PATHOLOGY

PATHOLOGY REVIEW

By Christine Ragudo

Multiple Choice

A 32yo woman with poorly controlled DM delivers a healthy boy at 38 wks AOG. Due to maternal hyperglycemia during pregnancy, pancreatic islets in the neonate would be expected to show which of the following morphologic responses to injury?

• Atrophy

• Dysplasia

• Hyperplasia

• Metaplasia

​- Infants of diabetic mothers show 10% incidence of developmental abnormalities including anomalies of the heart or NTDs.

​

- During fetal development, the islet cells of pancreas have PROLIFERATIVE capacity and respons to INCREASED demand for insulin -> Physiologic hyperplasia

​

- Metaplasia is conversion of one differential cell pathway to another.​

Multiple Choice

A 52yo woman loses her right kidney after an automobile accident. A CT scan of the abdomen after 2 years showed marked enlargement of the left kidney. The renal enlargement is an example of which of the following adaptations?

• Atrophy

• Dysplasia

• Hyperplasia

• Hypertrophy

D​

​- Hypertrophy is a response to INCREASED FUNCTIONAL DEMAND, and is usually a normal process.

​

- If one kidney is inoperative because of vascular occlusion, the other kidney hypertrophies due to increased demand.

Subject | Subject

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Multiple Choice

A 20yo man from China is evaluated for persistent cough, night sweats, low-grade fever, and general malaise. A CXR showed “Ghon complex”. Sputum cultures grow acid-fast bacilli. Examinatino of hilar lymph nodes in this patient would most likely demonstrate which of the following pathologic changes?

• Caseous necrosis

• Coagulative necrosis

• Fat necrosis

• Fibrinoid necrosis

A​

- Caseous necrosis is a ​characteristic of PRIMARY TUBERCULOSIS, where necrotic cells FAIL to retain their cellular outlines. They DO NOT disappear by lysis (liquefactive necrosis) but persist as coarse granular , eosinophilic debris, which resembles CLUMPY CHEESE - caseous.

​

- Ghon complex is often accompanied by ​pleural effusion

- Fibrinoid necrosis - seen in necrotizing vasculitis​

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Multiple Choice

A 22yo construction worker sticks himself with a sharp, rusty nail. Within 24 hours, the wound has enlarged to become a 1-cm sore that drains thick, purulent material. This skin wound illustrates which of the following morphologic type of necrosis?

• Coagulative necrosis

• Liquefactive necrosis

• Fat necrosis

• Fibrinoid necrosis

B

- Polymorphonuclear leukocytes (segmented neutrophils) ​rapidly accumulate at sites of injury, loaded with acid hydrolases and capable of digesting dead cells. Thus, creating an abscess with central liquefaction (pus).

​

- Liquefactive necrosis - commonly seen in the brain

- Caseous necrosis - granulomas

- Fat necrosis - acute pancreatitis

- Fibrinoid necrosis - necrotizing vasculitis​

Multiple Choice

A 60 yo farmer presents with multiple patches of discoloration on his face. Biopsy revealed actinic keratosis. Which of the following terms best describe this response of the skin to chronic sunlight exposure?

• Atrophy

• Dysplasia

• Hyperplasia

• Metaplasia

B

• Actinic keratosis is a form of DYSPLASIA in SUN-EXPOSED skin.

• It has atypical squamous cells varying in size and shape.

• Dysplasia is a PRE-NEOPLASTIC LESION, but still may revert to normal.

Multiple Choice

A 22yo woman nursing her newborn develops a tender erythematous area around the nipple of her left breast. A thick, yellow fluid is observed to drain from an open fissure. Examination of this breast fluid under the light microscope will most likely reveal an abundance of which of the following inflammatory cells?

• B lymphocytes

• Eosinophils

• Mast cells

• Neutrophils

D

• Thick, yellow fluid draining from the breast ​represents PURULENT EXUDATE.

• Purulent exudate is associated with pyogenic ​bacterial infections where the predominant cell type is NEUTROPHIL (PMNs)

• Mast cells predominate in response to ALLERGENS

• B lymphocytes and plasma cells are mediators for CHRONIC INFLAMMATION​

Multiple Choice

A 5yo boy punctures his thumb with a rusty nail. Four hours later, the thumb appears red and swollen. Initial swelling of the boy’s thumb is primarily due to which of the following mechanisms?

