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Self-Assessment Questions

Pulmonary Disease

Pulmonary Infectious Diseases: Review Questions

Ricardo A. López, MD, FCCP

Dr. López is an Instructor of Medicine, Mount Sinai School of Medicine, New York, NY; an Adjunct Clinical Assistant Professor of Medicine, New York College of Osteopathic Medicine, Westbury, NY; and Section Head of Critical Care, Queens Hospital Center, Jamaica, NY.

Choose the single best answer for each question.

Questions 1 and 2 refer to the following case study.

A nonsmoking 26-year-old woman sees a pulmonologist for evaluation of a 5-month history of persistent cough, wheezing, nasal congestion, and weight loss. She reports no reflux. She emigrated from Guyana 5 years ago and had no significant medical history in her native country. She took no medications until recently when she was treated with antibiotics, systemic and inhaled corticosteroids, and albuterol in an emergency department (ED); despite treatment, symptoms persisted, and a leukotriene antagonist was added, again with little relief of symptoms. Laboratory studies at that time showed leukocytosis (leukocyte count, 28 x 103/mm3) with a differential of 16.3 x 103/mm3 (58%) eosinophils; erythrocyte sedimentation rate was 37 mm/h. Results of serum chemistries were normal, and an antinuclear antigen assay was negative. Results of pulmonary function tests were as follows: forced vital capacity (FVC), 61%; forced expiratory volume in 1 second (FEV1), 65% (with a significant bronchodilator response); FEV1/FVC, 85; total lung capacity, 61%; functional residual capacity, 50%; residual volume, 54%; diffusing capacity of the lung for carbon monoxide, 54%. Arterial blood gas analysis revealed a pH of 7.41, Pco2 of 36 mm Hg, Po2 of 102 mm Hg, oxygen saturation of 98% on room air, and an alveolar arterial gradient of 5 mm Hg. Chest radiography revealed a fine interstitial infiltrate, and a high resolution computed tomography scan of the chest revealed a fine nodular pattern in both middle and lower lung fields.

1. Which of the following diagnostic steps is most appropriate to assess the patient’s condition?
  1. Measure serum IgG4 level
  2. Perform bronchoscopy with bronchoalveolar lavage and transbronchial biopsy
  3. Perform open lung biopsy
  4. Test for Aspergillus precipitins
  5. Test stool for ova and parasites
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2. Administration of which of the following is the most appropriate treatment for this patient?
  1. Amphotericin B
  2. Diethylcarbamazine
  3. Inhaled corticosteroids
  4. Itraconazole
  5. Systemic corticosteroids
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Questions 3 and 4 refer to the following case study.

A 31-year-old woman from the Ivory Coast is admitted to the hospital because of a 3-month history of fever, chills, weight loss, and a productive cough. She came to the ED when her sputum became tinged with blood. Chest radiography reveals a left upper lobe infiltrate with a cavity. She is placed in respiratory isolation; sputum is collected and sent for analysis for acid-fast bacillus (AFB), along with blood for a CD4+ count and an HIV test. Results of the sputum sample test are positive for AFB, her CD4+ count is 68/mm3, and she is HIV-positive.

3. Which of the following is the most appropriate next step in this patient’s treatment?

  1. Start 4 antituberculous medications
  2. Start 4 antituberculous medications after obtaining AFB sensitivity
  3. Start 4 antituberculous medications plus antiretroviral medications
  4. Start highly active antiretroviral medications
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4. The triage nurse in the ED is concerned because she was significantly exposed to the patient while the patient had been coughing. Results of purified protein derivative (PPD) skin testing in the past have always been negative. Which of the following is the most appropriate next step for the pulmonologist to take?

  1. Offer reassurance
  2. Perform a PPD skin test
  3. Perform a PPD skin test, and start preventive treatment if induration is greater than 5 mm
  4. Start 4 antituberculous medications
  5. Start preventive treatment
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