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.