• Decreased intravacular hydrostatic pressure

• Decreased intravascular oncotic pressure

• Increased capillary permeability

• Vasoconstriction of arterioles

C

​- Forces that regulate the balance of vascular and tissue fluids are: (1) hydrostatic pressure, (2) oncotic pressure, (3) osmotic pressure, and (4) lymph flow)

​

- During inflammation, an INCREASE IN PERMEABILITY ​of the endothelial cell barrier results in LOCAL EDEMA

​

- ​VASODILATION -> increases HYDROSTATIC PRESSURE

- Acute inflammation IS NOT associated with ​changes in oncotic pressure.

Multiple Choice

A 33yo man presents with a 5-week history of calf pain and swelling and low-grade fever. Serum levels of creatine kinase are elevated. A muscle biopsy reveals numerous eosinophils. What is the most likely etiology of this patient’s myalgia?

• Autoimmune disease

• Bacterial infection

• Muscular dystrophy

• Parasitic infection

D

• Eosinophils are evident during ALLERGIC-TYPE reactions and PARASITIC infestations.

• Bacterial infections are associated with ​neutrophilia

• Patients with muscular dystrophy ​has increased creatine kinase, but NO EOSINOPHILS seen on muscle biopsy.

• Viral infections are associated with ​lymphocytosis

• Polymyositis (autoimmune disease) ​has NO EOSINOPHILS

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Multiple Choice

A 10yo girl presents with a 2-week history of puffiness around her eyes and swelling of the legs and ankles. Laboratory studies show hypoalbuminemia and proteinuria. The urinary sediment contains no infl ammatory cells or red blood cells. Which of the following terms describes this patient’s peripheral edema?

• Effusion

• Exudate

• Lymphedema

• Transudate

D

• Hypoalbuminemia (kidney disease) or decreased synthesis of plasma proteins (liver disease/ malnutrition) REDUCES plasma ONCOTIC PRESSURE. Therefore, NONINFLAMMATORY EDEMA -> TRANSUDATE.

• Transudate - edema fluid with LOW PROTEIN content

• Exudate - edema fluid with HIGH PROTEIN and INFLAMMATORY CELLS

• Effusion - EXCESS fluid in a body cavity like peritoneum/ pleura

• Lymphedema - OBSTRUCTION of lymphatic flow (surgery/ infection)

Multiple Choice

A 68yo man with prostate cancer and bone metastases presents with shaking chills and fever. The peripheral WBC count is 1,000/μL (normal = 4,000 to 11,000/μL). Which of the following terms best describes this hematologic finding?

• Leukocytosis

• Leukopenia

• Pancytopenia

• Leukemoid reaction

B

• Leukopenia - DECREASE in circulating WBC count. This is associated with CHRONIC conditions (malnourish/ typhoid fever/ chronic disease/ rickettsial infection)

• Leukocytosis - INCREASE in circulating WBC count.

• Pancytopenia - DECREASE in circulating levels of ALL formed elements in the blood.

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Multiple Choice

A 68yo coal miner with a history of smoking and emphysema develops severe air-flow obstruction and expires. Autopsy reveals a “black lung,” with coal-dust nodules scattered throughout the parenchyma and a central area of dense fibrosis. The coal dust entrapped within this miner’s lung was sequestered primarily by which of the following cells?

• Macrophages

• Endothelial cells

• Lymphocytes

• Fibroblasts

A

​- Coal workers' pneumoconiosis reflects the inhalation of CARBON particles.

​

- Nodules consist of dust-laden macrophages ​associated with a fibrotic stroma. Nodules occur when coal is admixed with fibrogenic dusts such as silica and more properly classified as anthracosilicosis.

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Multiple Choice

A 25yo woman sustains a deep, open laceration over her right forearm in a motorcycle accident. The wound is cleaned and sutured. Which of the following cell types mediates contraction of the wound to facilitate healing?

• Endothelial cells

• Myofibroblasts

• Fibroblasts

• Smooth muscle cells

B

• The myofibroblast is the cell responsible for ​WOUND CONTRACTION as well as the deforming pathologic process termed WOUND CONTRACTURE.

• Fibroblasts tend to be solitary cells​, surrounded by collagen fibers

• Endothelial cells respond to growth ​and form capillaries, responsible in delivering nutrients and inflammatory cells.

• Smooth muscle cells DOES NOT mediate wound contraction.

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Multiple Choice

A 4yo boy falls on a rusty nail and punctures his skin. The wound is cleaned and covered with sterile gauze. Which of the following is the initial event in the healing process?

