Drug-induced pulmonary diseases: recognition and management MCQs With Answer
This question set is designed for M.Pharm students studying Pharmacotherapeutics I (MPP 102T) to deepen understanding of drug-induced pulmonary diseases. It emphasizes mechanisms of lung injury, characteristic clinical and imaging patterns, diagnostic tests (PFTs, DLCO, HRCT, BAL), common culprit drugs and high-risk scenarios, and evidence-based management including when to stop offending agents, use corticosteroids, and prevent recurrence. Questions integrate pharmacology, pathophysiology and clinical decision-making to prepare students for exam-style assessment and practical therapeutics. Answers are provided to reinforce learning and to help students recognize presentations early and select appropriate interventions.
Q1. Which of the following mechanisms is a predominant cause of bleomycin-induced pulmonary toxicity?
- Impaired mitochondrial beta-oxidation leading to lipid accumulation
- Free radical–mediated DNA strand breaks and oxidative injury
- Bradykinin accumulation in airway smooth muscle
- Autoimmune antibody formation against alveolar basement membrane
Correct Answer: Free radical–mediated DNA strand breaks and oxidative injury
Q2. A patient on chronic amiodarone develops progressive dyspnea and interstitial infiltrates. Which clinical feature most strongly suggests amiodarone pulmonary toxicity?
- Marked peripheral eosinophilia on CBC
- High cumulative amiodarone dose, elevated serum transaminases, and increased alveolar-arterial gradient
- Rapid resolution with bronchodilators alone
- Isolated lobar consolidation without interstitial change
Correct Answer: High cumulative amiodarone dose, elevated serum transaminases, and increased alveolar-arterial gradient
Q3. Which pulmonary function test finding is most characteristic of early drug-induced interstitial lung disease?
- Normal FVC, increased TLC, and increased DLCO
- Restrictive pattern with reduced FVC and reduced DLCO
- Obstructive pattern with reduced FEV1/FVC and normal DLCO
- Isolated increased residual volume with normal DLCO
Correct Answer: Restrictive pattern with reduced FVC and reduced DLCO
Q4. Which drug class is most commonly associated with a persistent dry cough due to increased bradykinin levels?
- Angiotensin-converting enzyme (ACE) inhibitors
- Beta-2 adrenergic agonists
- Loop diuretics
- Calcium channel blockers
Correct Answer: Angiotensin-converting enzyme (ACE) inhibitors
Q5. Which antibiotic is classically linked to eosinophilic pneumonia and should be suspected when new pulmonary infiltrates and peripheral eosinophilia occur shortly after therapy?
- Doxycycline
- Daptomycin
- Azithromycin
Correct Answer: Daptomycin
Q6. Which management step is most appropriate for acute drug-induced diffuse alveolar hemorrhage suspected from anticoagulant therapy?
- Continue anticoagulation and add high-dose inhaled corticosteroid
- Stop anticoagulant, provide supportive care, and reverse anticoagulation if indicated
- Administer broad-spectrum antibiotics immediately
- Initiate chronic macrolide therapy
Correct Answer: Stop anticoagulant, provide supportive care, and reverse anticoagulation if indicated
Q7. Which pattern on high-resolution CT (HRCT) most commonly corresponds to nonspecific interstitial pneumonia (NSIP) from drug toxicity?
- Predominant upper-lobe centrilobular nodules with bronchiectasis
- Diffuse ground-glass opacities with reticular changes and subpleural sparing
- Single cavitary lesion with air-fluid level
- Large pleural effusion with mediastinal shift
Correct Answer: Diffuse ground-glass opacities with reticular changes and subpleural sparing
Q8. A patient on nitrofurantoin presents with fever, cough, and eosinophilia within days of starting the drug. The most likely mechanism is:
- Direct dose-dependent cytotoxicity causing fibrosis
- Hypersensitivity reaction causing acute interstitial pneumonitis
- Cholestatic liver injury with secondary pulmonary edema
- Thromboembolism due to platelet activation
Correct Answer: Hypersensitivity reaction causing acute interstitial pneumonitis
Q9. Which of the following increases the risk of bleomycin pulmonary toxicity during anesthesia?
- Administration of high inspired oxygen concentrations intraoperatively
- Use of regional anesthesia instead of general anesthesia
- Perioperative beta blocker therapy
- Prophylactic corticosteroids during anesthesia
Correct Answer: Administration of high inspired oxygen concentrations intraoperatively
Q10. Which laboratory or BAL finding supports a diagnosis of drug-induced eosinophilic pneumonia?
