Tuberculosis and interstitial lung disease

22 NEET-PG practice questions on Tuberculosis and interstitial lung disease, part of General Medicine. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 32-year-old auto-rickshaw driver at a PHC has had cough for 3 weeks with evening fever and weight loss. He has never been treated for TB. Sputum Truenat shows MTB detected, rifampicin resistance not detected. Under NTEP, which regimen should he start?

   1. A2HRZES / 1HRZE / 5HRE
   2. B2HRZE / 4HR
   3. CBPaLM for 6 months
   4. D2HRZE / 4HRE

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   Answer: D · 2HRZE / 4HRE

   NTEP treats drug-sensitive TB with daily fixed-dose combinations: isoniazid, rifampicin, pyrazinamide and ethambutol for 8 weeks, then isoniazid, rifampicin and ethambutol for 16 weeks, with doses by weight band. Ethambutol is kept in the continuation phase in India, partly because isoniazid resistance is common. His sample should also go for line probe assay to detect isoniazid resistance, which would change the regimen. He is notified, linked to Ni-kshay Poshan Yojana support and followed with sputum tests.

   • A: The streptomycin-containing retreatment regimen is no longer used under NTEP.
   • B: The continuation phase without ethambutol is the WHO standard, not the NTEP regimen.
   • C: BPaLM is for rifampicin-resistant TB, which Truenat did not detect.

2. Question 2 · Medium

   A 31-year-old woman has tender red nodules on both shins, painful swollen ankles and fever for 10 days. Chest X-ray shows bilateral hilar lymphadenopathy with clear lung fields. Four statements are made about her likely condition: 1. Hypercalcaemia can occur because granuloma macrophages make 1-alpha-hydroxylase. 2. Serum angiotensin-converting enzyme is often raised. 3. Tissue biopsy typically shows caseating granulomas. 4. This presentation usually resolves on its own. Which statements are correct?

   1. A1, 2 and 4 only
   2. B2 and 4 only
   3. C1 and 3 only
   4. D1, 2, 3 and 4

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   Answer: A · 1, 2 and 4 only

   Erythema nodosum, ankle arthritis, fever and bilateral hilar lymphadenopathy make up Lofgren syndrome, an acute form of sarcoidosis. Statements 1, 2 and 4 are correct: activated macrophages convert vitamin D to calcitriol, causing hypercalcaemia and hypercalciuria; serum ACE is raised in many patients; and Lofgren syndrome usually remits within months, often needing only NSAIDs. Statement 3 is false: sarcoid granulomas are non-caseating, and caseation should raise suspicion of TB, which is important to exclude in India.

   • B: Omits statement 1; granuloma macrophages make calcitriol and can cause hypercalcaemia.
   • C: Includes statement 3; sarcoid granulomas are non-caseating, and omits true statements 2 and 4.
   • D: Includes statement 3; caseation suggests TB rather than sarcoidosis.

3. Question 3 · Medium

   At a home visit in Kolkata, the medical officer sees a 3-year-old girl whose father began treatment for sputum-positive pulmonary TB last week. The child is playful, gaining weight, with no cough or fever, and her chest X-ray is normal. What should be done for the child?

   1. AGive a second dose of BCG vaccine
   2. BReview her only if symptoms appear
   3. CDo a tuberculin skin test and treat only if positive
   4. DStart TB preventive treatment without further testing

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   Answer: D · Start TB preventive treatment without further testing

   Under India's TB preventive treatment guidelines, household contacts under 5 years of age are given preventive treatment once active TB has been ruled out, without testing for TB infection first. Young children who are infected progress quickly to severe forms such as miliary TB and TB meningitis. Active disease is excluded by symptom screening, and chest X-ray where available. The family is counselled on adherence and on the symptoms that need review.

   • A: BCG revaccination is not recommended and does not prevent progression in an infected child.
   • B: Waiting for symptoms risks severe disseminated TB in a young child.
   • C: Testing is not required before preventive treatment in a contact under 5, and a negative test would not rule out recent infection.

