Pathology Review for USMLE

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.

Questions 206-210: General pathology image questions

Question 206

A 64-year-old male is involved in a motor vehicle accident and sustains lethal injuries. The forensic pathologist performing the autopsy examines the organs histologically. In the microscopic section of the lung, she identifies the lesion pictured in the image. Of the following, what was the most likely etiology for this change?

A. Trauma
B. Long standing hypertension
C. Previous exposure to chlorine gas
D. Infection with Strongyloides stercoralis
E. Use of cigarettes

Answer for Question 206

Answer: E (Use of cigarettes)

Explanation: The lesion is squamous metaplasia (with some probable dysplasia, as the nuclei are large and there is a mitotic figure at the black arrow). Squamous metaplasia in the lung is most commonly due to cigarette smoke. The chemicals in the smoke irritate the respiratory mucosa, and metaplasia occurs (i.e., change to a type of epithelium that can better handle the irritant). Metaplasia can lead to dysplasia and dysplasia leads to neoplasia. Previous infection with chlorine gas and infection with Strongyloides stercoralis could potentially lead to squamous metaplasia, but, their incidence would be much more rare than cigarette smoking–remember, on the USMLE, more than one answer may be possible–but, only one answer is the best–don’t be fooled by the distractors.

Question 207

A 43-year-old male with a history of hypertension, diabetes mellitus, and a hereditary clotting disorder presents to the emergency room accompanied by his wife and complaining of sudden onset of severe abdominal pain. Physical examination reveals a blood pressure of 151/93 mmHg, pulse rate of 106 bpm, and pain to palpation in the right upper quadrant of the abdomen. The disease process causing his symptoms is illustrated below. Of the following, what was the most likely mechanism by which it occurred?

A. Decreased flow through an artery
B. Decreased flow through a vein
C. Decreased flow through an artery and a vein
D. Decreased flow through two veins
E. Decreased flow through two arteries

Answer for Question 207

Answer: C (Decreased flow through an artery and a vein).

Explanation: The image is an infarct of the liver (the coagulative necrosis is at the blue star and the viable hepatocytes are at the yellow star). In the liver, red infarcts generally occur because of a dual blood supply (the black arrow indicates extravasated red blood cells, which could make the infarct appear more red grossly). The dual blood supply to the liver is arterial (hepatic artery) and venous (portal vein). This patient could have atherosclerosis of the hepatic artery and developed a thrombus in the portal vein. Neither vessel needs to be completely obstructed, just compromised.

Question 208

A dermatopathologist is reviewing a punch biopsy of a skin lesion taken by a referring clinician. In the dermis, the pathologist identifies the pigment illustrated in the image below. Of the following, what is the most likely diagnosis?

A. Invasive melanoma
B. Past tattoo procedure
C. Benign soft tissue tumor
D. Resolving bruise
E. Parasitic infection

Answer for Question 208

Answer D (Resolving bruise)

Explanation: The pigment pictured is hemosiderin (it can be described as chunky (i.e., variable in size–yellow arrows are good examples of the variability in size and shape) and yellow-brown in appearance). Hemosiderin is deposited when red blood cells break down, such as after a bruise. Melanin is more finely stippled and black, as would be tattoo pigment.

Question 209

A 53-year-old male with a history of hypertension and diabetes mellitus type II collapses while mowing the lawn. Despite resuscitative measures, he is pronounced dead. To determine the cause of death, the medical examiner performs an autopsy and identifies the finding in the image below (reference: the normal interventricular septal thickness is 1.5 cm or less). Of the following, which type of protein is most increased in amount in this organ?

A. Fibrillin
B. Endothelin
C. Pepsin
D. Actin
E. Cytokeratin

Of the following, what process has occurred in this organ?

A. Metaplasia
B. Dysplasia
C. Hyperplasia
D. Hypertrophy
E. Atrophy

Answer for Question 209

Answers: D (Actin) and D (Hypertrophy)

Explanation: The thickness of the wall is increased. The yellow line on the interventricular septum indicates the normal maximal thickness of a heart wall (i.e., 1.5 cm); the white line indicates the thickness of this heart’s interventricular septum. Due to the patient’s hypertension, the heart has undergone hypertrophy (as cardiac myocytes are essentially not capable of division, hyperplasia of the muscle would not occur); the most common protein in the cell is actin, and as hypertrophy of the cells would require an increase in the amount of contractile protein, the best answer is actin. Fibrillin is found in the aorta and other blood vessels, but not significantly in the myocardium and cytokeratin is a marker for epithelial cells (such as squamous and glandular cells).

