April, 2020 | Pathology Review for USMLE

Questions 256-260: General pathology with images

Question 256

A forensic pathologist is performing an autopsy on a 29-year-old G0PO female who died in a motor vehicle accident. The pathologist identified the pathologic finding illustrated below. Of the following, assuming that the woman has a syndrome, what is autopsy also likely to identify?

A. Rocker bottom feet
B. A single palmar crease
C. Hypoplastic parathyroid glands
D. Atrophic ovaries
E. Congenital absence of the ovaries

Of the following, what would genetic testing most likely reveal?

A. Trisomy 21
B. Trisomy 18
C. Absence of one X chromosome
D. CGG repeats on the X chromosome
E. Deletion of 22q11.2

Answer for Question 256

Answer: D (Atrophic ovaries); C (Absence of one X chromosome).

Explanation: The patient has a horseshoe kidney, which can be seen in several different genetic conditions; however, Turner syndrome is one of the conditions most commonly associated with this abnormality. In Turner syndrome, the ovaries are described as streaked–they are atrophic and fibrotic. The cytogenetic abnormality is complete absence of the X chromosome (in many patients, there is not complete absence of the X chromosome and instead, patients are a mosaic, or have some structural abnormality of the X chromosome). Rocker bottom feet are seen in trisomy 13 and 18. A horseshoe kidney can occur in patients with trisomy 18; however, these patients rarely survive into adulthood, whereas Turner patients often do. Hypoplastic parathyroid glands are seen in DiGeorge syndrome (del 22q11.2). A single palmar crease (comment: the older, less politically correct term was simian crease) is characteristic of Down syndrome. In Turner syndrome, there is no congenital absence of the ovaries, instead there is just an accelerated loss of oocytes after birth, leading to atrophic and fibrotic, streak-like ovaries, and patients have primary amenorrhea (hence the G0P0).

Question 257

A 28-year-old female presents to an acute care clinic. Two days before, she was working in her garden when she stuck herself with a thorn on her rose bushes. She has no allergies to any substance that she knows of and has been stuck by thorns before; however, this time, she developed the reaction illustrated in the image. Of the following, which mediator most significantly contributed to the pathologic change?

A. IL-1
B. ICAM-1
C. Leukotriene B4
D. PGI2
E. Eotaxin

Answer for Question 257

Answer: D (PGI2)

Explanation: PGI2 (i.e., prostacyclin) plays a role in vasodilation. Vasodilation allows for the slowing of blood flow and is responsible for the red coloration of the skin associated with cellulitis, which is one specific example of acute inflammation. IL-1 plays a role in causing endothelial cells to express adhesion molecules and in the systemic response to the inflammation, including production of fever. ICAM-1 is an adhesion molecule on endothelial cells that plays a role in allowing leukocytes to adhere to the endothelium. Leukotriene B4 is a chemotactic agent.

Question 258

A 37-year-old male is brought to the emergency room by his girlfriend, who states that over the past two days he has become lethargic after a bout of fever, chills, and cough. An x-ray reveals patchy consolidation of both lungs. He sustains a cardiac arrest during his evaluation and is unable to be resuscitated. An autopsy confirms the x-ray findings and also reveals enlargement of the liver, with a representative histologic section below. Of the following, which test would best identify his risk factor for the condition identified in the liver?

A. A PPD test
B. Hepatitis serologic testing
C. HIV test
D. CA-125 for tumor
E. ACE

Of the following, which stain would help the pathologist identify the pathologic condition illustrated in the image?

A. Acid-fast bacillus (AFB) stain
B. Trichrome
C. Hemosiderin
D. Mucicarmine
E. Oil-red-O for fat

Answer for Question 258

Answers: C (HIV); D (Mucicarmine).

Explanation: The organism is Cryptococcus neoformans (blue arrows)–the clearing around the organism is the polysaccharide capsule that they have (and which India ink on a smear would highlight since it does not allow for the stain to color it and thus leaves a blank spot around the organism). Cryptococcus neoformans is most often associated with meningitis; however, it often starts as a lung infection and can disseminate. On histology, the organism will stain with mucicarmine or PAS (periodic acid schiff. Cryptococcus neoformans occurs in patients with AIDS, and thus, an HIV test is the best answer.

Question 259

A 52-year-old homeless male is found unresponsive on the ground adjacent to his camp site by a friend. For the past three days, he had been complaining of a cough, which was occasionally productive. He also voiced having a fever and chills. Upon arrival of emergency medical services, he was found to be asystolic. The coroner was summoned and determined that an autopsy was necessary to determine the cause of death. The microscopic examination identifies the histologic change exhibited in the following two images (one is low power and one is high power). Of the following, what was the most likely etiology for his death?

A. Bacterial infection
B. Viral infection
C. Parasitic infection
D. Neoplastic proliferation
E. Trauma
F. Acute drug toxicity

Answer for Question 259

Answer: A (Bacterial infection).

Explanation: There are neutrophils filling the alveolar airspaces. Of the choices, bacterial infection is most commonly associated with a neutrophilic infiltrate (viruses with lymphocytes and parasites with eosinophils). While aspiration pneumonia, which can occur in the homeless and in drug users, would appear similar, an acute drug toxicity by itself would not necessarily have an accompanying pneumonia unless the patient survived for a short period of time after the drug overdose. Neutrophils are multi-lobated and there is a prominent amount of cytoplasm (unlike lymphocytes). In most histologic sections, eosinophils will have easily identifiable red granules in the cytoplasm.

Question 260

A 23-year-old male was stabbed in the chest during a confrontation over the sale of illicit drugs. He was transported to hospital, where emergent surgery was performed to drain his hemopericardium and repair the superficial incised wound of his heart. Several days later, while still hospitalized, he develops severe hypotension, sustains a cardiac arrest, and is unable to be resuscitated. An autopsy is performed which identifies a vasculitis associated with intramural thrombosis as illustrated below. Of the following, what was the mechanism of the vasculitis?

A. Type I hypersensitivity reaction
B. Type II hypersensitivity reaction
C. Type IV hypersensitivity reaction
D. Delayed effects of physical trauma
E. Bacterial infection
F. Fungal infection

Answer for Question 260

Answer: F (Fungal infection)

Explanation: At the yellow arrows are aseptate hyphae, which could be consistent with a Zygomycete infection (there are numerous cross-sections of fungi in the image). An example of a microthrombus is present at the black arrow. Aspergillus and Zygomycetes are a cause of a vasculitis.

Questions 251-255: General pathology with images

Question 251

A 37-year-old male presents to the emergency room complaining of fever, chills, malaise, and a non-productive cough that has developed over five days. A chest x-ray reveals patchy infiltrates. His disease process is illustrated in the image below. Of the following, what was the most likely etiology for his infection?

