Last updated: June 2026
These interactive MCQs are designed for learning chemotherapy pharmacology, adverse effects, mechanisms of action, counselling points and clinical decision-making.
Question 1
A 26-year-old female presents with complaints of fever. She recently started induction therapy with daunorubicin and cytarabine for acute myelocytic leukemia. On examination, vital signs show a temperature of 38.8 C (101.8 F), heart rate of 118 beats per minute, and blood pressure of 85/65 mmHg. The patient is mildly agitated and delirious and found to have erythema, warmth, and tenderness around her chemotherapeutic catheter site. The patient is admitted and given intravenous hydration. Which of the following is the antibiotic of choice in this patient?
Show explanation
If a patient with a history of chemotherapy presents with a new fever, perform an infection workup, including blood cultures for anaerobic and aerobic organisms. Obtain two sets of blood culture samples and start broad-spectrum antibiotics within an hour for likely neutropenic fever.
Monotherapy regimens used in high-risk febrile neutropenic patients are cefepime, ceftazidime carbapenems, meropenem, imipenem, and piperacillin and tazobactam.
Correct dosages are:
- cefepime 2 g IV every eight hours
- meropenem 1 g IV every eight hours
- imipenem 500 mg IV every six hours, or ceftazidime 2 g IV every eight hours.
Other antibiotics (e.g., fluoroquinolones, aminoglycosides, and/or vancomycin) may be added to the empiric therapy in patients with complicated presentations.
Question 2
A 46-year-old patient with Hodgkin lymphoma was given treatment for his lymphoma with medication on a high dose. After 6 months of treatment, the patient developed signs and symptoms of congestive heart failure. Even during the early stages of treatment with this medication, the patient showed signs of cardiotoxicity in the form of minor EKG changes. What is the description of the liposomal technology used with this drug?
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- Liposomes are phospholipid spheres enclosing an aqueous inner vesicle.
- Liposomes can be used to target drug delivery, increase bioavailability, and protect the bioactive contents from gastric destruction.
- Newer liposomal technologies, such as the stealth system, are designed to extend half-lives, reduce toxicity, and better control drug release.
- Targeted and gene-based liposomes are not used with doxorubicin.
Question 3
A 53-year-old woman with a history of breast cancer presents with worsening hot flashes that interfere with her work and sleep. Her only medication is tamoxifen. What is the best treatment for this patient’s hot flashes?
Show explanation
Serotonin-norepinephrine reuptake inhibitors (SNRI) such as venlafaxine, although not FDA approved for the treatment of hot flashes, are recommended to manage hot flashes in a woman taking tamoxifen.
Nonprescribed, nonhormonal therapies studied include soy extract, red clover isoflavones, black cohosh, and Chinese herbs. Their safety and efficacy remain unclear. Although better quality studies are needed, some studies have found these nonhormonal options more effective than placebo.
Paroxetine and other selective serotonin reuptake inhibitors are not recommended for women with tamoxifen-induced hot flashes due to their effects as a potent inhibitor of the drug-metabolizing enzyme CYP2D6 and therefore interfering with tamoxifen’s therapeutic benefit.
Estrogen therapy is generally contraindicated in women with breast cancer
Question 4
A 65-year-old woman with Gilbert syndrome and recently diagnosed metastatic colorectal cancer that has spread to her lung starts treatment with irinotecan, 5-fluorouracil (5-FU), and leucovorin. Two days after irinotecan administration, she develops watery diarrhea. What is the most likely irinotecan pathway of metabolism contributing to this toxicity?
Show explanation
- Gilbert syndrome is a common, harmless liver condition in which the liver doesn’t properly process bilirubin. Bilirubin is produced by the breakdown of red blood cells. Gilbert syndrome is an inherited genetic condition
- Irinotecan, a DNA topoisomerase I inhibitor, is used to treat a variety of solid tumors.
- It is a prodrug that undergoes hydrolysis by carboxylesterase to form its active metabolite SN-38. SN-38 acts on bowel mucosa to cause diarrhea.