Question 210

A pathology resident is conducting an autopsy during his first month of residency. While palpating the lungs of a 53-year-old male who had a 45 pack-year smoking history and died from metastatic squamous cell carcinoma of the lung, the resident identifies the lesion illustrated in the image below. Of the following, what process has occurred?

A. Hypertrophy
B. Hyperplasia
C. Metaplasia
D. Atrophy
E. Neoplasia

Answer for Question 210

Answer: C (Metaplasia)

Explanation: The lesion is normal bone, but it is in the lung, which would represent a form of osseous metaplasia. Although much of the right side and bottom of the image exhibit the change, the yellow areas are representative areas of the osseous metaplasia. Layering of the bone can be identified and osteocyte lacunae (i.e., the small open spaces) are visible.

Questions 199-205: General pathology image questions

Question 199

A 72-year-old male suddenly loses strength and sensation in his right upper extremity. His family takes him to the hospital where he is then admitted. Despite treatment, he dies 6 days later and an autopsy is performed. The pathologist identifies a lesion in the lateral aspect of his left frontal and parietal lobes at the central sulcus. The lesion is exhibited below. Of the following, what process is occurring?

A. Coagulative necrosis
B. Liquefactive necrosis
C. Caseous necrosis
D. Gangrenous necrosis
E. Fat necrosis

Answer For Question 199

Answer: B (Liquefactive necrosis)

Explanation: In liquefactive necrosis, there is rapid break-down of the tissue after injury and the architecture is not identifiable (unlike in coagulative necrosis, in which the overall architecture of the organ is identifiable despite the death of the cells). In patients who sustain a stroke, liquefactive necrosis of the brain will quickly develop. Phagocytic cells (activated microglial cells and blood-derived macrophages (yellow arrows are examples)) will engulf the myelin and cellular debris

Question 200

A 31-year-old male with a past history of chronic alcoholism presents to the emergency room with a three-day history of abdominal pain. Despite therapeutic measures, he dies and an autopsy is performed, which reveals the finding illustrated in the image. Of the following, what was the mechanism for the pathologic change illustrated?

A. Widely disseminated metastatic tumor
B. Release of gastric contents
C. Release of pancreatic enzymes
D. Bacterial sepsis
E. Undiagnosed tuberculosis

Answer for Question 200

Answer: C ( Release of pancreatic enzymes)

Explanation: The image illustrates fat necrosis–white-yellow deposits in the greater omentum caused by lipases released from a damaged pancreas (e.g., in patients with acute pancreatitis) that cleave triglyceride esters in adipocytes. The subsequent linking of released fatty acids to calcium produces the deposits. Alcohol use is a major cause of pancreatitis as are gallstones in the duct.

Question 201

A pathology resident is completing his autopsy report and describing the microscopic appearance of lesions he identified during the exam. While viewing the section of the heart, which included a lesion he identified grossly, he found the features illustrated in the image below. Of the following, what would be the best description for the yellow star (first) and blue star areas (second) respectively?

A. Coagulative necrosis/coagulative necrosis
B. Coagulative necrosis/liquefactive necrosis
C. Dry gangrene/wet gangrene
D. Coagulative necrosis/abscess
E. Caseous necrosis/abscess

Answer for Question 201

Answer: B (Coagulative necrosis/liquefactive necrosis)

Explanation: At the yellow arrow, the nuclei are absent, but the architecture is preserved; at the blue arrow, the architecture is completely disrupted and the tissue type is not identifiable. There are no granulomas; and, at the blue arrow are only maybe a few scattered inflammatory cells and not a collection of neutrophils, as would characterize an abscess. Wet and dry gangrene are normally used in the context of the extremities and not the heart.

Question 202

A pathologist is examining histologic sections from an autopsy when he identifies the pathologic lesion illustrated below. There are numerous such lesions in the organ being examined under the microscope. Of the following, what is the most likely etiology?

