PATHOLOGY ANSWERS cells fail to retain their cellular outlines.

They do not
disappear by lysis, as in liquefactive necrosis (choice E), but
___1. A 32yo woman with poorly controlled diabetes mellitus persist indefinitely as amorphous, coarsely granular,
delivers a healthy boy at 38 weeks AOG. As a result of eosinophilic debris. Grossly, this debris resembles clumpy
maternal hyperglycemia during pregnancy, pancreatic islets cheese, hence the name caseous necrosis. Primary
in the neonate would be expected to show which of the tuberculosis is often asymptomatic or presents with
following morphologic responses to injury? nonspecifi c symptoms, such as low-grade fever, loss of
(A) Atrophy (D) Metaplasia appetite, and occasional spells of coughing. The Ghon
(B) Dysplasia (E) Necrosis complex includes parenchymal consolidation and ipsilateral
(C) Hyperplasia enlargement of hilar lymph nodes and is often accompanied
by a pleural effusion. Fibrinoid necrosis (choice D) is
Ans: The answer is C: Hyperplasia. Infants of diabetic mothers seen in patients with necrotizing vasculitis.
show a 5% to 10% incidence of major developmental Diagnosis: Tuberculosis, Mycobacterium tuberculosis
abnormalities, including anomalies of the heart and great
vessels and neural tube defects. The frequency of these ___4. An 82yo man has profound bleeding from a peptic
lesions relates to the control of maternal diabetes during ulcer and dies of hypovolemic shock. The liver at autopsy
early gestation. During fetal development, the islet cells of displays centrilobular necrosis. Compared to viable
the pancreas have proliferative capacity and respond to hepatocytes, the necrotic cells contain higher intracellular
increased demand for insulin by undergoing physiologic concentrations of which of the following?
hyperplasia. Fetuses exposed to hyperglycemia in utero may (A) Calcium (D) Iron
develop hyperplasia of the pancreatic β cells, which may (B) Cobalt (E) Selenium
secrete insulin autonomously and cause hypoglycemia at (C) Copper
birth. Metaplasia (choice D) is defined as the conversion of
one differentiated cell pathway to another. Ans: The answer is A: Calcium. Coagulative necrosis is
Diagnosis: Diabetes mellitus characterized by a massive infl ux of calcium into the cell.
Under normal circumstances, the plasma membrane
___2. A 52yo woman loses her right kidney following an maintains a steep gradient of calcium ions, whose
automobile accident. A CT scan of the abdomen 2 years later concentration in interstitial fluids is 10,000 times higher than
shows marked enlargement of the left kidney. The renal that inside the cell. Irreversible cell injury damages the
enlargement is an example of which of the following plasma membrane, which then fails to maintain this gradient,
adaptations? allowing the infl ux of calcium into the cell. The other choices
(A) Atrophy (D) Hypertrophy would most likely be released upon cell death.
(B) Dysplasia (E) Metaplasia Diagnosis: Coagulative necrosis
(C) Hyperplasia
___5. A 22yo construction worker sticks himself with a sharp,
Ans: The answer is D: Hypertrophy. Hypertrophy is a rusty nail. Within 24 hours, the wound has enlarged to
response to trophic signals or increased functional demand become a 1-cm sore that drains thick, purulent material. This
and is commonly a normal process. For example, if one skin wound illustrates which of the following morphologic
kidney is rendered inoperative because of vascular occlusion, types of necrosis?
the contralateral kidney hypertrophies to accommodate (A) Caseous necrosis (D) Fibrinoid necrosis
increased demand. The molecular basis of hypertrophy (B) Coagulative necrosis (E) Liquefactive necrosis
reflects increased expression of growth-promoting genes (C) Fat necrosis
(protooncogenes) such as myc, fos, and ras. Hyperplasia
(choice C) of renal tubular cells may occur, but enlargement Ans: The answer is E: Liquefactive necrosis.
of the kidney in this patient is best referred to as hypertrophy Polymorphonuclear leukocytes (segmented neutrophils)
(i.e., increased organ size and function). rapidly accumulate at sites of injury. They are loaded with
Diagnosis: Hypertrophy acid hydrolases and are capable of digesting dead cells. A
localized collection of these infl ammatory cells may create
___3. 20yo man from China is evaluated for persistent cough, an abscess with central liquefaction (pus). Liquefactive
night sweats, low-grade fever, and general malaise. necrosis is also commonly seen in the brain. Caseous necrosis
A chest X-ray reveals fi ndings “consistent with a Ghon (choice A) is seen in necrotizing granulomas. Fat necrosis
complex.” Sputum cultures grow acid-fast bacilli. Examination (choice C) is typically encountered in patients with acute
of hilar lymph nodes in this patient would most likely pancreatitis. Fibrinoid necrosis (choice D) is seen in patients
demonstrate which of the following pathologic changes? with necrotizing vasculitis.