A. Hiking in California
B. Inadequate childhood vaccination
C. Working at tuberculosis clinic
D. Intravenous drug use
E. Unprotected sexual contact

Answer for Question 251

Answer: A (Hiking in California).

Explanation: The lesion is a spherule (yellow arrow) filled with endospores (blue arrows) and is the typical histologic appearance of Coccidioides immitis, which is the dimorphic fungus found in the San Juaquin Valley area in California and Arizona. Immunocompetent individuals can be asymptomatic or they can present acutely with a respiratory type condition, or they can present insidiously.

Question 252

A 56-year-old black female over the past year has developed stiffness of her hands and when she goes outside in the cold, she often develops white discoloration of the distal third of her fingers and sometimes an accompanying blue discoloration of the distal tips of the fingers. She is referred to a rheumatologist who performs a punch biopsy of the skin, which is illustrated below. Of the following, the antibody responsible for her condition is directed against which substance?

A. Ro/SS-A
B. Cyclic citrullinated peptides
C. Double-stranded DNA
D. Smith antigen
E. DNA topoisomerase I

Answer for Question 252

Answer: E (DNA topoisomerase I)

Explanation: The patient has features of localized scleroderma (involving the skin)–the white and blue discoloration of the fingers is Raynaud phenomenon. The antibody often associated with scleroderma is anti-scl70, which is against DNA topoisomerase I. Anti-Ro/SS-A is found in Sjogren syndrome and antibodies against cyclic citrullinated peptides are found in rheumatoid arthritis. Antibodies against double-stranded DNA and Smith antigen are more characteristic of systemic lupus erythematosus.
The histologic features of localized scleroderma are fibrosis of the dermis, loss of rete pegs and loss of skin appendage. A trichrome stain would highlight the fibrosis (the black arrow is just representative of an area of fibrosis, most of the dermis in the section is fibrotic).

Question 253

A 41-year-old immunocompetent male develops fever, chills, some mild shortness of breath, and a non-productive cough and goes to an acute care clinic. The doctor has a chest x-ray performed, which reveals patchy infiltrates of the lungs. The image below illustrates the organism causing his infection. During his examination, the doctor asks about recent travel, and he states that he recently got back from a hiking trip. Of the following, which state did he most likely visit?

A. Washington
B. California
C. Montana
D. Michigan
E. New Mexico

Answer for Question 253

Answer: D (Michigan)

Explanation: Blue arrows indicate the characteristic histologic features of Blastomyces dermatitidis–a broad-based budding yeast. The fungus has a thick, double-contoured wall (both of which would distinguish it from Histoplasma capsulatum). Like Histoplasma, Blastomyces is associated with the Ohio-Mississippi River valleys, but also the northern midwest, upstate New York, and southern Canada (all locations around the Great Lakes.)

Question 254

A researcher is studying acute inflammation in mice as a model for humans. Assuming the same mediators are present, of the following, which is most directly responsible for the position of the cells at the star?

A. P-selectin
B. ICAM-1
C. CD20
D. CD31
E. Eotaxin
F. Neutrotaxin

Answer for Question 254

Answer: D (CD31)

Explanation: The cells at the star are neutrophils (not eosinophils) and they are outside the vessel. The most important mediator in the list is CD31 (PECAM-1), which allows transmigration of the neutrophil out of the vessel. P-selection and ICAM-1 would play a role in getting the neutrophil to be adherent to the wall, but not in moving through it. A similar question to this one is included in the NBME’s sample question group (available from their website).

Question 255

A forensic pathologist is testifying in court regarding an alleged homicide, in which a woman was beaten by a man and later died. At the time of autopsy, he took sections of the skin from the injuries and a section from the most vital injury in the court case is illustrated below. If asked to give an approximation of the time lapsed between the injury and death, of the following, which would be the best response?

A. Immediate
B. Around 30 minutes
C. Around 12 hours
D. Around 6 days
E. Around two weeks

Answer for Question 255

Answer: C (Around 12 hours).

Explanation: The cells surrounding the blood vessel (yellow arrows) are neutrophils (with a few eosinophils also present). In the inflammatory response, neutrophils are most common around 6-24 hours; at around 1-2 days or more, macrophages start being found.

Questions 246-250: Cardiovascular pathology with images

Questions 246

A 62-year-old male is diagnosed with metastatic colonic adenocarcinoma, and, the following day, commits suicide with his handgun. The pathologist performing the autopsy identifies that the kidneys appear granular, not smooth. Histologic examination of the kidney reveals the finding illustrated in the image below. Of the following conditions, which is most likely described in this man’s past medical history.

A. Long-standing hypertension
B. Recent onset severe hypertension
C. Plasma cell neoplasm
D. Notation of a flank bruit
E. Ehlers-Danlos type IV

Answer for Question 246

Answer: A (Long-standing hypertension)

Explanation: At the arrows is hyaline arteriolosclerosis (i.e., an eosinophilic, acellular expansion of the vessel wall), which is associated with benign hypertension which would be consistent with a history of long-standing hypertension. Individuals with recent onset of severe hypertension, if they manifested changes in the arterioles, would have fibrinoid necrosis, or, hyperplastic arteriolosclerosis. While amyloidosis of the vessels can occur association with a plasma cell neoplasm, and the histologic appearance would be similar, this would be rare compared with vascular changes due to hypertension (or, diabetes mellitus, which also causes the development of hyaline arteriolosclerosis). A flank bruit can indicate stenosis of the renal artery, which occurs most commonly due to fibromuscular dysplasia or atherosclerosis, and which could lead to hypertension, but would be less common than hypertension as a cause, and the opposite kidney would be the gross and histologically affected one.

Question 247

A forensic pathologist is examining sections of a coronary artery from a man who died in a motor vehicle accident from blunt force injuries of the head and identifies the lesion illustrated in the image below. Of the following, which played the most significant role in developing the feature indicated by the star (i.e., just the region of the pale white-tan band)?

A. Smooth muscle cells
B. LDL receptor
C. Scavenger receptor
D. EBV receptor
E. Nicotinic acid receptor

Answer for Question 247

Answer: C (Scavenger receptor)

Explanation: The white star indicates the atheromatous core of the plaque, where there is accumulated intracellular and extracellular oxidized LDL. The oxidized LDL is taken up mostly by macrophages, using the scavenger receptor, not the LDL receptor. While smooth muscle cells can uptake lipid and form foam cells in the plaque, their contribution is less. The black arrow indicates the fibrous cap of the atheroma. The yellow area indicates the lumen of the vessel. There are aggregates of red blood cells in the lumen, but there is no thrombus.

Question 248

A pathologist is examining the heart from a 43-year-old male patient who died as the result of a self-inflicted gunshot wound. The only pathologic finding is illustrated below. Of the following, what was the most likely etiology?