A. Bacterial infection
B. Viral infection
C. Parasitic nematode infection
D. Neoplastic proliferation
E. Trauma
F. Mycobacterial infection

Answer for Question 202

Answer: F (Mycobacterial infection)

Explanation: The lesion is a granuloma, which is composed of epithelioid histiocytes (macrophages), which are macrophages with prominent cytoplasm (which is why there is alot of pink and not as much blue associated with the cell). The granuloma is outline below with the white lines. Giant cells (yellow arrow) are often found in granulomas, but are not required for the diagnosis. Of the conditions listed, granulomas are most often associated with a mycobacterial infection, such as tuberculosis. Although tuberculosis is normally associated with caseating granulomas and the granuloma below has no caseation, the history of numerous granulomas in the organ (which is the liver) is consistent with miliary tuberculosis, and non-caseating granulomas do occur in patients with tuberculosis

Question 203

A researcher in a medical school laboratory is studying the effects of introducing an infectious organism to a mouse model. Following the infection of the mouse, a short time period is allowed and then the mouse is sacrificed and the tissue studied microscopically. Assuming the mouse model mimics a human reaction (i.e., similar cellular mediators are involved), of the following, which chemokine played the largest role in producing the illustrated image?

A. C-X-C chemokine
B. C-C chemokine
C. C chemokine
D. CX3C chemokine
E. C-D-C chemokine

Answer for Question 203

Answer: B (C-C chemokine)

Explanation: The prominent cell type in the image is an eosinophil (blue arrows). Eotaxin, which is specific for eosinophils, is a C-C chemokine. C-X-C chemokines are chemoattractants for neutrophils; C chemokines for lymphocytes, and CX3C chemokines are chemoattractants for monocytes and T-cells.

Question 204

An 18-month-old child dies due to cardiorespiratory failure following a lengthy disease course dating back to near his time of birth and characterized by muscular hypotonia. An autopsy is performed and the pathologist identifies a markedly enlarged heart and a mildly enlarged liver. A microscopic section of the heart reveals the finding illustrated below. Of the following, what is the most likely enzyme deficiency causing the disease process?

A. Glucose-6-phosphatase
B. Muscle phosphorylase
C. Lysosomal glucosidase
D. Glucocerebrosidase
E. Sphingomyelinase

Answer for Question 204

Answer: C (Lysosomal glucosidase).

Explanation: The clinical scenario, autopsy findings, and image indicate Pompe disease, which is due to a deficiency of lysosomal glucosidase. Essentially the only glycogen storage disease that primary involves the heart is Pompe disease. Glucose-6-phosphatase is deficient in vonGierke disease, which primarily involves the liver and muscle phosphorylase is deficient in McArdle disease, which involves the skeletal muscles and presents in adults. Glucocerebrosidase is deficient in Gaucher disease, which primarily involves the liver and spleen in the most common form; and sphingomyelinase is deficient in Niemann-Pick disease, which primarily involves the liver and spleen, but also the CNS in the most common form.

Question 205

A 53-year-old chronic alcoholic who is homeless was brought to the emergency room by his friends because he has been coughing up blood for two days. His friends also report that he has had a chronic cough and has been losing weight. He does smoke cigarettes. Physical examination reveals him to be cachectic. Despite treatment in the hospital, he dies and an autopsy is performed, which reveals a 7.3 cm soft friable area in the upper lobe of the right lung and numerous small (few millimeter) soft white-yellow nodules in the liver and spleen. The image below depicts one of the small nodules in the spleen. Of the following, what is the most likely etiology for this change?

A. Giant cell neoplasia
B. Infection with gram positive bacilli
C. Infection with gram negative bacilli
D. Infection with acid-fast bacilli
E. Aspiration of food
F. Methanol poisoning

Answer for Question 205

Answer: D (Infection with acid-fast bacilli)

Explanation: The lesion is a caseating granuloma. The central area is caseous necrosis (yellow arrow), which appears grossly as soft yellow, white-yellow, or yellow-tan material, and can be referred to as “cheesy”. The architecture is not identifiable. Surrounding the caseous necrosis are inflammatory cells–epithelioid macrophages (blue arrows) and often multi-nucleated giant cells (red arrows). The lesions in the liver and spleen came from blood-borne spread of the bacillus from the lesion in the lung (the lesions in the spleen and liver would be called miliary TB). Tuberculosis is an acid fast bacillus and is most commonly associated with caseous necrosis. Other conditions can cause caseous necrosis, and tuberculosis infections can produce non-caseous necrosis.