(A) Caseous necrosis (D) Fibrinoid necrosis Diagnosis: Abscess, acute infl ammation
(B) Coagulative necrosis (E) Liquefactive necrosis
(C) Fat necrosis ___6. A 5yo boy suffers blunt trauma to the leg in an
automobile accident. Six months later, bone trabeculae have
Ans: The answer is A: Caseous necrosis. Caseous necrosis is a formed within the striated skeletal muscle at the site of
characteristic of primary tuberculosis, in which the necrotic tissue injury. This pathologic condition is an example of which
of the following morphologic adaptations to injury? failure. Which of the following cellular proteins was directly
(A) Atrophy (D) Metastatic calcification involved in the development of hepatotoxicity in this patient?
(B) Dysplasia (E) Dystrophic calcification (A) Acetaldehyde dehydrogenase
(C) Metaplasia (B) Alcohol dehydrogenase
(C) Glucose-6-phosphate dehydrogenase
Ans: The answer is C: Metaplasia. Myositis ossifi cans is a (D) Mixed function oxygenase
disease characterized by formation of bony trabeculae within (E) Superoxide dismutase
striated muscle. It represents a form of osseous metaplasia
(i.e., replacement of one differentiated tissue with another Ans: The answer is D: Mixed function oxygenase. The
type of normal differentiated tissue). Although dystrophic metabolism of CCl4 is a model system for toxicologic studies.
calcifi cation (choice E) frequently occurs at sites of prior CCl4 is fi rst metabolized via the mixed function oxygenase
injury, it does not lead to the formation of bone trabeculae. system (P450) of the liver to a chloride ion and a highly
Diagnosis: Myositis ossifi cans, metaplasia reactive trichloromethyl free radical. Like the hydroxyl
radical, this radical is a potent initiator of lipid peroxidation,
___7. A 32yo woman develops an Addisonian crisis (acute which damages the plasma membrane and leads to cell
adrenal insuffi ciency) 3 months after suffering massive death. The other choices are not involved in the formation of
hemorrhage during the delivery of her baby. A CT scan of the the trichloromethyl free radical in liver cells.
abdomen shows small adrenal glands. Which of the following Diagnosis: Hepatic failure, hepatotoxicity
mechanisms of disease best accounts for adrenal atrophy in
this patient? ___10. A 22yo woman nursing her newborn develops a
(A) Chronic inflammation (D) Lack of trophic signals tender erythematous area around the nipple of her left
(B) Chronic ischemia (E) Tuberculosis breast. A thick, yellow fl uid is observed to drain from an
(C) Hemorrhagic necrosis open fissure. Examination of this breast fluid under the light
microscope will most likely reveal an abundance of which of
Ans: The answer is D: Lack of trophic signals. Atrophy of an the following inflammatory cells?
organ may be caused by interruption of key trophic signals. (A) B lymphocytes (D) Neutrophils
Postpartum infarction of the anterior pituitary in this patient (B) Eosinophils (E) Plasma cells
resulted in decreased production of adrenocorticotropic (C) Mast cells
hormone (ACTH, also termed corticotropin). Lack of
corticotropin results in atrophy of the adrenal cortex, which Ans: The answer is D: Neutrophils. The thick, yellow fl uid
leads to adrenal insufficiency. Symptoms of acute adrenal draining from the breast fissure in this patient represents a
insuffi ciency (Addisonian crisis) include hypotension and purulent exudate. Purulent exudates and effusions are
shock, as well as weakness, vomiting, abdominal pain, and associated with pathologic conditions such as pyogenic
lethargy. The other choices are unlikely causes of postpartum bacterial infections, in which the predominant cell type is the
adrenal insufficiency. segmented neutrophil (polymorphonuclear leukocyte). Mast
Diagnosis: Sheehan syndrome, adrenal insuffi ciency cells (choice C) are granulated cells that contain receptors for