- Patients with Gilbert syndrome are at risk for a higher incidence of irinotecan-related toxicity; therefore, dose reduction is recommended for these patients.
- Also, the assessment of UGT1A1 is critical to assess the risk of toxicity, as this is the key enzyme involved in irinotecan metabolism
Question 5
A 44-year-old woman presents with a history of abnormal vaginal bleeding. She cannot recall the last time she has been to a doctor. Upon physical examination a palpable mass is palpated in her cervix – a biopsy reveals squamous carcinoma of the cervix. She is prescribed pembrolizumab, what is the most appropriate dosing regimen for her?
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- The most common administration schedule is a 200 mg infusion given over 30 minutes every 3 weeks.
- An alternate approved schedule is 2 mg/kg every three weeks for pediatric patients.
- Most monoclonal antibodies are dosed based on body size, however, studies have shown that pembrolizumab fixed-dosing provides adequate coverage and yields the advantage of reduced dosage errors, convenience, and less waste (for an expensive therapy).
- While some of the earlier pembrolizumab clinical trials used every 2-week dosing, this is not one of the answer choices.
Question 6
A 61-year-old man born in the US, diagnosed with advanced testicular cancer, presents postoperatively to the clinician for medical management. He has not previously received radiation or chemotherapy for his condition. He has no travel history, was fully vaccinated as a child, and is currently up to date on vaccinations. His review of systems is positive for fatigue. The left testicle has been surgically removed. The physical exam is otherwise unremarkable. The preoperative chest X-ray was unremarkable, with no infiltrations noted. The patient is to be started on a chemotherapy regimen, including cisplatin. Which of the following must be included in the initial workup before administering cisplatin?
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- Before initiating cisplatin therapy, a complete blood count (CBC) should be ordered to assess white blood cell baseline levels due to cisplatin-induced myelosuppression. Serial CBC can help monitor the side effects of cisplatin administration and should be evaluated before each treatment course.
- Nephrotoxicity is a common complication of cisplatin use. Renal toxicity risk is minimized by ensuring adequate hydration before and after cisplatin administration. Close monitoring of renal function throughout treatment is important.
- Assessing electrolytes, blood-urea nitrogen (BUN), and creatinine before first administration is crucial to identifying the patient’s baseline and determining if modified renal dosing is required.Cisplatin can cause electrolyte wasting, especially hypomagnesaemia, hypokalaemia, and other renal tubular abnormalities.
- Renal impairment may require a change in dose or aggressive. pretreatment to reduce renal toxicity. Creatinine and electrolytes should be assessed before administering Cisplatin to monitor changes after treatment. Further monitoring may be necessary should a patient experience clinical symptoms such as neuropathy or vision loss.
- The viral panel is not necessary before treatment in an asymptomatic patient. This patient’s fatigue is likely secondary to advanced testicular cancer. TB test should be assessed before starting patients on TNFα inhibitors. This is not required before treating with cisplatin.
Question 7
Chemotherapeutic agents have adverse effects that pass through three stages: onset, maximum depression, and recovery. Which of the following indicates maximum depression?
Show explanation
- Nadir is the time of deepest depression. In chemotherapy, the term refers to the length of time before maximum bone marrow depression occurs.
- Many chemotherapeutic agents cause low leukocyte counts.
- When the white cell count drops, the patient is prone to many types of bacterial and viral infections.
- By anticipating the nadir, providers can take preventive steps to reduce the risk of infections.
Question 8
A 35-year-old man with small cell lung cancer is being treated with methotrexate. What is the mechanism of action of this drug?
Show explanation
- Methotrexate has a distinct mechanism of action regarding its use in chemotherapy and immunosuppression in autoimmune diseases.
- In cancer, methotrexate acts as an antifolate antimetabolite. Methotrexate is taken into the cell by human reduced folate carriers (SLC19A1), and it forms methotrexate-polyglutamate. Both the methotrexate and the methotrexate-polyglutamate inhibit the enzyme dihydrofolate reductase.
- Dihydrofolate reductase catalyzes the conversion of dihydrofolate into tetrahydrofolate, the active form of folic acid.
