I started a YouTube channel (MTPathologyDoc) and will gradually add short lectures (5-10 minutes each) on a variety of basic pathology topics, directed towards medical students and pathology trainees. The first lecture posted was on the histologic dating of myocardial infarcts.
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Kindle book: General and cardiovascular pathology image questions
The general and cardiovascular pathology image questions recently posted on this site were combined with image questions from http://www.pathologyreviewforstep1.com to produce a book with 120 image questions total in a Kindle format, for those who may prefer that method for reviewing the questions.
The price of the book is $2.99 (which is the lowest price we could offer, presumably because of the Mb size of the book, as our other two books without questions (and thus of a smaller Mb size) could be priced at $0.99).
The image book (Question Book 1.3) will be a free download on Amazon from 5/4/2020 to 5/8/2020.
The link for the book is: https://www.amazon.com/Pathology-Review-Image-Questions-pathology-ebook/dp/B0871PHRQS/ref=sr_1_3?dchild=1&keywords=kemp%2C+pathology&qid=1588298013&sr=8-3
Questions 261-265: Cardiovascular pathology with images
Question 261
A 53-year-old male dies as the result of blunt force injuries sustained during a motor vehicle accident. The pathologist performing the autopsy identifies a 1.5 cm lesion in the interventricular septum. The microscopic appearance of this lesion is illustrated in the image below. During a conversation with the decedent’s wife, he asks if her husband had complained of chest pain recently, and she says he had. Of the following, how much time elapsed between his chest pain and his death?
A. One or two hours
B. One or two days
C. One or two weeks
D. One or two months
E. One or two years
Answer for Question 261
Answer: C (One or two weeks).
Explanation: This is granulation tissue. In wound repair, granulation tissue usually appears around 4-5 days to one week, and scarring begins at about 2-3 weeks. The granulation tissue is composed of new blood vessels (yellow arrow) and fibrosis (black arrow). There are also scattered lymphocytes (white arrows).
Question 262
A 56-year-old male driver loses control of his vehicle on the ice during a snowstorm and is hit by a semi-truck. He sustains lethal head injuries. A forensic pathologist performs an autopsy and identifies the pathologic condition illustrated in the slide. Of the following, if this individual had survived the car accident, which condition would he have been most at risk for developing?
A. A dilated cardiomyopathy
B. Hemopericardium due to free wall rupture
C. Aneurysm of interventricular septum
D. Acute mitral insufficiency
E. Angiosarcoma of the heart
F. Liposarcoma of the heart
Answer for Question 262
Answer: C (Aneurysm of interventricular septum)
Explanation: The man has a remote infarct of the left ventricle (black, yellow, and white arrow), which involves, in this section, the entire interventricular septum–compare the wall thickness of the interventricular septum to the free wall thickness. Blood pumped against this portion of the wall, which will be essentially unmoving (i.e., not contracting normally), could cause the interventricular septum to bulge into the right ventricle. A remote myocardial infarct is not a risk factor for a dilated cardiomyopathy or angiosarcoma or liposarcoma of the heart. Although there is some discoloration of the postero-medial papillary muscle, this is fibrosis and therefore acute mitral insufficiency would not result. There is no acute full thickness infarct of the left ventricle, so free wall rupture would not be a risk.
Question 263
A 31-year-old female with no significant past medical history presents to an acute care clinic with complaints of chest pain that occurs even when she is resting. Her physical examination discloses a friction rub. Neither physical examination nor chest x-ray reveals any consolidation of the lungs. If the image below is illustrative of the pathologic condition causing her symptoms, of the following, what is the most likely etiology?
A. Massive acute myocardial infarct (2 days old)
B. Metastatic neoplasm
C. Staphylococcal bacterial infection
D. Viral infection
E. Trauma
Answer for Question 263
Answer: D (Viral infection)
Explanation: The heart has a fibrinous pericarditis (bread-and-butter appearance). A common cause is a viral infection. Acute pericarditis (i.e., not Dressler syndrome) occurring after an acute myocardial infarct would only be present on the epicardial surface overlying the infarct area and not the entire heart. A metastatic neoplasm would be unlikely in an otherwise healthy patient, and the exudate is often hemorrhagic. While a Staphylococcal infection of the lung can be associated with an adjacent pericarditis, there is no evidence of a pneumonia by physical examination or imaging. Trauma would be a rare, if ever, cause of fibrinous pericarditis.
Question 264
A 61-year-old male with a past medical history of treated hypertension and a 45 pack-year smoking history dies as the result of a motor vehicle accident. During the autopsy, the forensic pathologist identifies the lesion illustrated below during dissection of the proximal portion of the left anterior descending coronary artery. Examination of the myocardium reveals no pathologic lesion. Of the following, which best explains why no remote infarct was identified?
A. Redundancy of the left anterior descending coronary artery
B. Presence of extensive collateral circulation
C. Protective effects of nicotine
D. Protective effects of hypertension
E. Heterozygosity for LDL receptor mutation
Answer for Question 264
Answer: B (Presence of extensive collateral circulation)
Explanation: The lesion in the coronary artery is a stable plaque (i.e., no acute change), which is producing around 99% stenosis of the lumen. The black arrow indicates that residual lumen of the vessel. Extensive collateral circulation, which could develop as this plaque slowly increased in size, would have protected against a myocardial infarction. Both hypertension and cigarette smoking would have contributed to the development of the plaque, and would not be protective against a myocardial infarct. Heterozygosity for LDL receptor mutation would increase the risk for atherosclerosis; however, it would not explain why an infarct did not occur. While a redundancy of the left anterior descending coronary artery could be protective (i.e., in that flow is now through two vessels instead of one); however, this variation would be very rare, if it even occurred.
Question 265
A 53-year-old male was found dead in his bed by a friend who had come over to take him to a baseball game. On the bed next to him was a syringe with residue that tested presumptively positive for methamphetamine. An autopsy was performed and revealed the histologic change identified below. Of the following, an abnormal concentration of which electrolyte was most likely responsible for causing this change?
A. Magnesium
B. Sodium
C. Potassium
D. Calcium
E. Phosphorus
Answer for Question 265
Answer: D (Calcium)
Explanation: The cardiac myocytes exhibit contraction band necrosis (black arrows). Contraction band necrosis is found in the early stages of an acute myocardial infarct, as a result of reperfusion of a myocardial infarct, and in association with resuscitation or stimulant drug use (e.g., cocaine and methamphetamine). The histologic change is associated with increased concentrations of calcium in the cells.
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.