4. Question 4 · Medium

   A 41-year-old man in Nagpur, previously treated for TB 3 years ago, now has cough and weight loss again. Sputum NAAT detects Mycobacterium tuberculosis with rifampicin resistance. What is the next investigation needed to choose his regimen?

   1. ARepeat sputum smear microscopy at the DMC
   2. BHRCT chest to grade cavitation
   3. CTuberculin skin test and IGRA
   4. DSecond-line line probe assay for fluoroquinolone resistance

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   Answer: D · Second-line line probe assay for fluoroquinolone resistance

   Rifampicin-resistant TB is now treated with short all-oral regimens, and the most important resistance to know next is to fluoroquinolones, which decides whether moxifloxacin can be part of the regimen. Second-line line probe assay gives this result within days, and culture-based drug-susceptibility testing is sent alongside. Treatment should not be delayed for culture results. Rifampicin resistance also makes him a notifiable drug-resistant case with HIV and diabetes testing.

   • A: Smear shows bacilli but gives no information on drug resistance.
   • B: Imaging does not guide the choice of drugs.
   • C: TST and IGRA detect infection and add nothing once TB is confirmed.

5. Question 5 · Medium

   A 70-year-old man is diagnosed with idiopathic pulmonary fibrosis on a definite UIP pattern on HRCT. His FVC is 68% predicted and DLCO 52% predicted; he has no exposure or autoimmune cause. Which drug treatment is most appropriate?

   1. APrednisolone with azathioprine
   2. BNintedanib
   3. CInhaled budesonide-formoterol
   4. DMethotrexate

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   Answer: B · Nintedanib

   Antifibrotic drugs, nintedanib (a tyrosine kinase inhibitor) or pirfenidone, slow the decline of FVC in idiopathic pulmonary fibrosis and are the recommended treatment. Combined prednisolone, azathioprine and N-acetylcysteine increased deaths and hospital admissions in a trial and is avoided. Nintedanib commonly causes diarrhoea and raised liver enzymes. Pulmonary rehabilitation, oxygen when needed and lung transplant referral complete the care.

   • A: Steroids with azathioprine harmed patients with IPF in a trial and are not used.
   • C: Inhaled steroid with a bronchodilator treats airway disease, not fibrosis.
   • D: Methotrexate has no benefit in IPF and can itself cause pneumonitis.

6. Question 6 · Hard

   A 36-year-old man with HIV (CD4 60 cells/µL) and rifampicin-sensitive pulmonary TB started anti-TB treatment, and 2 weeks later began tenofovir, lamivudine and dolutegravir. Three weeks after starting ART he has new high fever, enlarging tender cervical lymph nodes and new infiltrates on chest X-ray. He has taken every dose, and repeat sputum NAAT shows no rifampicin resistance. Blood cultures are sterile. What is the best management?

   1. AStop all drugs and observe for 2 weeks
   2. BContinue ATT and ART, and add prednisolone
   3. CSwitch to a regimen for drug-resistant TB
   4. DStop ART until the TB treatment is complete

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7. Question 7 · Easy

   A 67-year-old retired bank manager has had slowly worsening breathlessness on exertion and a dry cough for 2 years. He has finger clubbing and fine end-inspiratory 'velcro' crackles at both lung bases. HRCT chest shows subpleural, basal reticulation with honeycombing and traction bronchiectasis, without ground-glass change. He has no exposure history, connective tissue disease or drug cause. What is the most likely diagnosis?

   1. ACryptogenic organising pneumonia
   2. BSarcoidosis
   3. CIdiopathic pulmonary fibrosis
   4. DHypersensitivity pneumonitis

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8. Question 8 · Medium

   A 45-year-old man from rural Punjab who keeps 40 pigeons on his roof has had cough, breathlessness and tiredness for 6 months, worse in the evenings after tending the birds. HRCT shows ill-defined centrilobular ground-glass nodules, mosaic attenuation and air trapping on expiratory images, mainly in the mid and upper zones. Bronchoalveolar lavage shows 55% lymphocytes. What is the most likely diagnosis?

