Respiratory
Isocyanates are the most common cause of occupational asthma
Hypercalcaemia + bilateral hilar lymphadenopathy → ?sarcoidosis
Patients with high oxygen-affinity haemoglobin variants can develop secondary polycythaemia
and hence have an increased risk of thrombotic events
Serial peak flow measurements at work and at home are used to detect occupational asthma
Pneumothorax management: the high-risk characteristics that determine the need for a chest
drain are:
● Haemodynamic compromise (suggesting a tension pneumothorax)
● Significant hypoxia
● Bilateral pneumothorax
● Underlying lung disease
● ≥ 50 years of age with significant smoking history
● Haemothorax
answer is allergic bronchopulmonary aspergillosis.
Major criteria for the diagnosis are:
● Clinical features of asthma
● Proximal bronchiectasis
● Blood eosinophilia
● Immediate skin reactivity to Aspergillus antigen
● Increased serum IgE (>1000 IU/ml)
Minor criteria:
● Fungal elements in sputum
● Brown flecks in sputum
● Delayed skin reactivity to fungal antigens
(Reference: Rosenberg M, Patterson R, Mintzer R et-al. Clinical and immunologic criteria for the
diagnosis of allergic bronchopulmonary aspergillosis. Ann. Intern. Med. 1977;86 (4): 405-14 ).
Loeffler syndrome is associated with evidence of tropical infections and there is no history of
foreign travel here. True asthma is not directly associated with bronchiectasis and Churg-Strauss
is associated with p-ANCA antibodies. DRESS syndrome is associated with eosinophilia but
,tends to cause a rash and systemic upset such as a fever.
Recurrent chest infections + subfertility - think primary ciliary dyskinesia syndrome
(Kartagener's syndrome)
Importance: 81
Primary ciliary dyskinesia or Kartagener's syndrome are characterised by reduced cilia motility
throughout the body. This results in recurrent chest infections and bronchiectasis but also can
result in male infertility. When Primary ciliary dyskinesia (PCD) is associated with situs inversus
(resulting in the quiet heart sounds), it is known as Kartagener's syndrome, however, this only
happens in 50% of PCD. This presentation of symptoms is similar to cystic fibrosis however the
negative sweat test ruled out this differential. The normal testicular examination ruled out a
varicocele and the normal hormonal analysis ruled out Klinefelter's syndrome.
Alpha-1 antitrypsin: PiMZ = carrier and unlikely to develop emphysema if a non-smoker
Importance: 52
Remember when testing for Alpha-1 antitrypsin:
M is normal, S is slow, and Z for very slow → PiMM is the normal genotype. You can remember
this by thinking of which letter comes first in the alphabet (M) and which comes last (Z -
slowest).
Therefore the genotype he has, PiMZ, is heterozygous. This means he has the carrier genotype,
unlikely to develop lung disease if he does not smoke. He may, however, pass on the A1AT
gene to his children.
The majority of patients with sarcoidosis get better without treatment
Importance: 65
Spontaneous resolution is correct. The patient has sarcoidosis. He has the Lofgren syndrome
subtype of the disease characterized by an acute onset of bilateral lower limb arthritis, erythema
nodosum and bilateral hilar lymphadenopathy and typically resolves in the absence
Dyspnoea, obstructive pattern on spirometry in patient with rheumatoid → ? bronchiolitis
obliterans
The presence of hyponatraemia strongly points towards a diagnosis of small cell lung cancer.
Transfer factor
, ● raised: asthma, haemorrhage, left-to-right shunts, polycythaemia
● low: everything else
The correct answer is anaemia, which causes a reduction in the carbon monoxide transfer factor
(TLCO). This occurs because anaemia results in fewer red blood cells and therefore less
haemoglobin being available to bind with carbon monoxide during the test. The TLCO
measurement depends on both the diffusion of CO across the alveolar-capillary membrane and
the amount of haemoglobin available for binding, so reduced haemoglobin leads to a lower TLCO
value.