Kindle book: Systemic pathology questions

The 205 questions about cardiovascular pathology, hematopathology, and lung pathology, which have been previously published on this blog and on www.pathologyreviewforStep1.com, have been combined into one book, randomized within those three headings, and published on Amazon.

The book costs $0.99, however, from 02/24/2020 to 02/28/2020, the book will be available for free download. The book can be found at the below link.

https://www.amazon.com/Pathology-Review-Questions-Question-Systemic-ebook/dp/B084TWG86L/ref=sr_1_2?keywords=kemp%2C+pathology&qid=1581988430&sr=8-2

Kindle book: General pathology questions

The general pathology questions (207 questions total) from this blog and www.pathologyreviewforStep1.com are available in Kindle format and can be downloaded from Amazon.

The book is priced at $ 0.99, but from 2/24 to 2/28, the book will be free to download.

https://www.amazon.com/Pathology-Review-Questions-Question-General-ebook/dp/B0848HH2H4/ref=sr_1_2?keywords=kemp%2C+pathology&qid=1581806738&sr=8-2

Questions 193-198: Cardiovascular pathology

Question 193

A 47-year-old male presents to an acute care clinic with complaints of a cough, fever, and difficulty breathing with exertion. He was diagnosed with asthma 4 years ago, frequently has episodes of allergic rhinitis, and underwent removal of nasal polyps surgically 1 year ago. A complete blood count reveals an elevated concentration of eosinophils (13%). Laboratory testing also reveals the presence of MPO-ANCA (p-ANCA). A chest x-ray reveals patchy infiltrates. Of the following, what would a biopsy of the lung most likely reveal?

A. Granulomatous inflammation and eosinophilic infiltrates of vessels
B. Neoplastic eosinophils
C. Nematode infestation
D. Foreign material, consistent with IV drug abuse
E. Small cell carcinoma

Answer for Question 193

Answer: A (Granulomatous inflammation and eosinophilic infiltrates of vessels)

Explanation: The clinical presentation (male patient in their 40s with a history of asthma, allergic rhinitis, nasal polyps, eosinophilia and pulmonary infiltrates) is consistent with eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss syndrome). Some of these patients (about 40%) will have MPO-ANCA (p-ANCA) directed against myeloperoxidase. A biopsy of the lung will reveal granulomatous inflammation and eosinophilic infiltrates of the vessels. Eosinophilic leukemia is very rare. While a nematode infestation could cause the eosinophilia, it would not be associated with the MPO-ANCA.

Question 194

A 61-year-old female presents to the emergency room with her husband. She reports that over the past two days she has had a severe headache and pain in her jaw on the left side, and now for the past 4 hours she has had double vision. Of the following, what is the most likely diagnosis?

A. Temporal arteritis
B. A non-ST elevation myocardial infarct with embolized mural thrombus
C. Aortic dissection with involvement of carotid artery
D. Polyarteritis nodosa
E. Late-onset systemic lupus erythematosus

Answer for Question 194

Answer: A (Temporal arteritis)

Explanation: The clinical presentation (patient >55 years of age, presenting with headache, jaw pain, and visual changes) is consistent with temporal arteritis. Embolization of mural thrombus could cause a stroke; however, the jaw pain associated with an acute myocardial infarct would not likely occur in association with the embolized mural thrombus; instead, the jaw pain would occur at the time of the infarct, but the embolus would occur days or weeks later. There is no history of chest pain to support an aortic dissection and involvement of the common carotid artery (where extension would occur) would likely cause a stroke. While a headache can occur during a stroke, the patient has no focal neurologic change (e.g., weakness, sensation loss or both on one side of her body). Polyarteritis nodosa does not commonly involve the aorta and while SLE can cause vasculitis, the changes in the clinical scenario are most consistent with the distribution of involvement of temporal arteritis.

Question 195

A 60-year-old female presents to the emergency room. She reports that over the past four days she has had a headache, which worsened today, and is now associated with pain in her jaw on the left side. For the past 2 hours she has had blurry vision. Laboratory testing will reveal an increase in which of the following?

A. Troponin I
B. Alkaline phosphatase
C. ESR
D. D-dimer
E. TSH

Answer for Question 195

Answer: C (ESR)

Explanation: The clinical presentation (patient >55 years of age, presenting with headache, jaw pain, and visual changes) is consistent with temporal arteritis. Patients with temporal arteritis will most often have an elevated ESR and elevated C-reactive protein. While a d-dimer can be elevated in patients with thrombosis, thrombosis is not necessarily a component of temporal arteritis, and thus would be less likely to be elevated.