IgE on their cell surface. They are additional cellular sources
___8. A 60yo farmer presents with multiple patches of of vasoactive mediators, particularly in response to allergens.
discoloration on his face. Biopsy of lesional skin reveals B lymphocytes (choice A) and plasma cells (choice E) are
actinic keratosis. Which of the following terms best describes mediators of chronic inflammation and provide antigen-
this response of the skin to chronic sunlight exposure? specific immunity to infectious diseases.
(A) Atrophy (D) Hypertrophy Diagnosis: Acute mastitis
(B) Dysplasia (E) Metaplasia
(C) Hyperplasia ___11. A 5yo boy punctures his thumb with a rusty nail. Four
hours later, the thumb appears red and swollen. Initial
Ans: The answer is B: Dysplasia. Actinic keratosis is a form of swelling of the boy’s thumb is primarily due to which of the
dysplasia in sun-exposed skin. Histologically, such lesions following mechanisms?
are composed of atypical squamous cells, which vary in size (A) Decreased intravascular hydrostatic pressure
and shape. They show no signs of regular maturation as the (B) Decreased intravascular oncotic pressure
cells move from the basal layer of the epidermis to the (C) Increased capillary permeability
surface. Dysplasia is a preneoplastic lesion, in the sense that (D) Increased intravascular oncotic pressure
it is a necessary stage in the multistep evolution to cancer. (E) Vasoconstriction of arterioles
However, unlike cancer cells, dysplastic cells are not entirely
autonomous, and the histologic appearance of the tissue may Ans: The answer is C: Increased capillary permeability. Forces
still revert to normal. None of the other choices represent that regulate the balance of vascular and tissue fl uids include
preneoplastic changes in sun-exposed skin. (1) hydrostatic pressure, (2) oncotic pressure, (3) osmotic
Diagnosis: Actinic keratosis, dysplasia pressure, and (4) lymph fl ow. During infl ammation, an
increase in the permeability of the endothelial cell barrier
___9. A 24yo woman accidentally ingests carbon results in local edema. Vasodilation of arterioles exacerbates
tetrachloride (CCl4) in the laboratory and develops acute liver fl uid leakage, and vasoconstriction of postcapillary venules
increases the hydrostatic pressure in the capillary bed (thus, (A) Constriction of postcapillary venules
not choice A), potentiating the formation of edema. (B) Constriction of precapillary arterioles
Vasodilation of venules decreases capillary hydrostatic (C) Dilation of postcapillary venules
pressure and inhibits the movement of fl uid into the (E) Ischemic necrosis
extravascular spaces. Acute infl ammation is not associated
with changes in plasma oncotic pressure (choices B and D). Ans: The answer is B: Constriction of precapillary arterioles.
Diagnosis: Infl ammatory edema The initial response of arterioles to neurogenic and chemical
stimuli is transient vasoconstriction. However, shortly
___12. A 36yo woman with pneumococcal pneumonia thereafter, vasodilation (choice D) occurs, with an increase in
develops a right pleural effusion. The pleural fl uid displays a blood fl ow to the infl amed area. This process is referred to
high specific gravity and contains large numbers of as active hyperemia. None of the other choices cause
polymorphonuclear (PMN) leukocytes. Which of the transient skin blanching.
following best characterizes this pleural effusion? Diagnosis: Laceration
(A) Fibrinous exudate (D) Serosanguineous exudate
(B) Lymphedema (E) Transudate ___15. A 25yo machinist is injured by a metal sliver in his left
(C) Purulent exudate hand. Over the next few days, the wounded area becomes
reddened, tender, swollen, and feels warm to the touch.