   1. ASarcoidosis
   2. BIdiopathic pulmonary fibrosis
   3. CAllergic bronchopulmonary aspergillosis
   4. DHypersensitivity pneumonitis

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9. Question 9 · Medium

   A 52-year-old man in the intensive phase of treatment for pulmonary TB wakes at night with severe pain and swelling of the right big toe. The joint is red and hot. Serum uric acid is 10.8 mg/dL. Which drug, by which mechanism, most likely caused this?

   1. AEthambutol, by increasing purine synthesis
   2. BRifampicin, by causing immune-complex arthritis
   3. CPyrazinamide, by reducing urate excretion
   4. DIsoniazid, by causing pyridoxine deficiency

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10. Question 10 · Medium

    A 39-year-old woman has had Raynaud's phenomenon for 5 years and now has thickened skin over the fingers and forearms, and exertional breathlessness. Anti-topoisomerase I (anti-Scl-70) antibody is positive. HRCT shows bilateral lower-lobe ground-glass opacities with fine reticulation and relative sparing of the immediate subpleural lung; there is no honeycombing. Which pattern of interstitial lung disease is this?

    1. ADesquamative interstitial pneumonia
    2. BNon-specific interstitial pneumonia
    3. CLymphocytic interstitial pneumonia
    4. DUsual interstitial pneumonia

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11. Question 11 · Medium

    A 29-year-old woman from Pune with pulmonary TB has a sputum NAAT showing rifampicin resistance not detected. Line probe assay on the same sample shows a katG mutation, and second-line line probe assay shows no fluoroquinolone resistance. Which regimen does NTEP recommend?

    1. AHigh-dose isoniazid added to the standard drug-sensitive regimen
    2. BIsoniazid, rifampicin, pyrazinamide and ethambutol for 2 months, then 4 months HRE
    3. CLevofloxacin, rifampicin, ethambutol and pyrazinamide for 6 months
    4. DBedaquiline, pretomanid, linezolid and moxifloxacin for 6 months

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12. Question 12 · Hard

    A 62-year-old man has breathlessness on climbing one flight of stairs. Spirometry and lung volumes: FEV1 1.8 L (63% predicted), FVC 2.1 L (56% predicted), FEV1/FVC 0.86, total lung capacity 58% predicted, DLCO 41% predicted. Oxygen saturation falls from 95% to 86% on a 6-minute walk. Which condition best explains these results?

    1. AMyasthenia gravis
    2. BObesity hypoventilation
    3. CSevere kyphoscoliosis
    4. DPulmonary fibrosis

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13. Question 13 · Medium

    A 58-year-old man has worked for 25 years cutting and polishing sandstone in a quarry in Rajasthan. He now has breathlessness and cough. Chest X-ray shows many small nodules in both upper zones and 'eggshell' calcification of the hilar lymph nodes. Which complication is he at a particularly high risk of developing?

    1. AAllergic bronchopulmonary aspergillosis
    2. BPulmonary sarcoidosis
    3. CPulmonary tuberculosis
    4. DMalignant mesothelioma

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14. Question 14 · Easy

    A 72-year-old man has taken a drug for recurrent ventricular tachycardia for 3 years. He now has progressive breathlessness and dry cough; HRCT shows bilateral reticular opacities with patchy high-attenuation areas. His TSH is also raised and he has bluish-grey skin on the face. Which drug is the most likely cause of his lung disease?

    1. AAmiodarone
    2. BDigoxin
    3. CMetoprolol
    4. DMexiletine

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15. Question 15 · Medium

    A 24-year-old woman has just been diagnosed with drug-sensitive pulmonary TB and will start the NTEP daily regimen. She takes a combined oral contraceptive pill and does not wish to become pregnant this year. What is the best advice on contraception?