Question 196

A 62-year-old male with systemic hypertension and a 35-pack-year smoking history presents to his primary care physician with complaints that over the past year he has had increasing shortness of breath when walking with his wife. While he used to be able to walk about a half of a mile, he can now only walk about 2 blocks before needing to stop. He also has shortness of breath at night and has started sleeping on two pillows and propped up in bed. Physical examination reveals an S3; however, there is no pitting edema of the lower extremities and his liver is not palpable. Of the following, which additional physical examination finding is most likely to be identified?

A. Elevated jugular venous distention
B. Massive splenomegaly
C. Crackles on auscultation of the chest
D. Bruit in the midportion of the right side of the back
E. Deviation of the tongue when extended

Answer for Question 196

Answer: C (Crackles on auscultation of the chest)

Explanation: Chronic dyspnea, manifested as dyspnea on exertion and orthopnea (i.e., shortness of breath at night requiring pillows) associated with a history of risk factors for coronary artery atherosclerosis (the hypertension and smoking history) and the physical finding of an S3, is consistent with congestive heart failure. As there is no pitting edema of the lower extremities or hepatosplenomegaly, this individual has left-sided heart failure, and, of the choices, crackles on auscultation of the chest is the most likely additional finding and which would be caused by fluid in the lungs. Elevated jugular venous distention is consistent with right sided failure. While it could be possible for an individual to have right sided heart failure and an elevated jugular venous distention without pitting edema or hepatosplenomegaly, the better choice is still crackles, as individuals with right sided symptoms due to left sided failure should also have fluid in the lungs. Although right sided heart failure can lead to splenomegaly, it is not likely massive, and, as above, the absence of pitting edema and hepatosplenomegaly greatly decrease the chance that the right side of the heart is failing. A bruit in the right mid back could suggest renal artery stenosis, which could be present in an older male with risk factors for atherosclerosis, but does not have to be present. And, deviation of the tongue would indicate hypoglossal nerve injury, which is not related to the case presentation, unless there were a subtle stroke.

Question 197

A 48-year-old male presents to an acute care clinic complaining of worsening shortness of breath with exertion. He has not seen a physician in 20 years and considers himself healthy, eating a balanced diet and getting plenty of exercise. Physical examination reveals a harsh, late-peaking systolic murmur that is heard best at the 2nd right intercostal space and radiates to the carotid arteries. In addition, the point of maximal impulse is sustained and the second heart sound is difficult to hear. Of the following, what is the most likely diagnosis?

A. Aortic stenosis due to degenerative calcification of a bicuspid aortic valve
B. Aortic stenosis due to degenerative calcification of a tricuspid aortic valve
C. Aortic regurgitation
D. Mitral stenosis
E. Mitral regurgitation

Answer for Question 197

Answer: A (Aortic stenosis due to degenerative calcification of a bicuspid aortic valve)

Explanation: The murmur is characteristic for aortic stenosis. The muffled 2nd heart sound is due to the fact that the valve is relatively immobile. Given the young age of the patient, the aortic stenosis is most likely due to a calcified bicuspid aortic valve, as aortic stenosis due to calcification of a tricuspid aortic valve normally occurs later in life.

Question 198

A 63-year-old female presents to her primary care physician. Yesterday she passed out while doing dishes, and for the past two weeks she has felt like her heart was beating irregularly and she sometimes she has shortness of breath while working in her vegetable garden. Her past medical history includes a laparoscopic cholecystectomy 25 years ago. Physical examination reveals an irregularly irregular pulse. Auscultation of her chest reveals no murmurs, gallops, or other abnormalities. If her disease process is not treated, of the following, which is she at greatest risk for?