Ans: The answer is C: Purulent exudate. The pleural effusion Redness at the site of injury in this patient is caused primarily
encountered in this patient represents excess fl uid in a body by which of the following mechanisms?
cavity. A transudate denotes edema fl uid with low protein (A) Hemorrhage (D) Vasoconstriction
content, whereas an exudate denotes edema fl uid with high (B) Hemostasis (E) Vasodilation
protein content. A purulent exudate or effusion contains a (C) Neutrophil margination
prominent cellular component (PMNs). A serous exudate or
effusion is characterized by the absence of a prominent Ans: The answer is E: Vasodilation. Vasodilation of
cellular response and has a yellow, strawlike color. Fibrinous precapillary arterioles increases blood fl ow at the site of
exudate (choice A) does not contain leukocytes. tissue injury. This condition (active hyperemia) is caused by
Serosanguineous exudate (choice D) contains RBCs and has a the release of specific mediators. Vasodilation and hyperemia
red tinge. are primarily responsible for the redness and warmth (rubor
Diagnosis: Bacterial pneumonia, pleural effusion and calor) at sites of injury. The other choices do not regulate
active hyperemia.
___13. A 33yo man presents with a 5-week history of calf Diagnosis: Acute infl ammation
pain and swelling and low-grade fever. Serum levels of
creatine kinase are elevated. A muscle biopsy reveals ___16. A 68yo man with prostate cancer and bone
numerous eosinophils. What is the most likely etiology of this metastases presents with shaking chills and fever. The
patient’s myalgia? peripheral WBC count is 1,000/μL (normal = 4,000 to
(A) Autoimmune disease (D) Parasitic infection 11,000/μL). Which of the following terms best describes this
(B) Bacterial infection (E) Viral infection hematologic fi nding?
(C) Muscular dystrophy (A) Leukocytosis (D) Pancytopenia
(B) Leukopenia (E) Leukemoid reaction
Ans: The answer is D: Parasitic infection. Eosinophils are (C) Neutrophilia
particularly evident during allergic-type reactions and
parasitic infestations. Infections with Trichinella are Ans: The answer is B: Leukopenia. Leukopenia is defi ned as
accompanied by eosinophilia, and skeletal muscle is typically an absolute decrease in the circulating WBC count. It is
infi ltrated by eosinophils. Patients with muscular dystrophy occasionally encountered under conditions of chronic
(choice C) show elevated serum levels of creatine kinase, but inflammation, especially in patients who are malnourished
eosinophils are not seen on muscle biopsy. Bacterial or who suffer from a chronic debilitating disease. Leukopenia
infections (choice B) are associated with neutrophilia, and may also be caused by typhoid fever and certain viral and
affected tissues are infi ltrated with PMNs. Viral infections rickettsial infections. Leukocytosis (choice A) is defined as an
(choice E) are associated with lymphocytosis, and affected absolute increase in the circulating WBC count. Neutrophilia
tissues are infi ltrated with B and T lymphocytes. (choice C) is defi ned as an absolute increase in the circulating
Polymyositis, an autoimmune disease (choice A), does not neutrophil count. Pancytopenia (choice D) refers to
feature eosinophils. decreased circulating levels of all formed elements in the
Diagnosis: Trichinosis blood.
Diagnosis: Prostate cancer
___14. A 14yo boy receives a laceration on his forehead
during an ice hockey game. When he is first attended to by ___17. A 50yo woman is discovered to have metastatic
the medic, there is blanching of the skin around the wound. breast cancer. One week after receiving her fi rst dose of
Which of the following mechanisms accounts for this chemotherapy, she develops bacterial pneumonia. Which of
transient reaction to neurogenic and chemical stimuli at the the following best explains this patient’s susceptibility to
site of injury? bacterial infection?
(A) Depletion of serum complement (B) Fibroblasts (E) Plasma cells
(B) Impaired neutrophil respiratory burst (C) Lymphocytes
(C) Inhibition of clotting factor activation
(D) Lymphocytosis Ans: The answer is D: Macrophages. Coal workers’
(E) Neutropenia pneumoconiosis refl ects the inhalation of carbon particles.
The characteristic pulmonary lesions of simple coal worker’s
Ans: The answer is E: Neutropenia. The importance of pneumoconiosis include nonpalpable coal-dust macules and
protection afforded by acute infl ammatory cells is palpable coaldust nodules, both of which are typically
emphasized by the frequency and severity of infections in multiple and scattered throughout the lung as 1- to 4-mm
persons with defective phagocytic cells. The most common black foci. Nodules consist of dust-laden macrophages
defect is iatrogenic neutropenia secondary to cancer associated with a fibrotic stroma. Nodules occur when coal is
chemotherapy. Chemotherapy would not be expected to admixed with fibrogenic dusts such as silica and are more
deplete serum levels of complement (choice A) or alter the properly classified as anthracosilicosis. Coal-dust macules and
respiratory burst within activated neutrophils (choice B). nodules appear on a chest radiograph as small nodular
Diagnosis: Bacterial pneumonia densities. The other choices are not phagocytic cells.