    1. AContinue the pill, as anti-TB drugs do not affect it
    2. BDouble the pill dose until ethambutol is stopped
    3. CStop all contraception, as TB itself prevents conception
    4. DUse a copper IUD, as rifampicin makes the pill unreliable

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16. Question 16 · Medium

    A 30-year-old man has had headache and fever for 3 weeks and is now drowsy, with neck stiffness and a left sixth nerve palsy. CSF: opening pressure raised, 220 cells/µL (90% lymphocytes), protein 240 mg/dL, glucose 28 mg/dL (blood glucose 110 mg/dL); CSF NAAT detects Mycobacterium tuberculosis, rifampicin-sensitive. Along with anti-TB drugs, what should be added?

    1. ADexamethasone
    2. BProphylactic phenytoin
    3. CMannitol for 6 weeks
    4. DIntrathecal streptomycin

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17. Question 17 · Hard

    A 55-year-old diabetic man on maintenance haemodialysis three times a week is diagnosed with drug-sensitive pulmonary TB. He weighs 60 kg. How should his first-line anti-TB drugs be adjusted?

    1. AGive all four drugs daily at the usual doses, before each dialysis session
    2. BOmit rifampicin and pyrazinamide, and give isoniazid with ethambutol for 18 months
    3. CGive ethambutol and pyrazinamide three times weekly after dialysis; isoniazid and rifampicin unchanged
    4. DHalve the doses of isoniazid and rifampicin; ethambutol and pyrazinamide unchanged

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18. Question 18 · Easy

    Cartridge-based NAAT and Truenat detect rifampicin resistance in Mycobacterium tuberculosis by finding mutations in which gene?

    1. ArpoB
    2. BgyrA
    3. CkatG
    4. DinhA

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19. Question 19 · Medium

    A 34-year-old truck driver is newly diagnosed with HIV and, in the same week, sputum-positive pulmonary TB that is rifampicin-sensitive. His CD4 count is 110 cells/µL; there are no features of meningitis. He has started the daily NTEP regimen. When should antiretroviral therapy be started?

    1. AAfter the full 6 months of anti-TB treatment
    2. BWithin 2 weeks of starting anti-TB treatment
    3. COnly when the CD4 count falls below 50 cells/µL
    4. DAfter the 2-month intensive phase is completed

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20. Question 20 · Hard

    A 23-year-old man in Mumbai has pulmonary TB with rifampicin resistance on NAAT; second-line line probe assay shows no fluoroquinolone resistance. He is not pregnant or on any other drug, and is to start the 6-month BPaLM regimen. The medical officer notes: 1. The regimen contains bedaquiline, pretomanid, linezolid and moxifloxacin. 2. Treatment lasts about 26 weeks. 3. Serial ECGs are needed to watch the QT interval. 4. If fluoroquinolone resistance is later found, the regimen is extended to 18-20 months with moxifloxacin continued. Which statements are correct?

    1. A1 and 3 only
    2. B1, 2, 3 and 4
    3. C1, 2 and 3 only
    4. D2, 3 and 4 only

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21. Question 21 · Easy

    A 38-year-old construction worker in Lucknow has had a productive cough for 3 weeks, low-grade evening fever and loss of appetite. He has never had TB treatment and has no other illness. The block PHC has a molecular testing machine. Under NTEP, which test should be done first on his sputum?

    1. ALiquid culture on the MGIT system
    2. BNucleic acid amplification test (CBNAAT or Truenat)
    3. CTwo Ziehl-Neelsen smears, morning and spot
    4. DInterferon-gamma release assay on blood

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22. Question 22 · Medium

    A 46-year-old woman in her fourth week of the drug-sensitive TB regimen has nausea, vomiting and yellow eyes. Serum bilirubin is 4.2 mg/dL and ALT 410 U/L (upper limit 40 U/L); hepatitis A, B and E markers are negative. She is alert, with no bleeding. What is the next best step?

    1. AStop pyrazinamide only and continue the other three drugs
    2. BChange to the bedaquiline-based regimen for drug-resistant TB
    3. CStop isoniazid, rifampicin and pyrazinamide, then reintroduce them one by one
    4. DContinue all four drugs and repeat liver tests in 2 weeks

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