- Marked neutrophilia in BAL with negative cultures
- Prominent eosinophils in peripheral blood and BAL fluid
- Low lymphocyte count in BAL and elevated BNP
- Transudative pleural fluid with low protein
Correct Answer: Prominent eosinophils in peripheral blood and BAL fluid
Q11. In a suspected case of methotrexate-induced pneumonitis, which is the most appropriate initial action?
- Increase the methotrexate dose and observe
- Stop methotrexate and consider systemic corticosteroids if respiratory compromise or progressive disease
- Switch immediately to another folate antagonist
- Start broad antiviral therapy
Correct Answer: Stop methotrexate and consider systemic corticosteroids if respiratory compromise or progressive disease
Q12. Phospholipidosis with foamy macrophages in the lung is most characteristically caused by which drug?
- Trimethoprim-sulfamethoxazole
- Amiodarone
- Rifampicin
- Ceftriaxone
Correct Answer: Amiodarone
Q13. Which feature best distinguishes hypersensitivity pneumonitis from simple drug-related pneumonitis on BAL differential cell count?
- Marked neutrophil predominance (>80%)
- Lymphocytosis (elevated lymphocyte percentage) in BAL
- Exclusive presence of red blood cells
- Absent inflammatory cells with only hemosiderin-laden macrophages
Correct Answer: Lymphocytosis (elevated lymphocyte percentage) in BAL
Q14. Which antihypertensive therapy is preferred in a patient who developed ACE inhibitor–related cough?
- Switch to an angiotensin receptor blocker (ARB)
- Increase ACE inhibitor dose
- Start a thiazide diuretic only
- Replace with a beta-2 agonist inhaler
Correct Answer: Switch to an angiotensin receptor blocker (ARB)
Q15. Drug-induced pulmonary arterial hypertension (PAH) has been strongly associated with which historical appetite suppressant?
- Phentermine
- Fenfluramine
- Orlistat
- Metformin
Correct Answer: Fenfluramine
Q16. Which of the following is the most important general principle in management of suspected drug-induced lung disease?
- Immediately start long-term antibiotics
- Stop the offending drug where possible and assess severity; consider corticosteroids for progressive cases
- Always perform lung biopsy before stopping any drug
- Switch to another drug in the same class without evaluation
Correct Answer: Stop the offending drug where possible and assess severity; consider corticosteroids for progressive cases
Q17. A cancer patient treated with immune checkpoint inhibitors develops new dyspnea and bilateral ground-glass opacities. The likely diagnosis and first-line treatment are:
- Pulmonary embolism treated with anticoagulation
- Immune-related pneumonitis treated by withholding checkpoint inhibitor and starting systemic corticosteroids
- Bacterial pneumonia treated with high-dose cephalosporin
- Cardiogenic pulmonary edema treated with diuretics only
Correct Answer: Immune-related pneumonitis treated by withholding checkpoint inhibitor and starting systemic corticosteroids
Q18. Which patient factor is NOT typically a risk factor for developing drug-induced pulmonary fibrosis?
- Advanced age and preexisting interstitial lung disease
- High cumulative dose of the offending agent
- Concurrent chest irradiation
- Long-term use of inhaled short-acting beta-agonists
Correct Answer: Long-term use of inhaled short-acting beta-agonists
Q19. Which diagnostic test is most useful to exclude infection and help identify drug-related lung disease phenotype via cellular analysis?
- Arterial blood gas alone
- Bronchoalveolar lavage (BAL) with cell differential and cultures
- Electrocardiogram
- Urine toxicology screen only
Correct Answer: Bronchoalveolar lavage (BAL) with cell differential and cultures
Q20. Chronic nitrofurantoin use can cause progressive interstitial fibrosis. Which monitoring or preventive strategy is most appropriate for long-term prophylactic use?
- Ignore respiratory symptoms as they are unrelated
- Regular assessment for respiratory symptoms, baseline and periodic chest imaging/PFTs, and consider alternative agents if symptoms occur
- Prophylactic high-dose corticosteroids from start of therapy
- Doubling the nitrofurantoin dose reduces pulmonary risk
Correct Answer: Regular assessment for respiratory symptoms, baseline and periodic chest imaging/PFTs, and consider alternative agents if symptoms occur
