Drug-induced pulmonary diseases: recognition and management MCQs With Answer

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

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