A. Infection with cytomegalovirus
B. Age
C. Past rheumatic fever affecting the aortic valve
D. Systemic hypertension
E. Coronary artery disease

Answer for Question 248

Answer: D (Systemic hypertension)

Explanation: The enlarged cardiac myocyte nuclei indicate cardiac hypertrophy (compare the size of the nuclei at the two arrows), which would be caused by systemic hypertension. There is no good histologic evidence of recent or remote ischemic injury, such as fibrosis or coagulative necrosis (as would be seen with coronary artery disease). Chronic rheumatic aortic valvulitis can lead to aortic stenosis, but, it would be rare compared to systemic hypertension.

Question 249

A 52-year-old male is playing racquetball with a friend when he suddenly develops a sharp pain in his chest that radiates to his back. He informs his friend of his pain, but says that he thinks he pulled a muscle and he wants to continue playing; however, his friend takes him to the emergency room instead. If the image below illustrates the underlying cause of his clinical symptoms. Of the following, what would physical examination most likely reveal?

A. A fixed split S2
B. An S4
C. A crescendo-decrescendo systolic murmur
D. A decrescendo diastolic murmur
E. A mid-systolic click
F. An opening snap

Answer for Question 249

Answer: D (A decrescendo diastolic murmur).

Explanation: The man has an aortic dissection. The intimal tear is at the black arrow, and is located just above the aortic valve. An aortic dissection can involve the aortic valve annulus, leading to aortic insufficiency, which would be a decrescendo diastolic murmur.

Question 250

A forensic pathologist is examining the body of an individual who died suddenly and unexpectedly and identifies the pathologic finding illustrated in the image. Given that the right ventricle is not normally present at the apex of the heart and given that both sections in the image are from the same individual and are representative of the pathology, of the following, what was the most likely cause of death?

A. Metastatic carcinoma
B. Acute myocardial infarct
C. Pulmonary thromboembolus
D. Dilated cardiomyopathy
E. Hypertrophic cardiomyopathy
F. Arrhythmogenic right ventricular dysplasia

Answer for Question 250

Answer: C (Pulmonary thromboembolus).

Explanation: In the section at the left side of the image, the right ventricle is present (black arrow)–this is the apical section. No right ventricle should be present in this section; therefore, the right ventricle is markedly dilated. When the pulmonary artery is obstructed by a thromboembolus, it would put great strain on the heart and acute dilation would result. The left ventricle is not dilated; the interventricular septum is not hypertrophied out of proportion to the free wall; there is no fatty replacement of the right ventricle (see the right side image). There is no evidence of an acute myocardial infarct or metastatic neoplasm.

Questions 241-245: Cardiovascular pathology with images

Question 241

A 53-year-old male with a past medical history of hypertension is working with his wife in the garage when he complains of a sharp pain in his chest. He says that he thinks he pulled a muscle and goes inside the house to lie down. Three hours later, she finishes her work in the garage and goes inside to check on him and finds him dead. The county coroner orders an autopsy, which identifies the pathologic condition pictured in the image. Of the following, what was the most likely cause for its development?

A. Ruptured myocardial infarct
B. Coronary artery dissection
C. Aortic dissection
D. Inflammation of the pericardium
E. Hemorrhage into a pericardial tumor

Answer For Question 241

Answer: C (Aortic dissection)

Explanation: Given his medical history of hypertension and the symptoms of sharp chest pain, of the choices, the most likely cause is an aortic dissection. A ruptured myocardial infarct would not present so quickly after the onset of symptoms, and the chest pain associated with an acute myocardial infarct would not typically be described as sharp. A coronary artery dissection would be a rare cause of a hemopericardium. Inflammation of the pericardium and rupture of a pericardial tumor could also be possible causes, but would be very rare compared to an aortic dissection. At the white arrow, a blue discoloration is apparent–this is blood within the pericardial sac.

Question 242

A 57-year-old male with a history of hypertension and hyperlipidemia often has a relatively brief pressure sensation in his chest after climbing four flights of stairs; however, today, he has much more severe pressure in his chest while at rest and the sensation lasts 30 minutes. His wife calls an ambulance. The pathologic lesion causing his symptoms is pictured below. What histologic change is identified by the arrow?

A. Coagulative necrosis
B. Liquefactive necrosis
C. Metastatic calcification
D. Dystrophic calcification
E. Caseous necrosis
F. Hemosiderin

Answer for Question 242

Answer D (Dystrophic calcification)

Explanation: Calcification appears as irregular, chunky blue to purple, and variably sized pigment-like material. Dystrophic calcification affects damaged tissue (such as coronary artery atherosclerosis) and occurs in people with normal calcium blood concentrations; metastatic calcification can affect normal or abnormal tissue and occurs in people with higher blood calcium concentrations–the histologic appearance would be similar, but dystrophic calcification is far more common.

Question 243

A forensic pathologist is examining histologic sections in her office one afternoon and identifies the histologic feature illustrated below. Of the following, what is the most likely cause of the individual’s death?

A. Viral infection of myocardium
B. Multiple myeloma
C. Delayed death after untreated chest trauma
D. Dysrhythmia after resuscitated myocardial infarct
E. Parathyroid gland hyperplasia

Answer for Question 243

Answer: D (Dysrhythmia after resuscitated myocardial infarct)

Explanation: The histologic finding is contraction band necrosis (examples are at the black arrows), which are a feature of reperfusion injury, such as could occur with a resuscitated infarct. They may be due to calcium influx into the cell; however, they are not associated with parathyroid gland hyperplasia. There are no lymphocytes present as would be seen with viral myocarditis.

Question 244

A 25-year-old male collapses while playing basketball with friends. He is taken to the emergency room, but despite aggressive resuscitation, he does not survive. An autopsy is performed. Histologic examination of the heart reveals the pathologic change illustrated below. Of the following, which would have been found on gross examination of the heart?

A. An atrial septal defect
B. Fatty infiltration of wall of right ventricle
C. Thick interventricular septum
D. Anomalous origin of a coronary artery
E. Severe coronary artery atherosclerosis

Of the following, a mutation of which protein is most commonly associated with this disease entity?

A. Plakoglobin
B. LDL receptor
C. IL-7
D. CD31
E. β-myosin heavy chain gene

Answer for Question 244

Answer: C (Thick interventricular septum) and E (β-myosin heavy chain gene)

Explanation: The pathologic change illustrated in the image is myofiber disarray, which is characteristic of hypertrophic cardiomyopathy, which is associated with sudden cardiac death. Gross features of this disease process include a thick interventricular septum and fibrosis of the left ventricular outflow tract corresponding to the anterior leaflet of the mitral valve. The most common mutation causing this disorder is a mutation of the β-myosin heavy chain gene. Fat in the right ventricle and mutations of plakoglobin are associated with arrhythmogenic right ventricular dysplasia.

