Surgery MCQs Q19

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PULMONOLOGY • INTERNAL MEDICINE

A 39-year-old woman presents with recurrent severe chest infections since childhood. She now complains of hemoptysis. Chest radiograph shows bilateral cystic changes with tram-line shadows.

What is the most probable diagnosis?

A Carcinoma of lung

B Hamartoma

C Lung abscess

D Pulmonary embolism

E Bronchiectasis

Bronchiectasis. The combination of lifelong recurrent infections and "tram-line shadows" is pathognomonic for bronchiectasis, where chronic inflammation leads to permanent bronchial dilation.

Decoding Clue

1

CLUE "Recurrent infections since childhood + hemoptysis + tram-line shadows"

TRANS Chronic inflammation + dilated/thickened bronchi → Bronchiectasis.

Explanation

E. Bronchiectasis: Correct. A condition of permanent dilation of bronchi due to wall destruction. Tram-line shadows represent parallel thickened bronchial walls seen end-on.

A. Carcinoma of lung: Typically presents in older patients with a smoking history; unlikely to cause symptoms since childhood.

B. Hamartoma: A benign pulmonary nodule often showing "popcorn calcification"; it doesn't cause recurrent diffuse cystic changes.

C. Lung abscess: Presents with acute/subacute fever and air-fluid levels in a single cavity, not lifelong bilateral cystic disease.

D. Pulmonary embolism: Causes acute chest pain and dyspnea; radiology may show Hampton's hump but not tram-line shadows or cystic changes.

🧠 High-Yield Pearls

Feature	Finding / Detail	Clinical Significance
Gold Standard Dx	HRCT Chest	Shows "Signet ring sign" (dilated bronchus > adjacent artery)
Tram-line Shadows	Parallel lines	Corresponds to thickened, non-tapering bronchial walls
Congenital Causes	Cystic Fibrosis	Primary Ciliary Dyskinesia / Kartagener (Situs inversus)
Classic Sputum	Three-layered	Top: Frothy, Mid: Serous, Bottom: Purulent/debris

Integrated Clinical Questions

1. Most common symptom of bronchiectasis?

Answer: Chronic productive cough with copious purulent sputum.

2. Most sensitive investigation?

Answer: High-Resolution CT (HRCT) of the chest.

3. Classical sputum description?

Answer: Copious, purulent, and often foul-smelling.

4. A major life-threatening complication?

Answer: Massive hemoptysis (due to bleeding from hypertrophied bronchial arteries).

5. Underlying congenital causes?

Answer: Cystic fibrosis, Kartagener syndrome (triad: bronchiectasis, situs inversus, sinusitis), and hypogammaglobulinemia.

⚡ Exam Pearls

• Tram-line = bronchiectasis (must remember).
• Chronic history since childhood = think congenital/structural disease.
• Hemoptysis in chronic lung disease = think bronchiectasis or TB.
• HRCT is gold standard; look for "signet ring sign".

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