• (A) Accumulation of acute inflammatory cells

• (B) Deposition of proteoglycans and collagen

• C) Differentiation and migration of myofibroblasts

• (D) Formation of a fibrin clot

D

• The initial phase of the repair reaction, which typically begins with hemorrhage, involves the formation of a fibrin clot -> filling the gaps created by the wound.​

• A thrombus (clot) known as "SCAB" after drying out, form on the wounded skin as a barrier to invading microorganisms.

• ​Thrombus is rich in fibronectin

• ​Accumulation of inflammatory cells occur after fibrin clot.

• ​Myofibroblasts begin to accumulate on the wound on the 3rd day

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Multiple Choice

 A 10yo boy trips at school and scrapes the palms of his hands. The wounds are cleaned and covered with sterile gauze. Which of the following terms best characterizes the healing of these superficial abrasions?

• Fibrosis

• Granulation tissue

• Primary intention

• Regeneration

D

• Superficial abrasions of the skin heal by regeneration.

• Cellular migration is the predominant means by which the wound surface is reepitheliazed.

• - Fibrosis is aberrant healing with deposition of collagen-rich scar tissue.

• Granulation tissue forms during the repair of DEEP WOUNDS.

• Primary and Secondary intentions are features of healing in DEEPER WOUNDS.​

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Multiple Choice

A 30yo firefighter suffers extensive third-degree burns over his arms and hands. This patient is at high risk for developing which of the following complications of wound healing?

• Contracture

• Dehiscence

• Keloid

• Traumatic neuroma

A

• A mechanical reduction in the size of a wound depends on the presence of MYOFIBROBLASTS and cell contraction.

• Exaggerated process is termed CONTRACTURE which results in severe deformity of wound and surrounding tissues.

• Contractures are common in the healing of serious burns compromising movement of joints.

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Multiple Choice

A 20yo woman with a history of asthma and allergies undergoes skin testing to identify potential allergens in her environment. A positive skin reaction to ragweed in this patient would be mediated by which of the following classes of immunoglobulin?

• IgA

• IgD

• IgE

• IgM

C

• Type 1 hypersensitivity reactions feature the formation of IgE antibodies, which accounts for the term Cytophilic Antibody.

• ​

• Responses to allergen releases a cascade of proinflammatory mediators which are responsible for smooth muscle contraction, edema formation, and recruitment of eosinophils.

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Multiple Choice

A 20yo gardener presents to his family physician for treatment of what he describes as “poison ivy.” The patient’s hands and arms appear red and are covered with oozing blisters and crusts. Which of the following best describes the pathogenesis of these skin lesions?

• Cytotoxic antibody production

• Delayed-type hypersensitivity

• IgE-mediated mast cell degeneration

• Deposition of circulating immune complexes

B

• Poison ivy is a TYPE IV hypersensitivity reaction to plants of the Rhus genus.

• ​

• This presents as urticaria and bullous eruption.​

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Multiple Choice

A 65yo man dies after a protracted battle with metastatic colon carcinoma. At autopsy, the liver is filled with multiple nodules of cancer, many of which display central necrosis (umbilication). Which of the following best explains the pathogenesis of tumor umbilication in this patient?

• Chronic inflammation

• Stimulation of angiogenesis

• Granulomatous inflammation

• Ischemia and Infarction

D

​- Angiogenesis is a requirement for continued growth of cancers.

- In the absence of new vessels, malignant tumors do not grow.

- Causes of tumor cell death:

1. programmed cell death (apoptosis)

2. inadequate blood supply -> ischemia

3. paucity of nutrients

4. vulnerability to host defenses.​

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Multiple Choice

A 50yo fire fighter emerges from a burning house with 3rd-degree burns over 70% of his body. The patient expires 24 hours later. Which of the following was the most likely cause of death?

• Congestive heart failure

• Disseminated intravascular coagulation

• Hypovolemic shock

• Pulmonary saddle embolism

C

• Hypovolemic shock may be caused by hemorrhage, fluid loss from severe burns, diarrhea, excessive urine formation, perspiration, or trauma.

• Burns or traums produces direct damage to the microcirculation leading to increased vascular permeability

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Multiple Choice

A 50yo alcoholic is rushed to the hospital with bleeding esophageal varices and expires. At autopsy, the patient’s protruding abdomen is found to contain a large volume of serous fluid. What is the appropriate term used to describe this fluid?

• Ascites

• Exudate

• Hydrothorax

• Lymphedema

A

• A protruding belly and fluid accumulation in patients with cirrhosis represents ASCITES (accumulation of serous fluid in the abdominal cavity)

• It is due to portal hypertension and hypoalbuminemia

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Multiple Choice

A healthy adult runs a marathon in the summer and develops hot dry skin, cessation of sweating, lactic acidosis, hypocalcemia, and muscle necrosis (rhabdomyolysis). Which of the following is the appropriate diagnosis?