A. Mitral stenosis
B. Atrial myxoma
C. Acute pericarditis
D. Local thrombosis of a coronary artery leading to acute myocardial infarct
E. Pulmonary hypertension
F. Acute cerebral infarct

Answer for Question 198

Answer: F (Acute cerebral infarct)

Explanation: The physical examination reveals an irregularly irregular pulse, which is consistent with atrial fibrillation. Atrial fibrillation can cause syncope and palpitations, as the patient reports. Individuals with atrial fibrillation are at risk for forming mural thrombi in the left atrium. If these mural thrombi break loose and embolize, they can lead to a cerebral infarct (among other conditions). While embolism can lead to an acute myocardial infarct, atrial fibrillation would not predispose to the development of a thrombus within a coronary artery itself. If a thrombus forms locally, it is not an embolus. A thrombus can embolize; however, if this were the case, the thrombus would not have developed locally – it would have developed at a remote location and been carried by blood flow to the point where it caused symptoms. Atrial fibrillation can occur as a result of left atrial dilation and hypertrophy from mitral stenosis, but it is not a direct cause of mitral stenosis.

Questions 189-192: Cardiovascular pathology

Question 189

A 25-year-old male graduate student is being seen by his family physician. Over the past two years, on several occasions during each year, he has developed several painful oral ulcers that resolved within about a week. Once during the last year, he developed a painful ulcer on his penis; however, he is not sexually active and did not seek treatment. Today, he presents with red lesions on his legs and he also reports a cluster of painful ulcers in his mouth. Of the following, in which country was he most likely born?

A. Turkey
B. Russia
C. Scotland
D. Brazil
E. Mexico

Answer for Question 189

Answer: A (Turkey)

Explanation: In young males, the combination of oral ulcers, genital ulcers and skin lesions is consistent with Behcet syndrome. Skin lesions can include a variety of conditions, including erythema nodosum, which would produce the red lesions on the legs. The incidence of Behcet syndrome is highest from the eastern Mediterranean to China, which would include Turkey.

Question 190

A 26-year-old male is found unresponsive in his apartment after not reporting for work. An autopsy is performed, revealing a left hemothorax due to a ruptured thoracic aortic aneurysm. His past medical history includes recurrent oral ulcers, sometimes occurring in clusters, at least 5-6 times per year. The oral ulcers have been associated with occasional ulcers of the penis and several times, eye pain and redness. Of the following, which HLA type is associated with his disease process?

A. HLA B21
B. HLA B27
C. HLA B40
D. HLA B43
E. HLA B51

Answer for Question 190

Answer: E (HLA B51)

Explanation: In a young male, recurrent episodes of apthous ulcers associated with penile ulcers and eye symptoms is consistent with Behcet syndrome. While not characteristic for the disease process, other organ systems can be involved, including the thoracic aorta in around 3-5% of patients. Behcet syndrome is associated with HLA B51.

Question 191

A 46-year-old male, who was diagnosed with asthma 4 years ago, and has had one outpatient surgery for nasal polyps, presents to an acute care clinic with complaints of a cough, fever and dyspnea with exertion. A complete blood count reveals an elevated concentration of eosinophils (14%). A chest x-ray reveals patchy infiltrates. Additional laboratory testing reveals MPO-ANCA. Of the following, what is the most likely diagnosis?

A. Granulomatosis with polyangiitis
B. Exacerbation of asthma
C. Illicit drug reaction
D. Polyarteritis nodosa
E. Eosinophilic granulomatosis with polyangiitis

Answer for Question 191

Answer: E (Eosinophilic granulomatosis with polyangiitis)

Explanation: The clinical presentation (male patient in their 40s with a history of asthma, nasal polyps, eosinophilia and pulmonary infiltrates) is consistent with eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss syndrome). Some of these patients (about 40%) will have MPO-ANCA (p-ANCA) directed against myeloperoxidase. Granulomatosis with polyangiitis is not associated with asthma or eosinophilia, and PR3-ANCA (c-ANCA) is most often present. Polyarteritis nodosa rarely involves the lungs, is not associated with eosinophilia, and is not routinely associated with ANCA. An exacerbation of asthma or illicit drug reaction would not explain the ANCA.

Question 192

A 49-year-old male, who was diagnosed with asthma 3 years ago and frequently has episodes of allergic rhinitis, presents to an acute care clinic with complaints of a cough and fever. A complete blood count reveals an elevated concentration of eosinophils (15%). A chest x-ray reveals patchy infiltrates. Additional laboratory testing reveals MPO-ANCA. Of the following, which test or procedure would best confirm the diagnosis?