Question 245

A 62-year-old male presents to his family physician complaining of chest pain, which he describes as occurring after a consistent amount of physical exertion for the last three months and which lasts about 10 minutes. He has had no other symptoms associated with his chest pain. If the image illustrates the lesion causing his symptoms, of the following combinations, which best describes his symptoms and his underlying pathology?

A. Stable angina; vulnerable plaque
B. Stable angina; complicated plaque
C. Unstable angina; vulnerable plaque
D. Unstable angina; complicated plaque
E. Variant angina; vulnerable plaque
F. Variant angina; complicated plaque

Answer for Question 245

Answer: A (Stable angina; vulnerable plaque)

Explanation: Given the history, the patient has stable angina (recurring chest pain with exertion that has been occurring for some period of time and after a set amount of exertion). The plaque has a thin fibrous cap (white arrow), and thus, could be consider vulnerable to rupture or another acute change. The material at the blue arrow is calcification.

Questions 236-240: General pathology with images

Question 236

A 62-year-old male is mowing his lawn when he suddenly feels a pressure in his chest. He finishes mowing the lawn and then tells his wife, who calls an ambulance. He is admitted to the hospital from the emergency room. A troponin I obtained 3 hours after the episode of chest discomfort is elevated. Of the following, which would be most characteristic of the cell indicated by the yellow arrow?

A. Triglyceride accumulation
B. Swelling of rough endoplasmic reticulum
C. Plasma membrane blebs
D. Nuclear chromatin clumps
E. Fragmentation of nucleus

Answer for Question 236

Answer E (Fragmentation of the nucleus)

Explanation: The cells in the top left corner of the image, including the one at the arrow, are undergoing coagulative necrosis–which is irreversible cell injury. Comparing these cells to those in the bottom right corner, those in the top left hand corner are more eosinophilic and have lost their nucleus. Answers A-D are found with reversible cell injury; answer E is the only one listed that is characteristic of irreversible cell death. A-D can all be present in the irreversibly injured cells (since they can remain to some degree as the cells transition from reversible to irreversible injury), but the best choice to answer the question is fragmentation of the nucleus.

Question 237

A pathologist is performing an autopsy on a 9-month-old infant. Gross examination of the liver identifies the parenchyma to be slightly firm and vaguely nodular. Microscopic examination of the liver reveals the findings illustrated in the slide below. Of the following, what substance is accumulating in the liver?

A. Glucocerebroside
B. Sphingomyelin
C. Iron
D. Cholesterol
E. Thorotrast

Answer for Question 237

Answer: C (iron)

Explanation: The infant has neonatal hemochromatosis. At the white arrows (and elsewhere) are hemosiderin-laden macrophages. The blue arrow indicates fibrosis (secondary to the iron accumulation). The yellow arrows indicate extramedullary hematopoiesis. Cells with glucocerebroside, sphingomyelin, and cholesterol would be foamy in appearance.

Question 238

A forensic pathologist performs an autopsy on a 42-year-old male with a strong family history of sudden cardiac death who died unexpectedly five days after a minor surgical procedure. The pathologist identifies severe coronary artery atherosclerosis as the cause of death, but the region of the minor surgical procedure is shown below. Of the following, what was most likely present at the location of the yellow star at the time of the surgical procedure (the black line roughly outlines the rest of the pathologic process)?

A. A neoplasm
B. Deposits of hemosiderin
C. Aggregates of lymphocytes
D. Sheets of neutrophils
E. Parasites

Answer for Question 238

Answer: D (Sheets of neutrophils).

Explanation: The patient had an abscess. The area of the star is the cavity, and would have been filled with neutrophils, which would be cleaned out by surgical debridement. Now the cavity contains granulation tissue. At the edge of the cavity is a thick rim of fibrosis (outlined in white). Abscesses often have a thick fibrous rim.

Question 239

A 64-year-old male with a long-standing history of diabetes mellitus underwent an amputation of the distal portion of the right foot. Six months previously, he had undergone an amputation of the great toe and 2nd digit of the same foot. Of the following, what has occurred at the site of the first amputation?

A. Scarring by primary intention
B. Scarring by secondary intention
C. An abscess
D. Ulcer
E. Foreign body granulomas

Answer for question 239

Answer: D (Ulcer)

Explanation: Because of damage to nerves, diabetics do not feel injury to their feet, and because of damage to the blood vessels, when injury occurs, it often does not heal. At the location of the previous amputation is a deep cavitary defect in the skin–there is no scar. Diabetics often develop ulcers on the toes and foot, and, after an amputation, may not be able to heal at the site of the surgical resection, also allowing an ulcer to develop. Repeat amputations are common.

Question 240

A 34-year-old male with recently diagnosed AIDS secondary to an untreated HIV infection presents to the emergency room with complaints of malaise and decreased urine production. Laboratory testing reveals an elevated BUN and creatinine. The image illustrates the etiology of his renal abnormalities. Of the following, what is the most likely cause?

A. Cryptococcus neoformans
B. Staphylococcus aureus
C. Mycobacterium tuberculosis
D. Entamoeba histolytica
E. Cytomegalovirus

Answer for Question 240

Answer: E (Cytomegalovirus).

Explanation: The image is that of a large cell (the “megalo”) with the characteristic intranuclear inclusion of CMV; also seen are intracytoplasmic inclusions (which are not as commonly found on histologic examination as the intranuclear inclusions). The inclusion is due to a cytopathic effect produced by the virus. Cowdry A inclusions due to HSV infection look the same (i.e., an intranuclear inclusion with a clear halo), but the cells affected are not enlarged. CMV often affects endothelial cells and can cause infarcts of organs.

Questions 231-235: Cardiovascular pathology with images

Question 231

A pathologist is examining a section of aorta from a 37-year-old male who died in a motor vehicle accident. Grossly, he saw linear slightly raised yellow lesions at the intimal surface. Histologic examination of these pathologic findings revealed the lesion illustrated below. Of the following, what was the cell type from which the feature indicated at the arrow originated?

A. An adipocyte in the adventitia
B. Displaced endothelial cell
C. A blood neutrophil
D. A blood monocyte
E. A blood eosinophil

Answer for Question 231

Answer: D (A blood monocyte).

Explanation: The arrow is indicating a lipid-laden foam cell. Blood monocytes enter the intima to become macrophages, and engulf oxidized LDL via scavenger receptors to become foam cells.

Question 232

A 12-year-old male had a recent cold that included a cough and sore throat; however, his parents did not take him to the emergency room or his pediatrician at that time. However, over the past two days, he has developed a rash and a pain in his left knee. If the image illustrates the pathologic cause of his current symptoms, of the following, what might physical examination also reveal?