Acetazolamide is used more in the prevention of altitude related disorders, rather than the
treatment.
Alveolar haemorrhage is indeed the correct answer. When blood fills the alveolar spaces, there
is an increased amount of hemoglobin available to bind carbon monoxide during TLCO testing.
This results in an elevated TLCO measurement as more CO can be taken up by the additional
hemoglobin present in the alveolar spaces. This is one of the few conditions where TLCO is
increased rather than decreased.
Chronic sinusitis + nephritic syndrome → ? granulomatosis with polyangiitis
Importance: 27
Granulomatosis with polyangiitis (GPA) is the correct diagnosis given the patient's presentation
of chronic sinusitis unresponsive to antibiotics, nasal congestion, epistaxis, and a swollen nasal
bridge, which strongly suggests involvement of the upper respiratory tract—a key feature of GPA.
The clinical findings of dark urine, pedal oedema, and a urinalysis revealing haematuria,
proteinuria, and red blood cell casts are indicative of glomerulonephritis, another hallmark
manifestation of GPA. The co-occurrence of upper respiratory tract disease and renal
impairment is highly suggestive of GPA. Furthermore, GPA is typically associated with a positive
c-ANCA/PR3 test result that would assist in confirming this diagnosis.
Indications for corticosteroid treatment for sarcoidosis are: parenchymal lung disease, uveitis,
hypercalcaemia and neurological or cardiac involvement
Importance: 82
The correct answer is Hypercalcaemia. Sarcoidosis can cause hypercalcaemia due to increased
production of 1,25-dihydroxyvitamin D by activated macrophages in granulomas. This leads to
increased intestinal absorption and renal reabsorption of calcium. Hypercalcaemia can have
serious health implications and can lead to symptoms such as fatigue, confusion, constipation
and arrhythmias. In the case of sarcoidosis-induced hypercalcaemia, glucocorticoids like
Isocyanates are the most common cause of occupational asthma
Hypercalcaemia + bilateral hilar lymphadenopathy → ?sarcoidosis
Patients with high oxygen-affinity haemoglobin variants can develop secondary polycythaemia
and hence have an increased risk of thrombotic events
Serial peak flow measurements at work and at home are used to detect occupational asthma
Pneumothorax management: the high-risk characteristics that determine the need for a chest
drain are:
● Haemodynamic compromise (suggesting a tension pneumothorax)
● Significant hypoxia
● Bilateral pneumothorax
● Underlying lung disease
● ≥ 50 years of age with significant smoking history
● Haemothorax
answer is allergic bronchopulmonary aspergillosis.
Major criteria for the diagnosis are:
● Clinical features of asthma
● Proximal bronchiectasis
● Blood eosinophilia
● Immediate skin reactivity to Aspergillus antigen
● Increased serum IgE (>1000 IU/ml)
Minor criteria:
● Fungal elements in sputum
● Brown flecks in sputum
● Delayed skin reactivity to fungal antigens
(Reference: Rosenberg M, Patterson R, Mintzer R et-al. Clinical and immunologic criteria for the
diagnosis of allergic bronchopulmonary aspergillosis. Ann. Intern. Med. 1977;86 (4): 405-14 ).
Loeffler syndrome is associated with evidence of tropical infections and there is no history of
foreign travel here. True asthma is not directly associated with bronchiectasis and Churg-Strauss
is associated with p-ANCA antibodies. DRESS syndrome is associated with eosinophilia but
,tends to cause a rash and systemic upset such as a fever.