A. Lung biopsy
B. Pneumonectomy
C. Pulmonary function tests
D. MRI of the chest
E. Echocardiogram

Answer for Question 192

Answer: A (Lung biopsy)

Explanation: The clinical presentation (male patient in their 40s with a history of asthma, allergic rhinitis, eosinophilia and pulmonary infiltrates) is consistent with eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss syndrome). Some of these patients (about 40%) will have MPO-ANCA (p-ANCA) directed against myeloperoxidase. The best diagnostic procedure would be a lung biopsy to confirm the presence of the vasculitis. Removal of an entire lung is not necessary. While pulmonary function tests, MRI of the chest, and echocardiogram could be performed to help determine extent of the disease process, as eosinophilic granulomatosis with polyangiitis can involve the heart, none of these procedures would allow for a specific diagnosis such as a biopsy would.

Questions 185-188: Cardiovascular pathology

Question 185

A 47-year-old female has a history of hypertension for many years that has been poorly controlled with medication. She is otherwise healthy and does not smoke. She decides to change physicians and her new physician conducts a thorough physical examination and identifies a bruit on the right side of the lower back. Of the following, which would best allow for definitive diagnosis of her underlying disease process?

A. Complete metabolic panel to include BUN and creatinine
B. Urine culture
C. Pelvic examination
D. Angiogram
E. CT scan of the abdomen

Answer for Question 185

Answer: D (Angiogram)

Explanation: The clinical scenario is consistent with fibromuscular dysplasia of the renal artery, which would cause secondary hypertension that might be difficult to control with medication and would potentially have a bruit upon physical examination. The disease is most common among women 40-60 years of age. As fibromuscular dysplasia causes thickening of segments of the affected artery and can produce outpouchings, an angiogram of the vessel would be the definitive diagnostic procedure.

Question 186

A researcher is attempting to trigger intracerebral hemorrhage in laboratory rats to study the development of the condition. To facilitate this process, he is dosing the rats with various substances. A substance or combination of substances that does which of the following would have the best chance to produce an intracerebral hemorrhage?

Answer for Question 186

Answer: E (Increase of all four–heart contractility, heart rate, peripheral resistance, and blood volume)

Explanation: One of the most common causes of intracerebral hemorrhage is hypertension. Blood pressure is cardiac output (which is determined by stroke volume and heart rate) x peripheral resistance. Heart contractility determines stroke volume and blood volume helps determine stroke volume. All other factors being equal, a substance or substances that increases heart contractility, heart rate, peripheral resistance and blood volume should cause the highest blood pressure, and should have the greatest chance to induce an intracerebral hemorrhage.

Question 187

A researcher wishes to study hypertension in vitro. Their lab has perfected a way to remove vascular tissue from rats and maintain their viability for several hours in which to conduct their experiments. To induce hypertension, the vessel is exposed to a mixture of four substances (prostacyclin, kinins, thromboxane and endothelin). Which combination of concentrations of substances below would be most effective in inducing hypertension?

Answer for Question 187

Answer: C (Decreased prostacyclin and kinins, and increased thromboxane and endothelin)

Explanation: Both thromboxane and endothelin are vasoconstrictors, which would increase peripheral resistance and thus help induce hypertension in the vessel, whereas both prostacyclin and kinins are vasodilators, so a decreased concentration of these two substances would indirectly help induce hypertension (i.e., as there would be less opposition to the effects of the thromboxane and endothelin).

Question 188

A 23-year-old male presents to an acute care clinic complaining of pain in both his eyes and sensitivity to light that developed over night. He was no past medical history; however, he reports that he frequently develops ulcers in his mouth, about 5-6 times per year, which last for around 1 week, and four months ago he had a painful ulcer on his penis, which resolved over one week but he was afraid to report his symptoms. He has one sexual partner and they always use condoms for birth control. Of the following, what is the most likely diagnosis?

A. Herpes simplex infection
B. Syphilis
C. Cholesterol emboli
D. Drug reaction
E. Behcet disease

Answer for Question 188

Answer: E (Behcet disease)

Explanation: Behcet disease occurs in younger adults, and characteristic features are recurrent oral apthous ulcers, ocular symptoms, and genital ulcers. Patients can also have musculoskeletal complaints, and GI or CNS involvement. While HSV can cause painful genital ulcers, the recurrent involvement of the mouth, eyes, and genitalia, in a patient with essentially no risk factor for a sexually transmitted disease would be more consistent with Behcet syndrome. Syphilis causes painless genital ulcers. While cholesterol emboli and a drug reaction could produce multi-system involvement, the history does not suggest either as a cause for the patient’s symptoms and past medical history.