A. Peripheral edema
B. Hepatomegaly
C. Increased JVD
D. Subcutaneous nodules
E. Painful red nodules on the shins

Answer for Question 232

Answer: D (Subcutaneous nodules)

Explanation: The patient has acute rheumatic fever. The lesion in the image is an Aschoff body–a loose collection of enlarged epithelioid-like cells often with central fibrinoid necrosis (blue arrows) and Anitschkow cells may be seen (not in the image, except possibly at the yellow arrow). Patients with acute rheumatic fever have carditis (endocarditis, myocarditis, or pericarditis), chorea, migratory polyarthritis, erythema marginatum, and subcutaneous nodules.

Question 233

A 61-year-old female with insulin-dependent type II diabetes mellitus presents to the hospital with complaints of diarrhea and wheezing. During her evaluation in the emergency room, a nurse mistakenly gives her a dose of potassium instead of insulin after which she sustains a cardiac arrest. An autopsy is performed. A carcinoid tumor of the appendix with metastatic spread to the liver and the pathologic condition of the mitral valve illustrated in the image below is identified. Of the following, which other pathologic finding that is related to the mitral valve lesion may also be present?

A. Mitral annular calcification
B. Fusion of aortic valve commissures
C. Thick interventricular septum
D. Ventricular septal defect
E. Angiosarcoma of the heart

Histologic examination of the heart from this 61-year-old patient would reveal which of the following

A. Extensive amyloid deposits
B. Lipofuscin
C. Aschoff nodules
D. Granulomas
E. Aggregates of calcium

Answer for Question 233

Answer: B (Fusion of aortic valve commissures)

Explanation: The mitral valve has fusion, thickening, and shortening of the chordae tendinae at the yellow arrows (compare to a relatively normal at the blue arrow). This gross feature is very characteristic for chronic rheumatic mitral valvulitis and would contribute to the development of mitral stenosis (the leaflets in the image are also thickened and fibrotic, but the valve was not markedly stenotic). Carcinoid heart disease can look similar, but involves the tricuspid valve. Involvement of the aortic valve as a feature of rheumatic heart disease would cause fusion at the commissures. Mitral annular calcification, ventricular septal defect, and angiosarcoma of the liver are not significantly associated with past episodes of acute rheumatic fever.

Answer: B (lipofuscin).

Explanation: Given the age of the patient, lipofuscin deposits would be expected. Aschoff nodules are found in the epicardium, myocardium, and endocardium of patients with acute rheumatic fever, but would not be present years after the acute infection.

Question 234

A 32-year-old male is playing basketball with his friends, when he develops sudden onset shortness of breath and a continued stabbing chest pain. He attributes the symptoms, although fairly severe, to a pulled muscle and continues to play. Twenty minutes later, while getting water for fatigue and lightheadedness, he collapses. His friends call the ambulance, but, upon arrival to the emergency room 15 minutes later, he is pronounced dead. Autopsy reveals a dilated aortic root and an aortic dissection, with histologic examination of the aorta revealing the pathologic change illustrated below. Of the following, what is another pathologic condition commonly associated with his disease process?

A. Ankylosing spondylitis
B. Hypertrophic cardiomyopathy
C. Cirrhosis of the liver
D. Colonic adenocarcinoma
E. Myxomatous mitral valve

Answer for Question 234

Answer: E (Myxomatous mitral valve)

Explanation: The histologic change is cystic medial degeneration. The yellow arrows indicate areas of the acellular myxoid (or, light blue) material in pockets in the wall of the vessel. The older term for this change was cystic medial necrosis, but there is no necrosis. The individual has Marfan syndrome. While cystic medial degeneration is not specific for Marfan syndrome and is seen in hypertension and Ehlers-Danlos, given his young age, pathologic findings, and possible tall stature, Marfan syndrome is a strong possibility. Manifestations of the disease include aortic root dilation, aortic dissection, ectopia lentis, and tall stature. In addition, 25% of patients with Marfan syndrome have a myxomatous mitral valve.

Question 235

A 34-year-old male has been told he has a heart murmur since he was a child. He presents to a family physician for a comprehensive physical examination, during which a Grade II/VI crescendo-decrescendo murmur is heard at the right 2nd intercostal space. His PMI is not sustained. If the image below is representative of his pathologic condition, of the following, which is he at greatest risk for developing within the next few years?

A. Cor pulmonale
B. Sudden cardiac death
C. Severe right ventricular hypertrophy
D. Infective endocarditis
E. Atrial myxoma

Answer for Question 235

Answer: D (Infective endocarditis)

Explanation: The patient has a bicuspid aortic valve. The midline raphe is at the yellow arrow. Compare the red arrow to the black arrow to appreciate the incomplete separation of the cusps at the commissure at the location of the midline raphe. Patients with a bicuspid valve are at increased risk for infective endocarditis. The valve by itself is not a risk factor for sudden cardiac death. The valves below appear thin and pliable, so there is no significant aortic stenosis–cardiac hypertrophy, which will result from aortic stenosis, is a risk factor for sudden death. At the white arrow, the right coronary commissure is slightly high in location, which is sometimes associated with sudden death in the forensic literature, but is a very poor association (unlike the association between a bicuspid valve and infective endocarditis). Therefore, the risk for endocarditis in the next few years would be higher than any risk for sudden death. A bicuspid aortic valve would not significantly involve the right side of the heart primarily, so has no increased risk for cor pulmonale or right ventricular hypertrophy. Bicuspid aortic valves are not associated with a risk for atrial myxomas.

Questions 226-230: Cardiovascular pathology images

Question 226

A 43-year-old male is brought to the emergency room by his family members who said that he has been complaining of a bad headache for two days and then today began to act confused. If the pathologic change illustrated below is characteristic of his disease process, of the following, what feature might be identified upon physical examination?

A. Jugular venous distention
B. A new crescendo-decrescendo systolic murmur
C. Pulsus alternans
D. Retinal hemorrhages
E. Pedal petechiae

Answer for Question 226

Answer: D (Retinal hemorrhages)

Explanation: The pathologic change is hyperplastic arteriolosclerosis (onion-skinning of the arteriole at the black arrow), which is associated with malignant hypertension. Individuals with severe hypertension can present with headache and confusion. Physical examination can reveal retinal hemorrhages. Pulsus alternans and jugular venous distention would be found in patients with congestive heart failure. Petechiae of the feet are not characteristic of malignant hypertension.

