway compression and b) to assess the response to chemotherapy. A number of commentators recommend rapid initiation of steroid therapy, but with the availability of CT scanning, this would seem a sensible measure first.

148. A 78-year-old White woman presents with left upper lobe cavitating consolidation and sputum samples confirm the presence of Mycobacterium tuberculosis, which is fully sensitive. There is no previous history of treatment for tuberculosis (TB). The most appropriate antibiotic regimen is? Bacillus CalmetteGuerin (BCG) vaccination Rifampicin/clarithromycin 12 months Rifampicin/ethambutol 12 months Rifampicin/isoniazid/pyrazinamide/ethambutol 2 months then rifampicin/isoniazid 4 months Rifampicin/isoniazid/pyrazinamide 4 months then rifampicin/isoniazid 8 months

Your answer

In a white patient with pulmonary Mycobacterium tuberculosis that is fully sensitive, and not previously treated, the use of four drugs for 2 months (rifampicin/isoniazid/pyrazinamide/ethambutol) and then two drugs (rifampicin/isoniazid) for 4 months is perfectly acceptable. Indications for using a four-drug regimen include previously treated tuberculosis, HIV risk factor(s) or being non-White.

149. You are fast-bleeped to see a 50-year-old woman on the medical ward. She was admitted earlier that day with a swollen lower leg following her return from a holiday in Australia. Her D-dimers were raised and she was started on subcutaneous unfractionated heparin. She is now short of breath, pale, clammy, tachycardic and hypotensive. Her ECG shows sinus tachycardia. The house officer has given her iv fluids, but her blood pressure is continuing to fall. What would you consider doing next? Intravenous heparin Further iv fluids Thrombolysis Your answer Echocardiogram V/Q scan

This is a woman who has a high clinical probability of having had a massive pulmonary embolus (PE). She has respiratory and cardiovascular compromise from this PE and is likely to die without treatment. Investigation with either echocardiogram showing pulmonary hypertension or CT showing a clot(s), would be reasonable to confirm the diagnosis, but this woman is rapidly deteriorating. She is not well enough for a V/Q scan. She has had iv fluids and unfractionated heparin already, with no effect. Thrombolysis can be used for acute pulmonary emboli causing circulatory collapse and there is emerging evidence to support this treatment. The risk/benefit analysis must be considered, but in a patient who is at imminent risk of arrest/death, give alteplase 100 mg over 1.5 hours peripherally. (see BTS guidelines for the management of suspected acute pulmonary embolism. Thorax 2003,58(6),470).

150. A 24-year-old man with HIV and a CD4+ lymphocyte count of 150/l has been complaining of gradually worsening dyspnoea associated with a nonproductive cough and fever for the last 2 weeks. A chest X-ray shows bilateral diffuse ground-glass opacities. What is the diagnosis? Tuberculosis Legionellosis Pneumocystis jiroveci pneumonia Your answer Infectious mononucleosis Toxoplasmosis

Pneumocystis jiroveci pneumonia (previously known as Pneumocystis carinii pneumonia) typically presents with gradually increasing dyspnoea and cough over weeks, but sometimes it presents as an acute illness with rapid deterioration over a few days. The chest X-ray usually shows diffuse ground-glass opacities, which strongly suggests the diagnosis; sometimes, however, it shows nodular opacities, lobar consolidation or a normal film. Cystic abnormalities and spontaneous pneumothoraces in patients with known or suspected HIV infection are usually caused by Pneumocystis jiroveci pneumonia. Pneumocystis jiroveci

pneumonia is unlikely in a patient who had a CD4+ cell count above 200 cells/l in the preceding 2 months in the absence of other HIV-associated symptoms. Approximately 90% of patients with Pneumocystis jiroveci pneumonia have an elevated serum lactic dehydrogenase, but this may occur with other pulmonary diseases. In recognition of its genetic and functional distinctness, the organism that causes human PCP was renamed Pneumocystis jiroveci (Frenkel 1999). Changing the organism's name does not preclude the use of the acronym PCP because it can be read "Pneumocystis pneumonia."