- Methotrexate-polyglutamate further inhibits the de novo purine synthesis of both purine and thymidylate synthase, thereby inhibiting DNA synthesis. This mechanism is utilized in the treatment of cancer because of its cytotoxic effect.
Question 9
A 65-year-old woman with a recent history of HER2 positive, estrogen receptor (ER) negative, and progesterone receptor (PR) negative breast cancer. Adjuvant chemotherapy has been initiated. Her baseline echocardiogram before chemotherapy showed an ejection fraction (EF) of 55%. After 4 cycles of chemotherapy, lower extremity edema develops, and an echocardiogram now reveals an EF of 35%. Which medication was used as a part of her regimen that caused this adverse effect?
Show explanation
- Trastuzumab is a monoclonal antibody directed against human epidermal growth factor receptor 2 (HER2) and is used to treat breast cancer.
- Trastuzumab is associated with a modest risk of cardiotoxicity, usually presenting as decreased ejection fraction.
- Trastuzumab cardiotoxicity is usually asymptomatic, and its risk increases in patients over 50.
- The risk of trastuzumab cardiotoxicity is also higher in patients with concurrent use of anthracyclines.
- Paclitaxel and docetaxel are not associated with cardiotoxicity but can cause bone marrow suppression
Question 10
A 65-year-old man presents with palpitations, dyspnea, and fever. The patient has a past medical history significant for chronic lymphocytic leukemia and underwent chemotherapy yesterday. His blood pressure is 100/70 mmHg, heart rate 125/min, respiratory rate 25/min, and temperature 102 F (38.8 C). Laboratory analysis reveals hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. An electrocardiogram is suggestive of ventricular arrhythmia. What is the most likely cause of this patient’s current condition?
Show explanation
- Tumor lysis syndrome is a clinical condition that can occur spontaneously or after the initiation of chemotherapy. It causes hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia leading to end-organ damage.
- Tumor lysis syndrome is caused by the massive release of intracellular ions such as potassium, phosphorus, and nucleic acids that have been metabolized to uric acid.
- The main organ responsible for the excretion of these substances is the kidney.
- When the compensatory response of the kidney is exhausted as a result of the massive release of intracellular ions, uric acid obstructive uropathy develops, which can then progress to acute kidney injury
Question 11
A 65-year-old man presents to the hospital with complaints of fatigue and weakness. He reports that he has had increasing trouble going on a walk with friends because of the increasing fatigue. Physical examination is largely unremarkable. Results from routine lab testing are notable for hemoglobin of 7.7g/dL (reference range >13.5g/dL) and leukocyte count of 45/microliter (reference range: 4.5 to 11.0/microliter). Differential count on peripheral blood smear is:
Show differential count
| Differential count | Result |
|---|---|
| Neutrophils | 43% |
| Lymphocytes | 11% |
| Eosinophils | 4% |
| Basophils | 5% |
| Monocytes | 5% |
| Promyelocytes | 4% |
| Myelocytes | 10% |
| Metamyelocytes | 8% |
| Bands | 10% |
Which of the following is an appropriate therapy to start the patient on?
Show explanation
- This patient with anemia, leukocytosis, and myeloid precursors likely has chronic myeloid leukemia.
- Imatinib is a drug that can be used for chronic myeloid leukemia. Imatinib mesylate is a 2-phenylamino pyrimidine derivative protein tyrosine kinase inhibitor initially targeted to the platelet-derived growth factor receptor. Subsequently, it has additionally been found to inhibit other protein tyrosine kinases such as c-kit (gastrointestinal stromal tumors) and BCR-ABL fusion protein (Philadelphia chromosome chronic myelogenous leukemia).
- These protein tyrosine kinases as a whole phosphorylate specific amino acids on substrate proteins which induce signal transduction resulting in changes to cell biology, including cell growth, differentiation, and death; constitutive activation of which, through mutation or other means, can lead to malignancy. Blocking this constitutive action has been shown to induce downstream apoptosis without further differentiation.