Question 227

A 51-year-old male presents to the emergency room. He says that 30 minutes ago, he started to have a severe pressure in his chest that also involves his left and right arm, and that he feels nauseous. He has no significant past medical history, but has smoked 2 packs of cigarettes per day since he was 17 years old. Other than a heart rate of 105 beats per minute, his physical examination is unremarkable. A blood draw for troponin I is ordered immediately upon his arrival to the emergency room and found to be within a normal range. His EKG has no changes. Given that the pathologic change illustrated in the image is the cause of his symptoms, which of the following most likely explains the normal troponin I concentration during laboratory testing?

A. Specimen mix-up
B. Factious low concentration due to hypercholesterolemia
C. Insufficient time since onset of symptoms
D. Competing serologic factor
E. Angina-like non-cardiac chest pain

Answer for Question 227

Answer: C (Insufficient time since onset of symptoms).

Explanation: The image illustrates an acute plaque change, with apparent hemorrhage into the plaque (black arrow) and a near occlusive intraluminal thrombus (purple arrow). Although troponin I will rise rapidly after an infarct, 30 minutes is most likely not sufficient, and a few hours is required; hence, the utility of serial troponin I measurements in individuals with suspected anginal pain. Since the thrombus is not completely occlusive, it is also possible that this individual was only having unstable angina, and would not have an elevation in troponin I; however, this possibility was not a choice listed, and given the choices, the best answer is that there was insufficient time between the onset of symptoms and the time of the blood draw to have allowed for an elevation in troponin I to occur.

Question 228

A 53-year-old male is walking with his wife on the sidewalk near their house when he starts to complain of a pressure in his chest. They turn around to return to the house and when they reach the door he collapses. Other than treated hypertension, he has no other past medical history. His brother sustained a myocardial infarct at the age of 49 years. Of the following, laboratory testing prior to his death may have revealed which abnormality that is a risk factor for his condition illustrated in the image?

A. Elevated HDL
B. Reduced LDL
C. Hypochloremia
D. Hyperhomocysteinemia
E. Hyperkalemia

Answer for Question 228

Answer: D (Hyperhomocysteinemia)

Explanation: Hyperhomocysteinemia is a risk factor for atherosclerosis (which involves the coronary artery and is located by the arrow), although the mechanism is not well understood. Low concentrations of HDL and elevated concentrations of LDL are risk factors for atherosclerosis. Electrolyte abnormalities are not identified as a direct risk factor for atherosclerosis.

Question 229

A 71-year-old male who has no significant past medical history and has not seen a physician in 30 years presents to the emergency room with complaints of a pressure-like pain in his chest after minor exertion. If the pathologic condition illustrated in the image below is the cause of his symptoms, of the following, what is the most likely mechanism for its development?

A. Recurrent Streptococcal infections
B. Hypercholesterolemia
C. Cigarette smoking
D. Metastatic calcification
E. Dystrophic calcification

Examination of the heart would most likely reveal which of the following additional pathologic changes?

A. Right ventricular hypertrophy
B. Left ventricular hypertrophy
C. Metastatic parathyroid carcinoma
D. Myxomatous change of mitral valve
E. Granulomatous inflammation

Answer for Question 229

Answer: E (Dystrophic calcification) and B (Left ventricular hypertrophy)

Explanation: The patient has aortic stenosis due to dystrophic calcification of a tricuspid aortic valve (nodules of calcium at blue arrows). With chronic rheumatic aortic valvulitis, the commissures should be fused, which they are not (yellow arrow). Aortic stenosis leads to left ventricular hypertrophy, which is the source of the patient’s chest pain–the amount of blood that enters the coronary arteries after passing through the stenotic valve is insufficient to oxygenate the heart muscle, and angina occurs with exertion.

Question 230

A 62-year-old male with a past history of hypertension for 15 years, treated with medication, and with a 60-pack-year smoking history tells his wife who he is bowling with him that he suddenly developed abdominal pain. He says he is going to go to the car to take a break and tells her to finish her game. Thirty minutes later, she finds him unresponsive in the car, dead. An autopsy is performed, which identifies a hemoperitoneum and the pathologic condition that is the cause is illustrated in the image. Of the following choices, which is the most likely etiology of his condition?

A. Syphilis infection
B. Bicuspid aortic valve
C. Matrix metalloproteinase imbalance
D. Glycogen storage disorder
E. Past episode of abdominal trauma

Answer for Question 230

Answer: C (Matrix metalloproteinase imbalance)

Explanation: The individual has a ruptured abdominal aortic aneurysm (at the black arrow is thrombus exuding through the rupture site–the green arrow indicates the location of the renal arteries; the blue line and blue arrow indicates the extent of the aneurysm). An imbalance of matrix metalloproteinases contributes to the development of wall weakness and aneurysm formation. Syphilitic aortitis and aneurysms associated with a bicuspid aortic valve involve the thoracic aorta and vasculitis is another cause of thoracic aortic aneurysms. Remote trauma could be a very rare cause of an abdominal aortic aneurysm. A glycogen storage disorder is not normally associated with an abdominal aortic aneurysms.

Questions 221-225: General pathology with images

Question 221

A 48-year-old male is involved in a motor vehicle accident and sustains a fracture of his left and right femur. His extrication from the car is difficult and on the way to the hospital, he sustains a cardiac arrest secondary to blood loss. He is resuscitated successfully. One day later, he complains of nausea and vomiting. Physical examination reveals a slightly enlarged and tender liver. Laboratory testing reveals elevated ALT and AST. The microscopic appearance of his condition is shown in the image. Of the following, what is the most likely etiology for his symptoms.

A. Undiagnosed hepatic trauma
B. Fat necrosis
C. Hypotension
D. Bacterial infection
E. Unspecified toxin exposure

Answer for Question 221

Answer: C (Hypotension)

Explanation: The patient has ischemic hepatitis–the pathologic change is centrilobular necrosis, which is commonly due to impaired perfusion of the liver due to hypotension (as could occur with blood loss and cardiac arrest). Blood enters the hepatic lobule at the portal tract (these cells survive in patients with centrilobular necrosis because they get the oxygen first) and filters down to the central vein (these cells die in patients with centrilobular necrosis, because they get oxygenated blood last, and with hypotension, may not be perfused). The cells around the central vein are undergoing coagulative necrosis. The dashed yellow line is the very rough dividing line between histologically viable hepatocytes and those undergoing necrosis.

Question 222

A 67-year-old male presented to his family physician with complaints of a painful red nodule on his hand. A short time ago, he was working outside on his farm and cut his hand on his plow. He washed the wound when he was done with his work, and did not think twice about it. He has no history of drug use and has only had one sexual partner during his life, his wife of 44 years. He has had type II diabetes mellitus for 10 years. A biopsy of the wound reveals the findings illustrated in the image below. Of the following, what is the most likely diagnosis?

