Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine-Hematologic and Oncologic Disorders--->Hemopoietic Cell Transplantation
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Question 1# Print Question

A 34-year-old woman presents to the ED with several days of worsening abdominal pain, anorexia, nausea, and copious diarrhea. Three months ago, she had underwent matched unrelated-donor allogeneic stem cell transplant for acute lymphocytic leukemia (ALL). Examination reveals an:

  • afebrile woman with a maculopapular rash over her neck, shoulders, and palms
  • HR 140
  • BP 70/40
  • RR 14 100% RA

She is given 30 mL/kg IVF and SBP remains in the 80s, prompting ICU admission. Laboratory test results are notable for:

  • WBC 6,000/µL
  • plt 150,000/µL
  • Cr 1.6 mg/dL
  • BUN 3 mg/dL

Which of the following statements about the most likely diagnosis is true?

A. Liver biopsy should be a high priority
B. The extent of skin and gut involvement predicts a higher mortality
C. Initial treatment in this case would be topical steroids
D. The pathology is primarily neutrophil-driven
E. Aggressive treatment will reduce the probability of relapsed ALL

Question 2# Print Question

A 23-year-old man with pre-B ALL who had an allogeneic stem cell transplant 1 week ago is transferred to the ICU for close monitoring with neutropenic fever and mild septic shock. He improves on antibiotics, has count recovery, and discussions begin about transferring back to the floor 5 days after ICU transfer. However, the oncologists are concerned about rising direct bilirubin (up to 8 mg/dL) associated with epigastric/RUQ pain and weight gain. RUQ ultrasound reveals hepatomegaly and ascites but does not show evidence of biliary obstruction.

Which of the following is the most likely diagnosis?

A. Ascending cholangitis
B. Acalculous cholecystitis
C. Acute hepatitis B
D. Cholestasis of sepsis
E. Hepatic sinusoidal obstruction syndrome

Question 3# Print Question

A 35-year-old woman who had an allogeneic BMT 10 years ago for pre-B ALL complicated by GVHD of the skin (controlled with topical steroids) presents to the ED with several months of worsening dyspnea. PFTs done a month ago revealed FEV1 of 24% predicted, FVC of 70% predicted, and FEV1/FVC of 0.35. She is afebrile, normotensive, and not hypoxemic but becomes severely dyspneic with mild activity. Chest X-ray is clear. High-resolution chest CT reveals mosaic perfusion and evidence of extensive air-trapping on expiratory views.

Which of the following statements is correct?

A. Lung biopsy is indicated
B. Azithromycin given posttransplant is effective for prevention of this condition
C. Lung transplantation has been reported to be an option in this type of patient
D. Bone marrow biopsy is likely to reveal recurrent leukemia
E. Reduced immunosuppression is indicated

Question 4# Print Question

A 58-year-old man with a new diagnosis of AML receives induction chemotherapy with cytarabine and doxorubicin on the Oncology ward. About 10 days later he develops neutropenic fever in association with worsening hypoxemic respiratory failure. A chest CT is performed (see figure below) and Infectious Disease and Pulmonary are consulted, with bronchoscopy performed the following day notable for friable-appearing airways but with minimal mucous. Gram stain of BAL is unrevealing. Postbronchoscopy the patient has worsening hypoxemic respiratory failure and is transferred to the ICU and intubated. Despite the administration of vancomycin, cefepime, and voriconazole, fevers persist and hypoxemia continues to worsen, requiring high levels of ventilator support. Serial plain films of the chest show progressive whiteout on the right side. Three days postintubation the patient develops massive hemoptysis and cannot be ventilated, resulting in cardiac arrest and subsequent transition to comfort measures after discussion with family. 

The BAL cultures are most likely to show:

A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Pseudomonas aeruginosa
D. Aspergillus fumigatus
E. Influenza A

Question 5# Print Question

A 63-year-old man develops acute respiratory failure after autologous stem cell transplant for lymphoma. His initial posttransplant course was notable for mucositis. Approximately 2.5 weeks posttransplant, following count recovery, he develops a dry cough and worsening arterial hypoxemia. Chest CT reveals diffuse ground glass opacities, and he is transferred to the ICU, given diuretics, and placed on high flow nasal cannula oxygen and broad-spectrum antibiotics. On ICU day 2 he is intubated for worsening work of breathing and fatigue. Bronchosopy is unremarkable, and microbiologic studies of BAL including respiratory viral PCR are unrevealing. His ventilatory settings escalate despite low-tidal volume ventilation, and after another week of mechanical ventilation, his course is complicated by multiorgan failure. Care is transitioned to comfort measures only.

Which of the following is the most likely diagnosis?

A. Invasive pulmonary aspergillosis (IPA)
B. P. aeruginosa bronchopneumonia
C. Idiopathic pneumonia syndrome
D. Acute graft-versus-host disease
E. Cardiogenic pulmonary edema

Category: Critical Care Medicine-Hematologic and Oncologic Disorders--->Hemopoietic Cell Transplantation
Page: 1 of 1