- Imatinib, as a therapeutic, does just that - it blocks the constitutive action of protein tyrosine kinase by working as a competitive inhibitor of the ATP binding side of ABL, inducing apoptosis of leukemic cells.
- Cetuximab is typically used for colorectal cancer. Trastuzumab is typically used for breast cancer. Vemurafenib is typically used for melanoma.
Question 12
An 18- year-old male patient diagnosed with high-grade osteogenic sarcoma of the femur, received neoadjuvant chemotherapy with methotrexate, Adriamycin and cisplatin regimen following which he underwent surgical resection. The resected tumor specimen showed less than 10 percent viable tumor. He was subsequently planned for chemotherapy in the adjuvant setting. Which of the following is the chemotherapeutic regimen of choice?
Show explanation
- The European and American Osteosarcoma Study Group trial (EURAMOS-1) was a large collaborative trial involving four major osteosarcoma study groups. The aim of the trial was to improve treatment outcomes in patients with high-grade osteosarcoma.The study included patients younger than 40 years, with either localized or metastatic high-grade osteosarcoma.
All patients initially received standard chemotherapy with:
- High-dose methotrexate
- Adriamycin/doxorubicin
- Cisplatin
This regimen is commonly referred to as MAP or MAC.
After neoadjuvant chemotherapy and surgical resection, tumor response was assessed histologically.
A good histological response was defined as:
- Less than 10% viable tumor
- This means more than 90% of the tumor was necrotic/dead after chemotherapy.
In good responders, the trial studied whether adding pegylated interferon-alpha-2b to standard chemotherapy would improve outcomes.
The addition of pegylated interferon-alpha-2b did not improve disease-free survival or overall survival.
Several factors were associated with worse clinical outcomes, including:
- Presence of metastatic disease
- Pulmonary metastases
- Non-pulmonary metastases
- Axial tumor location, such as pelvis or spine
Certain histological subtypes had different prognostic outcomes:
- Conventional osteoblastic osteosarcoma and telangiectatic osteosarcoma were associated with relatively more favorable outcomes.
- Chondroblastic osteosarcoma was associated with less favorable outcomes.
In patients who underwent complete surgical resection, a poor histological response to neoadjuvant chemotherapy was associated with worse prognosis.
A poor response means:
- 10% or more viable tumor remains
- This suggests the tumor was less sensitive to the initial chemotherapy.
In poor responders, ifosfamide plus etoposide (IE) was added to the standard chemotherapy regimen. However, adding IE did not improve disease-free survival or overall survival.
Therefore, the standard chemotherapy regimen with methotrexate, Adriamycin/doxorubicin, and cisplatin (MAC/MAP) remains the recommended regimen of choice for high-grade osteosarcoma.
Question 13
A 65-year-old female patient has a past medical history significant for stage 3 colon cancer status post colectomy and currently on chemotherapy. She presented with fever, dysuria, and an increased frequency of urine. She was diagnosed with a urinary tract infection leading to sepsis and was admitted. On examination, she has a high-grade fever, the blood pressure is 100/70 mmHg, the heart rate is 100/min, and the respiratory rate is 16/min. Mild suprapubic tenderness is also present, but otherwise, her examination is unremarkable. Pertinent labs include WBC of 14,000/µL, hemoglobin 12.0, platelets 120,000/µL and creatinine of 1.0 mg/dL. What is the most appropriate option to be included in her prophylactic regime?
Show explanation
Cancer patients have an increased risk of a thrombotic event (DVT and PE) and they are even at greater risk when hospitalized thereby warranting a method of DVT prophylaxis unless there is a clear contraindication. In her case platelet count is 120,000/µL, and creatinine is 1.0 mg/dL, so there is no major contraindication to pharmacological prophylaxis.
Low molecular weight heparin is the preferred method in patients with cancer if there are no contraindications like increased risk of bleeding or renal impairment.
Enoxaparin 40 mg daily or 30 mg daily in patients with mild renal impairment.
Warfarin is not normally used in DVT prophylaxis in patients with cancer because it has delayed onset, requires INR monitoring, and has many drug/food interactions.
Aspirin does not have a role in DVT prophylaxis in patients with cancer.