A. Xanthoma
B. Calcinosis
C. Gaucher disease
D. Cryptococcal infection
E. Cytomegalovirus infection
F. Granulomatous inflammation

Answer for Question 222

Answer: D (Cryptococcal infection)

Explanation: Although the man is not immunocompromised, Cryptococcal infections can occur in immunocompetent individuals. Skin infections are one manifestation, and most commonly occur in males. In tissue, the characteristic capsule (blue arrow) surrounding the fungal organism (yellow arrow) is easily identified; however, the organism can be highlighted with PAS or mucicarmine.

Question 223

A surgical pathologist is examining a liver biopsy from a patient in the hospital who is being seen by the internal medicine service. He identifies the microscopic finding illustrated in the image. Of the following, what would examination of the patient reveal?

A. Large bruise on the chest
B. Fingers with remote burnt skin (dry and yellow)
C. Large dark black mole on the back
D. Yellow skin
E. Prominent psoriasis
F. Fungal skin infection
G. Numerous tattoos

Answer for Question 223

Answer: D (Yellow skin)

Explanation: The pigment is bile (blue arrows); which can appear more globular (rounded) and yellow-green than other pigments (lipofuscin is more finely stippled; hemosiderin is most often more variable in size or chunky in appearance); patients who are jaundiced (i.e., the yellow skin) can have evidence of cholestasis (bile accumulation) in the liver. No fungal organisms are present. A large bruise would not result in a deposition of iron in the liver that is so easily identifiable as the pigment in the image. Melanin, associated with melanoma, is more often finely stippled and black. Tattoo pigment remains localized. Fingers with dry yellow discolorations is consistent with a smoker; smoker’s pigment is finely stippled and brown-yellow or black, and occurs in the lung, not the liver. Psoriasis is not commonly directly associated with pigmentation of the internal organs.

Question 224

An autopsy pathologist has during three separate cases identified a nodule in the thyroid gland such as that illustrated in the image below. She hypothesizes that the nodule was from a past episode or episodes of hemorrhage into the gland. If her hypothesis is correct, of the following, which component of the red blood cell most contributed to the changes seen in the image.

A. Plasma membrane
B. Hemoglobin
C. Iron
D. Nuclear membrane
E. Nucleolus

Answer for Question 224

Answer: A (Plasma membrane)

Explanation: At the blue arrows (and around the arrows at the same area) are cholesterol clefts. Cholesterol is a major component of the plasma membrane. Hemoglobin would be a protein accumulation and iron is not present (based upon this view). A red blood cell lacks a nucleus, so nuclear membrane and nucleolus would not contribute.

Question 225

A 71-year-old female is eating lunch with friends when she suddenly drops her fork and fumbles to pick it up. Her friends call 9-1-1 and she is transported to the hospital, where she is diagnosed with a minor stroke of her left frontal lobe. Six days later, she sustains an acute myocardial infarct in the hospital and dies. Her family requests an autopsy and the pathologist identifies a soft 2.0 cm region in her left frontal lobe; the microscopic appearance is illustrated below. Of the following, what is the main process occurring here?

A. Coagulative necrosis
B. Liquefactive necrosis
C. Apoptosis
D. Hemorrhage
E. Undiagnosed fungal infection

Answer for Question 225

Answer: B (Liquefactive necrosis)

Explanation: The neurons are dead (none are visible) and the architecture is not identifiable; there are many foamy macrophages–the macrophages are derived from microglial cells, mainly, and some blood macrophages, and engulf myelin so they become foamy. Yes, there is hemorrhage, but it is not the main process–hemorrhage can be a secondary event in many lesions. The foamy macrophages are on centered in the lower left side of the image.

Questions 216-220: General pathology with images

Question 216

A 43-year-old male with an HIV infection secondary to intravenous drug use and sharing of needles and who has been non-compliant with his anti-viral drug regimen presents to the emergency room because he has had a fever for several days and has felt tired. He occasionally coughs, but does not produce much sputum. The image illustrates the cause of his disease process. Of the following, what is the most likely diagnosis?

A. Coccidioides immitis
B. Blastomyces dermatitidis
C. Aspergillus fumigatus
D. Mycobacterium tuberculosis
E. Pneumocystis jiroveci

Answer for Question 216

Answer: E (Pneumocystis jirovecki)

Explanation: The stain is a GMS (Grocott methenamine silver) stain, which will stain a fungus black. Pneumocystis is described as being cup-shaped (blue arrow).

Question 217

A 51-year-old male with a history of multiple sclerosis required prolonged intubation following a cardiac arrest after aspiration of food. Although he was bed bound and expected to die, when he did, his distraught family requested an autopsy. The pathologist identified the lesion illustrated below. Of the following, what was the most likely etiology?

A. HIV infection
B. Trauma
C. Prolonged intubation
D. Retained foreign body
E. Gastric reflux

Answer for Question 217

Answer: C (Prolonged intubation)

Explanation: The pathologic lesion at the arrow is a fistula (an abnormal connection between two organs, or an organ and the skin–enterocutaneous fistulas can result from colon cancer). In this case, the fistula is between the esophagus and the trachea. A fistula results when a non-healing infection or another chronic process causes two organs to stick together and a path to develop between them. Neoplasia is a cause of fistulas also. Prolonged intubation could allow for necrosis and continued inflammation and the potential development of a fistula.

Question 218

A 53-year-old female presents to her family physician. Over the past year, she has noticed frequent burning and itching of her eyes, and, within the past several months, has had some difficulty eating, in that the swallowing of food is difficult. She is also experiencing some stiffness in the joints of her left and right hands. The image illustrates the pathologic condition causing her symptoms. Of the following, what is the antigen against which the antibodies causing her disease react?

A. Ribonucleoprotein
B. DNA
C. Centromeric protein
D. RNA
E. Phosphatidylcholine

Answer for Question 218

Answer: A (Ribonucleoprotein)

Explanation: The dry mouth and dry eyes, and the accompanying stiffness of the joints (i.e., which can occur in rheumatoid arthritis) is characteristic of Sjogren syndrome. The two antibodies characteristically seen in Sjogren syndrome are anti-Ro/SS-A and anti-La/SS-B, which are both ribonucleoproteins.

Question 219

A 43-year-old female with a history of sarcoidosis dies in a motor vehicle accident. The pathologist who performs the autopsy samples the lung for histologic examination and identifies the pathologic finding illustrated in the below image. What cell type is indicated by the yellow arrow?

A. A B lymphocyte
B. A T lymphocyte
C. A macrophage
D. An eosinophil
E. A plasma cell

Of the following, which cytokine played the largest role in activating the cell type indicated by the yellow arrow?