• Heat stroke

• Malignant hyperthermia

• Myotonic dystrophy

• Polymyositis

A

• Exertional heat stroke occurs in healthy men during vigorous exercise with high temperature.

  ​

• Malignant hyperthermia occurs in surgical patients after anesthesia​

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Multiple Choice

A 65yo man undergoes cardiac bypass surgery and is

placed on postoperative, broad-spectrum, antibiotic prophylaxis. Several days later, he develops fever, abdominal pain, and bloody diarrhea. Colonoscopic biopsy demonstrates a thick mucopurulent exudate. Which of the following is the

most likely etiology of this patient’s gastrointestinal disorder?

• Clostridium botulinum

• Clostridium difficile

• Clostridium perfringens

• Clostridium tetani

B

• C. difficile is the most common cause of diarrhea in patients on antibiotic therapy (Clindamycin or cephalosporins) who are hospitalized for >3 days.

• Necrotizing enterocolitis (pseudomembranous colitis) is a disease that may affect the entire colon. The mucosa is covered by yellow-green, necrotic exudates.

• C. perfringens - food poisoning, 48h after ingestion of contaminated meal

• C. tetani produces neurotoxin causing muscle spasms

• C. botulinum produces neurotoxin causing paralysis​

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Multiple Choice

A 24yo beating victim is brought to the ER with a 4-cm linear tear of the skin caused by blunt trauma. Which of the following terms best describes this patient’s skin lesion?

• Abrasion

• Avulsion

• Contusion

• Laceration

D

​- Laceration - linear tear of the skin due to a force causing unidirectional displacement.

​

- Abrasion - skin defect caused by crushes or scrapes.

​

​- Avulsion - tearing away or forcible separation

​

- Contusion - localized mechanical injury with focal hemorrhage​

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Multiple Choice

A 76yo woman presents with a 1-hour history of substernal chest pain. Shortly after admission the patient expires. At autopsy, extensive calcium deposits are noted in the coronary and other arteries affected by severe atherosclerosis. Which of the following terms best describes these autopsy findings?

• Dystrophic calcification

• Hyperplastic calcification

• Hypertrophic calcification

• Physiologic calcification

A

• Dystrophic clacification is a response to cell injury

  ​

• The pathogenesis of atherosclerotic plaque leads to erosion, ulceration of fissuring on the surface of the plaque, plaque hemorrhage, mural thrombosis, and calcification.​

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Multiple Choice

A 56yo man with a history of cigarette smoking presents with difficulty swallowing and a muffled voice. Laryngoscopy reveals a 2-cm laryngeal mass. If this mass is a malignant neoplasm, which of the following is the most likely histologic diagnosis?

• Adenocarcinoma

• Leiomyosarcoma

• Squamous cell carcinoma

• S

• Majority of laryngeal cancers are squamous cell carcinomas and occur principally in smokers.

  ​

• Adenocarcinoma, Leiomyosarcoma, and small cell carcinoma are rarely encountered in the larynx​

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Multiple Choice

A 20yo woman presents with a 2-year history of difficulty swallowing and increasing fatigue. A CBC shows iron-deficiency anemia. Upper endoscopy reveals an annular narrowing in the upper third of the esophagus. A mucosal biopsy shows no evidence of inflammation or neoplasia. Which of the following is the most likely diagnosis?

• Achalasia

• Barrett esophagus

• Diverticulum

• Esophageal web

• Esophageal rings and webs cause dysphagia.

• Esophageal webs and rings present as dysphagia, esophageal substernal pain, and aspiration or regurgitation of foods and liquids.

• Plummer-Vinson syndrome is characterized by a cervical esophageal web, mucosal lesions of mouth and pharynx, and iron-deficiency anemia.

• Schatzki ring occurs near the gastroesophageal junction​

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Multiple Choice

A 60yo woman complains of increasing abdominal girth of 4 weeks in duration. Physical examination discloses ascites, and cytologic examination of the fl uid reveals malignant cells. Exploratory laparotomy shows multiple tumor nodules on the serosal surface of the intestines. Which of the following is the most likely diagnosis?

• Carcinoid tumor

• LIposarcoma

• Gastrointestinal stromal tumor

• Metastatic carcinoma

• Metastatic carcinoma is the most common malignant disorder affecting the peritoneum.