Intermittent pneumatic compressions (IPC) might help but cannot be used as a stand-alone method. IPC is often used when a patient has a high risk of bleeding and cannot safely receive blood-thinning medicines like LMWH or heparin.
For example:
- Low platelets
- Active bleeding
- Recent surgery, or very high bleeding risk
Question 14
A 65-year-old female presents with complaints of abdominal swelling, a sense of fullness after little eating, weight loss of 20 lbs, discomfort in the pelvis area, frequent urination, and altered bowel habits for the past 3 months. Her Cancer Antigen 125 (CA 125) levels were elevated. A transvaginal ultrasound was performed that showed a solid mass in the ovaries. A CT scan of the pelvis was done that revealed a 4x5 cm mass present in the left ovary with no enlarged lymph nodes in the pelvic areas, no signs of spread to the liver, kidneys, or bladder. The patient is started on chemotherapy by an agent that acts as an antimicrotubule agent and promotes the assembly of microtubules by enhancing the action of tubulin dimers and stabilizing current microtubules while inhibiting their disassembly. Which adverse effect, if seen in the patient, should result in a decreased dose of this drug?
Show explanation
Peripheral neuropathy is a common adverse effect of paclitaxel. It is used as the 1st line of treatment in ovarian cancer along with cisplatin.
Patients with preexisting neuropathies are at a higher risk of developing peripheral neuropathy than other patients.
Certain prior chemotherapy regimens can increase a patient’s risk along with comorbid conditions, such as diabetes mellitus.
For patients who develop severe peripheral neuropathy, the dose should be reduced by 20%.
Cancer Antigen 125.
It is a protein/tumour marker measured in the blood, most commonly associated with epithelial ovarian cancer. A commonly used upper reference limit is around 35 U/mL, so values above 35 U/mL are often called “elevated,” although exact lab ranges can vary.
Important point:
CA-125 is not diagnostic by itself. It can be elevated in ovarian cancer, but also in non-cancer causes such as endometriosis, pelvic inflammatory disease, fibroids, liver disease, peritonitis, and other inflammatory conditions. Also, some ovarian cancers may have normal CA-125, especially early disease
Question 15
A 65-year-old female has an abnormal mammogram. She denies any symptoms of breast pain, lump, skin changes, nipple discharge, or bleeding. The screening mammogram demonstrates a 1.2 cm spiculated mass in the upper outer quadrant of the right breast. This is confirmed on a diagnostic mammogram. A targeted ultrasound shows a hypoechoic mass measuring 1.3 x 1.1 x 0.8 cm. The clinical exam reveals a palpable mass in the upper outer quadrant of the right breast. The axillary examination is negative. Breast biopsy reveals a moderately differentiated invasive ductal carcinoma measuring 1.2 cm that was ER/PR positive and HER2/neu negative. What is the next best step?
Show explanation
- Breast conservation therapy may include quadrantectomy, wide excision, or lumpectomy.
- In clinically negative axilla, sentinel node biopsy has replaced upfront axillary node dissection.
- Radiation therapy is recommended after lumpectomy to reduce the risk of local recurrence.
- Radiation options for node-negative breast cancer include whole breast radiotherapy (conventional fractionation or hypofractionation) or partial breast irradiation.
- Mastectomy — can be an option, but it is not required for a small 1.2 cm tumour if breast-conserving surgery is feasible.
Question 16
A 75-year-old male with prostate cancer has suboptimally responded to management despite surgical castration. Oral anti-androgen therapy is being considered for him. The patient also gives a history of irritable bowel syndrome (IBS) with diarrhea and almost daily alcohol intake. His history includes epilepsy that started with generalized tonic-clonic seizures around three years back for which he is on oral phenytoin. Occupationally he has worked for 40 years in a glass manufacturing factory. His chest computed tomography scan and spirometry confirmed interstitial lung disease (ILD), although his breathing is well-controlled on salmeterol - budesonide combination inhaler. Which of the following antiandrogens is preferred for his further medical management?