A. IL-1
B. TNF-β
C. Major basic protein
D. IFN-γ
E. IL-13

Answer for Question 219

Answers: C (A macrophage) and D (IFN-γ)

Explanation: The image illustrates a granuloma. The cell at the yellow arrow is an activated macrophage (i.e., a large amount of cytoplasm and the cell is referred to as epithelioid). Macrophages are activated by IFN-γ, which is secreted by T lymphocytes. The white arrows are lymphocytes and the blue arrows are multi-nucleated giant cells (produced by fusion of the activated macrophages). Sarcoidosis, among other conditions, is associated with granulomas.

Question 220

A 63-year-old male with a history of hypertension for 27 years and a 35 pack-year smoking history, is working in his backyard trimming the hedge when he suddenly losses his balance and falls down. He is unable to stand and calls for his wife to help him. Emergency medical services is called and he is transported to the hospital. Imaging studies 2 hours later reveal a pathologic lesion. The photomicrograph below illustrates the microscopic changes associated with the pathologic lesion identified on imaging. Of the following, where was the lesion located.

A. Frontal lobe
B. Parietal lobe
C. Midbrain
D. Cerebellum
E. Medulla

What pathologic process is occurring?

A. Dystrophic calcification
B. Caseous necrosis
C. Coagulative necrosis
D. Liquefactive necrosis
E. Fat necrosis

Answer for Question 220

Answer: Cerebellum (D) and Coagulative necrosis (C)

Explanation: Although review books describe coagulative necrosis as occurring below the neck and liquefactive necrosis as occurring above the neck (i.e., the brain). After a stroke or other ischemic injury to the brain, coagulative necrosis develops first (i.e., increased eosinophilia of the cells and loss of nuclear and cellular basophilia, but with retention of architecture) followed quickly by liquefactive necrosis. With coagulative necrosis, the architecture is intact and identifiable, even though the cells are dead. In the image on the left below, the blue arrow is the granular layer, the black arrows are the necrotic Purkinje cells, and the red arrow is the molecular layer.

Questions 211-215: General pathology image questions

Question 211

A 52-year-old male presents to his family physician because of prolonged weakness and some back pain. An x-ray reveals some osteolytic lesions in his cranium. A serum protein electrophoresis reveals an increased amount of protein, with a spike in the gamma region. A subsequent bone marrow biopsy reveals 25% plasma cells. One year later, the man dies and an autopsy is performed. The pathologist identifies some vessels with a thickened wall that is eosinophilic and acellular. A specific stain is ordered and illustrated below. Of the following, what substance is within the wall of the vessel?

A. Cholesterol
B. Hemosiderin
C. Foreign material
D. Amyloid
E. Fibrosis

Answer for Question 211

Answer: D (Amyloid)

Explanation: The stain is a Congo red stain, which reveals apple-green birefringence (blue arrows) when staining amyloid. In patients with multiple myeloma, the amyloid is from the excessive production of light chains.

Question 212

A 23-year-old male is drinking at a bar downtown when, after watching a football game on television, a fight ensues. During the fight, he is knocked over and falls backward, striking his head on the floor of the bar, sustaining the injury illustrated below. Of the following, how will this injury most likely heal?

A. By primary intention
B. By secondary intention
C. By tertiary intention
D. By quaternary intention

Answer for Question 212

Answer: B (By secondary intention)

Explanation: The wound is a gaping laceration with rough irregular edges. Although the wound can be sutured closed in the emergency room, the wound edges will only be approximated, resulting in more granulation tissue, and a larger more prominent scar. Healing by primary intention occurs in surgical incisions, where there is close re-approximation of the edges of the wound, minimal granulation tissue to bridge the gaps, and minimal scar formation.

Question 213

A pathologist is working with a research laboratory to develop an immunohistochemical stain that will target the pathologic change identified by the arrows in the image. Of the following, which target would be most useful to identify this cellular change?

A. Phosphatidylcholine
B. Phosphatidylinositol
C. Phosphatidylglycerol
D. Phosphatidylserine
E. Phosphatidylethanolamine

Answer for Question 213

Answer: D (Phosphatidylserine)

Explanation: The cells indicated by the arrow are hepatocytes undergoing apoptosis (note the shrunken eosinophilic cell with a pyknotic nucleus). There is no neutrophilic response. The lymphocytes are in the portal tract–the patient has hepatitis. The expression of phosphatidylserine on the surface of the cell helps the body identify the apoptotic cell and remove it, without causing a significant inflammatory response

Question 214

A 33-year-old male is found unresponsive in the morning by his wife. She calls 9-1-1; however, he is declared dead and the coroner is summoned. His wife indicates that over the last week, he has been complaining of upper respiratory tract like symptoms. He has no past medical history and no history of sudden cardiac death in his family. An autopsy is performed and identifies the pathologic finding illustrated in the image (the scissors and finger are pulling open the pericardial sac). Of the following, what is the most likely cause of this man’s death?

A. A bacterial infection
B. A fungal infection
C. A viral infection
D. A metastatic neoplasm
E. Unreported trauma

Answer for Question 214

Answer: C (A viral infection)

Explanation: The image illustrates a serous pericardial effusion (white arrow; the clear liquid, with the heart visible through the effusion. The scissors is cutting the pericardial sac), which is a watery, cell-poor effusion. A, B, and D also result in an effusion, but, the infiltrate would be cell-rich, and thus cloudy and not clear. If undiagnosed trauma produced an effusion, it would be most likely hemorrhagic.

Question 215

A pathologist is examining a section of liver from a man he autopsied who was 67 years of age and died in a motor vehicle accident. His only past medical history was hypertension and chronic obstructive pulmonary disease associated with a 40 pack-year smoking history. The pathologist identifies the change illustrated in the image in the centrilobular hepatocytes. Of the following, what is the most likely etiology for this change?

A. A genetic mutation
B. Metastatic skin neoplasm
C. Smoking
D. Bile duct obstruction
E. Cellular wear

Answer for Question 215

Answer: E (Cellular wear)

Explanation: The pigment is lipofuscin, which is wear-and-tear pigment. The centrilobular hepatocytes are the last cells in the liver to receive oxygen, and therefore, the most prone to injury. The pigment is finely stippled and yellow-brown. It is also commonly found in the heart (around the nuclei) and in the neurons in older individuals. Pigment from smoking would be in the lungs and would not deposit in the liver; melanin is usually darker, and the pigment would not be found in the liver hepatocytes. Iron can appear similar, but there is no history of hemochromatosis or reason for multiple blood transfusions in the history. A Prussian blue stain will stain iron blue. Bilirubin is usually more globular (i.e., rounded, like little globs of material), shiny or smooth in texture, and yellow-green in color; however, to absolutely distinguish hemosiderin, lipofuscin, and bile in the hepatocytes would best be done with stains directed at iron and bile to exclude their presence. The location for the lipofuscin in the image (i.e., centrilobular hepatocytes) is classic, as this area has the highest degree of “wear and tear” in the liver.