Recurrent chest infections + subfertility - think primary ciliary dyskinesia syndrome
(Kartagener's syndrome)
Importance: 81
Primary ciliary dyskinesia or Kartagener's syndrome are characterised by reduced cilia motility
throughout the body. This results in recurrent chest infections and bronchiectasis but also can
result in male infertility. When Primary ciliary dyskinesia (PCD) is associated with situs inversus
(resulting in the quiet heart sounds), it is known as Kartagener's syndrome, however, this only
happens in 50% of PCD. This presentation of symptoms is similar to cystic fibrosis however the
negative sweat test ruled out this differential. The normal testicular examination ruled out a
varicocele and the normal hormonal analysis ruled out Klinefelter's syndrome.
Alpha-1 antitrypsin: PiMZ = carrier and unlikely to develop emphysema if a non-smoker
Importance: 52
Remember when testing for Alpha-1 antitrypsin:
M is normal, S is slow, and Z for very slow → PiMM is the normal genotype. You can remember
this by thinking of which letter comes first in the alphabet (M) and which comes last (Z -
slowest).
Therefore the genotype he has, PiMZ, is heterozygous. This means he has the carrier genotype,
unlikely to develop lung disease if he does not smoke. He may, however, pass on the A1AT
gene to his children.
The majority of patients with sarcoidosis get better without treatment
Importance: 65
Spontaneous resolution is correct. The patient has sarcoidosis. He has the Lofgren syndrome
subtype of the disease characterized by an acute onset of bilateral lower limb arthritis, erythema
nodosum and bilateral hilar lymphadenopathy and typically resolves in the absence
Dyspnoea, obstructive pattern on spirometry in patient with rheumatoid → ? bronchiolitis
obliterans
The presence of hyponatraemia strongly points towards a diagnosis of small cell lung cancer.
Transfer factor
, ● raised: asthma, haemorrhage, left-to-right shunts, polycythaemia
● low: everything else
The correct answer is anaemia, which causes a reduction in the carbon monoxide transfer factor
(TLCO). This occurs because anaemia results in fewer red blood cells and therefore less
haemoglobin being available to bind with carbon monoxide during the test. The TLCO
measurement depends on both the diffusion of CO across the alveolar-capillary membrane and
the amount of haemoglobin available for binding, so reduced haemoglobin leads to a lower TLCO
value.
Acetazolamide is used more in the prevention of altitude related disorders, rather than the
treatment.
Alveolar haemorrhage is indeed the correct answer. When blood fills the alveolar spaces, there
is an increased amount of hemoglobin available to bind carbon monoxide during TLCO testing.
This results in an elevated TLCO measurement as more CO can be taken up by the additional
hemoglobin present in the alveolar spaces. This is one of the few conditions where TLCO is
increased rather than decreased.
Chronic sinusitis + nephritic syndrome → ? granulomatosis with polyangiitis
Importance: 27
Granulomatosis with polyangiitis (GPA) is the correct diagnosis given the patient's presentation
of chronic sinusitis unresponsive to antibiotics, nasal congestion, epistaxis, and a swollen nasal
bridge, which strongly suggests involvement of the upper respiratory tract—a key feature of GPA.
The clinical findings of dark urine, pedal oedema, and a urinalysis revealing haematuria,
proteinuria, and red blood cell casts are indicative of glomerulonephritis, another hallmark
manifestation of GPA. The co-occurrence of upper respiratory tract disease and renal
impairment is highly suggestive of GPA. Furthermore, GPA is typically associated with a positive
c-ANCA/PR3 test result that would assist in confirming this diagnosis.
Indications for corticosteroid treatment for sarcoidosis are: parenchymal lung disease, uveitis,
hypercalcaemia and neurological or cardiac involvement
Importance: 82
The correct answer is Hypercalcaemia. Sarcoidosis can cause hypercalcaemia due to increased
production of 1,25-dihydroxyvitamin D by activated macrophages in granulomas. This leads to
increased intestinal absorption and renal reabsorption of calcium. Hypercalcaemia can have
serious health implications and can lead to symptoms such as fatigue, confusion, constipation
and arrhythmias. In the case of sarcoidosis-induced hypercalcaemia, glucocorticoids like