Show explanation
- All these agents, i.e., flutamide, nilutamide, bicalutamide, and enzalutamide are Nonsteroidal Antiandrogens that competitively bind androgen receptors throughout the body. They share certain adverse effects like hot flashes, decreased libido, and the propensity for hepatotoxicity.
- Bicalutamide is a first-generation non-steroidal antiandrogen. Among the listed options, it is the best fit because it avoids the major red flags present in this patient:
- Diarrhoea,
- Alcohol-related reaction
- Interstitial lung disease (ILD)
- Seizure risk
- Nilutamide can cause interstitial pneumonitis/interstitial lung disease and can also cause alcohol intolerance-like reactions. This patient already has confirmed ILD and daily alcohol intake, so nilutamide is a bad choice.
- Enzalutamide’s adverse effects include the induction of seizures, especially in those with a predisposition.
- Flutamide is the most hepatotoxic and has a much higher potential of causing diarrhea than other options.
Question 17
A 16-year-old boy undergoes chemotherapy with multiple chemotherapeutic agents for acute lymphoblastic leukemia. What is the most common dose-limiting toxicity due to the chemotherapeutic agents used in this patient?
Show explanation
- In most conventional multi-agent chemotherapy regimens, including treatment for acute lymphoblastic leukemia (ALL), the most common dose-limiting toxicity is myelosuppression, also called bone marrow suppression.
- The goal of chemotherapy is to inhibit cell proliferation and tumor multiplication, thus avoiding invasion and metastasis. But this results in toxic effects of chemotherapy due to the effect on normal cells as well.
- Bone marrow suppression refers to the decreased production of one or more major hematopoietic lineages, which leads to diminished or absent hematopoietic precursors in the bone marrow and attendant cytopenias.
- Most chemotherapy drugs show activity in rapidly multiplying cells, so they tend to affect these cells, e.g., bone marrow, GI tract, hair follicles. Common toxicities associated with such agents include myelosuppression, nausea, vomiting, GI side effects, mucositis, alopecia, sterility, infertility, and infusion reactions.
Question 18
A 66-year-old African-American woman with a past medical history significant for a recent diagnosis of diffuse large B-cell lymphoma (DLBCL) on R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone), morbid obesity, hypertension, and arthritis presents to the clinic for an evaluation prior to her infusion of R-CHOP. She reports fatigue.The vitals and labs are given below.
Show vitals and laboratory results
| Category | Lab/test | Result |
|---|---|---|
| Vitals | Pulse | 82/min |
| BP | 135/95 mmHg | |
| Temperature | 37°C | |
| Respiratory rate | 14/min | |
| SpO₂ | 95% room air | |
| CBC | WBC | 4,000/µL |
| Hemoglobin | 9 g/dL | |
| Platelets | 115,000/µL | |
| Electrolytes | Sodium | 136 mEq/L |
| Potassium | 4.5 mEq/L | |
| Chloride | 105 mEq/L | |
| Bicarbonate | 22 mEq/L | |
| Renal function | BUN | 34 mg/dL |
| Creatinine | 1.1 mg/dL | |
| Calcium | Calcium | 8.8 mg/dL |
| Liver function | AST | 35 IU/L |
| ALT | 34 IU/L | |
| Total bilirubin | 1.1 mg/dL | |
| Albumin | 3.4 g/dL | |
| Urinalysis | Specific gravity | 1.025 |
| Blood/protein/WBC/nitrite/leukocyte esterase | Negative | |
| Bleeding check | Stool occult blood | Negative |
| Cardiac check | EKG/echocardiogram | No acute abnormality |
What is the next best step in the management of this patient?
Show explanation
- The patient has drop-in hemoglobin compared to her baseline, which can be expected with chemotherapy. There are no active signs of bleeding, and she looks hemodynamically stable.
- The management would be to continue the chemotherapy without any changes in the dosing.
- No indications for blood transfusion as the patient do not have any cardiac abnormalities. The goal for transfusion is hemoglobin less than 7 g/dL in non-cardiac patients.
- There is no indication for erythropoietin in this patient.