  ​

• Ovarian, gastric and pancreatic carcinomas are likely to seed the peritoneum

  ​

• Metastatic carcinoma to the abdomen persents in the form of multiple serosal nodules and ascites fluid containing malignant cells.​

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Multiple Choice

A 4yo girl is brought to the physician because her parents noticed that she has been having pale, fatty, foul-smelling stools. The patient is at the 50th percentile for height and 10th percentile for weight. Her symptoms respond dramatically to a gluten-free diet. Which of the following is the most likely diagnosis?

• Celiac sprue

• Cystic fibrosis of pancreas

• Tropical sprue

• Whipple disease

• Celiac sprue also known as GLUTEN-SENSITIVE ENTEROPATHY

• Risk factors include genetic predisposition and Gliadin exposure

• The HALLMARK of Celiac Disease: Flat mucosa with blunting of villi, damaged epithelial cells, intrepithelial T cells, and increased plasma cells in the LAMINA PROPRIA.

• Celiac sprue is characterized by:

  1. generalized malabsorption

  2. small intestinal mucosal lesions

  3. prompt clinical and histopathologic response

     ​

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Multiple Choice

A 3-day old neonate born after a 32-week gestation develops yellow skin. Physical examination of the infant is unremarkable. Which of the following is most likely to be increased in this neonate’s serum?

• Carotene

• Conjugated bilirubin

• Galactosyltransferase

• Unconjugated bilirubin

• 70% of normal newborns exhibit transient unconjugated hyperbilirubinemia

  ​

• Immature liver leads to inadequate conjugation of bilirubin, and more profound in premature infants due to inadequate heaptic clearance of bilirubin and increased erythrocyte turnover.​

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Multiple Choice

A 47yo man suffers from long-standing peptic ulcer disease, which is largely unresponsive to pharmacologic therapy. Endoscopic examination reveals multiple, nonhealed ulcerations of the duodenum and jejunum. Which of the following is the most likely diagnosis?

• Insulinoma

• Pancreatic adenocarcinoma

• Verner-Morrison syndrome

• Zollinger-Ellison syndrome

• Zollinger- Ellison syndrome is characterized by intractable gastric hypersecretion, severe peptic ulceration of the DUODENUM and elevated levels of GASTRIN in blood.

• The tumor responsible for this syndrom is PANCREATIC GASTRINOMA composed of G cells.

• ​

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Multiple Choice

A 5yo girl presents with the sudden onset of diffuse arthralgias and skin rash. Physical examination shows a violaceous maculopapular rash on the lower torso. Urinalysis discloses oliguria and 2+ hematuria. Urine cultures are negative. This child’s clinical presentation is commonly associated with which of the following diseases?

• Berger disease

• Goodpasture syndrome

• Hemolytic uremic syndrome

• Henoch-Schonlein purpura

• Henoch-Schonlein purpura is the MOST COMMON type of childhood vasculitis caused by vascular localization of immune complexes containing IgA. (IgA nephropathy)

  ​

• Hemolytic uremic syndrome is due to​ exposure to Shiga toxin strains of E.coli and not associated with angiopathy outside the kidney

  ​

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Multiple Choice

A 59yo woman presents with a 2-year history of vulvar itching and burning. Physical examination reveals a red, moist lesion of the labium major. Biopsy reveals clusters of pale vacuolated cells within the epidermis that stain positively for periodic acid-Schiff (PAS) and carcinoembryonic

antigen (CEA). Which of the following is the most likely diagnosis?

• Extramammary Paget disease

• Verrucous carcinoma

• Vulvar intrepithelial neoplasia

• Vulvar melanoma

• Extramammary paget disease of the vulva is named after similar-appearing tumors in the nipple, axilla, and perianal region

  ​

• The typical Paget cell has a pale, vacuolated cytoplasms containing GLYCOSAMINOGLYCANS

  ​

• It stains with PAS and Mucicar​mine and expresses CEA

  ​

• It occurs usually in the labia majora in older women

  ​

• Burning and pruritus for many year

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Multiple Choice

A 60yo woman presents with a 3-week history of a painful genital lesion and bleeding. Physical examination reveals an exophytic, ulcerated 1-cm polypoid mass near the external end of the urethra. What is the most likely diagnosis?

• Bartholin glannd cyst

• Caruncle

• Lichen sclerosis

• Condyloma acuminatum

• Caruncle is a polypoid inflamma​tory lesion near the female urethral meatus which elicits pain and bleeding

• Usually seen among postmenopausal women

• Urethral caruncle presents as an exophytic, ulcerated, polypoid mass 1-2 cm size.​

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