Question 19
A 68-year-old man with multiple myeloma presents with a severely painful red eye. He had an allogeneic stem cell transplant two months ago, and he is currently on bortezomib and prednisone as maintenance therapy. His specialist recently increased his prednisone dose and arranged for IV zoledronic acid infusion, which he had 4 days ago.
Show vital signs
| Category | Vital sign | Result |
|---|---|---|
| Vitals | Temperature | 37.2°C |
| Respiratory rate | 16/min | |
| SpO₂ | 96% room air | |
| Pulse | 102/min | |
| Blood pressure | 155/67 mmHg |
Examination of the face shows a red right eye with no swelling or erythema in or around the orbital cavity. The rest of his physical examination is unremarkable. What is the most likely diagnosis?
Show explanation
- The two most common bisphosphonates which cause uveitis are pamidronate and zoledronic acid. This condition can be diagnosed by a slit-lamp examination.
- Bisphosphonates can cause ocular complications, even in the recommended doses. Ocular complications caused by bisphosphonates are serious complications and require ophthalmologist specialist input.
- Bisphosphonates are not known to cause keratitis; instead, it causes conjunctivitis and they do not cause optic neuritis.
- Bisphosphonates can also cause scleritis, but not episcleritis. Both conditions are not that painful.
Question 20
- A 32-year-old woman with a past medical history of acute myelocytic leukemia presents complaining of cough with a small amount of bright red blood. She had a one-week history of cough productive of thick brown sputum, fever, and pleuritic chest pain. A chest x-ray done 5 days ago revealed a right upper lobe infiltrate; she was immediately started on oral antibiotics by her primary care provider. However, the symptoms persist. The patient underwent allogeneic stem cell transplantation for her acute myelocytic leukemia 5 weeks ago, complicated by acute graft-versus-host disease and neutropenia
Show vital signs, exam and laboratory results
| Category | Finding/test | Result |
|---|---|---|
| Vitals | Temperature | 39.5°C / 103.1°F |
| Blood pressure | 100/62 mmHg | |
| Pulse | 110/min | |
| Respiratory rate | 20/min | |
| Physical exam | Lung examination | Right-sided crackles |
| CBC | Leukocytes | 1,500/µL |
| Hematocrit | 28% | |
| Platelets | 138,000/µL |
Chest x-ray shows a right upper lobe infiltrate, increased in size compared to the previous x-ray. Chest CT scan reveals several nodular lesions with surrounding ground-glass opacities in the right upper lobe. Sputum gram stain shows no organisms. What is the best initial therapy for this patient?
Show explanation
This patient most likely has invasive pulmonary aspergillosis.The main population at risk of developing invasive aspergillosis is immunocompromised patients. These patients will typically present with a triad of fever, chest pain, and hemoptysis
Patient is highly immunocompromised because she has: AML + allogeneic stem cell transplant + acute graft-versus-host disease + neutropenia.
In addition now she has: persistent fever + cough + pleuritic chest pain + hemoptysis + worsening lung infiltrate despite antibiotics
The most important clue is the CT finding: nodular lung lesions with surrounding ground-glass opacity This is called the halo sign, which is classically associated with angioinvasive aspergillosis in neutropenic or stem-cell-transplant patients. The halo sign represents a pulmonary nodule surrounded by haemorrhage/ground-glass opacity due to fungal invasion of blood vessels. It is highly suggestive of angioinvasive fungal infection in severely immunocompromised patients.
Voriconazole is first-line initial therapy for invasive pulmonary aspergillosis. Guidelines recommend primary treatment with voriconazole and advise early antifungal therapy when invasive pulmonary aspergillosis is strongly suspected, even while diagnostic workup continues.
Voriconazole + caspofungin Combination therapy may be considered in selected severe or refractory cases, but it is not the standard initial therapy.
Caspofungin is an echinocandin. It has activity against Aspergillus but is generally used as salvage therapy or in combination, not as preferred first-line monotherapy.
Embolization is used for massive or life-threatening hemoptysis, not for small-volume bright red blood. Her main problem is active invasive fungal pneumonia, so she needs antifungal therapy.