Diagnosis: Anthracosilicosis, coal workers’ pneumoconiosis
___18. A 10yo girl presents with a 2-week history of puffiness
around her eyes and swelling of the legs and ankles. ___20. A 40yo man presents with 5 days of productive cough
Laboratory studies show hypoalbuminemia and proteinuria. and fever. Pseudomonas aeruginosa is isolated from a
The urinary sediment contains no infl ammatory cells or red pulmonary abscess. The CBC shows an acute effect
blood cells. Which of the following terms describes this characterized by marked leukocytosis (50,000 WBC/μL), and
patient’s peripheral edema? the differential count reveals numerous immature cells (band
(A) Effusion (D) Lymphedema forms). Which of the following terms best describes these
(B) Exudate (E) Transudate hematologic
(C) Hydropic change fi ndings?
(A) Leukemoid reaction (D) Myeloproliferative disease
Ans: The answer is E: Transudate. According to the Starling (B) Leukopenia (E) Neutrophilia
principle, the interchange of fluid between vascular and (C) Myeloid metaplasia
extravascular compartments results from a balance of forces
that draw fluid into the vascular space or out into tissues. Ans: The answer is A: Leukemoid reaction. Circulating levels
These forces include (1) hydrostatic pressure, (2) oncotic of leukocytes and their precursors may occasionally reach
pressure (reflects plasma protein concentration), (3) osmotic very high levels (>50,000 WBC/μL). Such a situation, referred
pressure, and (4) lymph flow. When the balance of these to as a leukemoid reaction, is sometimes difficult to
forces is altered, the net result is fluid accumulation in the differentiate from leukemia. In contrast to bacterial
interstitial spaces (i.e., edema). Although edema infections, viral infections (including infectious
accompanies acute inflammation, a variety of mononucleosis) are characterized by lymphocytosis, an
noninflammatory conditions also lead to the formation absolute increase in the number of circulating lymphocytes.
of edema. For example, obstruction of venous outflow or Parasitic infestations and certain allergic reactions cause
decreased right ventricular function results in a back pressure eosinophilia, an increase in the number of circulating
in the vasculature, thereby increasing hydrostatic pressure. eosinophils. Leukopenia is defi ned as an absolute decrease in
Loss of albumin (kidney disorders, this case) or decreased the circulating WBC count. Myloid metaplasia (choice C) and
synthesis of plasma proteins (liver disease, malnutrition) myeloproliferative disease (choice D) are chronic disorders of
reduces plasma oncotic pressure. Noninflammatory edema is the hematopoietic system. Although technically correct,
referred to as a transudate. A transudate is edema fl uid with neutrophilia (choice E) by itself does not demonstrate
a low protein content. An exudate (choice B) is edema fl uid immature cells (band forms) and usually refers to
with a high protein and lipid concentration that frequently lower levels of increased neutrophils.
contains inflammatory cells. An effusion (choice A) represents Diagnosis: Pulmonary abscess
excess fluid in a body cavity such as the peritoneum or
pleura. Lymphedema (choice D) is usually associated with ___21. A 19yo woman presents with 5 days of fever
obstruction of lymphatic fl ow (e.g., surgery or infection). (38°C/101°F) and sore throat. She reports that she has felt
Diagnosis: Nephrotic syndrome fatigued for the past week and has diffi culty swallowing. A
physical examination reveals generalized lymphadenopathy.
___19. A 68yo coal miner with a history of smoking and If this patient has a viral infection, a CBC will most likely show
emphysema develops severe air-fl ow obstruction and which of the following hematologic findings?
expires. Autopsy reveals a “black lung,” with coal-dust (A) Eosinophilia (D) Neutrophilia
nodules scattered throughout the parenchyma and a central (B) Leukopenia (E) Thrombocythemia
area of dense fibrosis. The coal dust entrapped within this (C) Lymphocytosis
miner’s lung was sequestered primarily by which of the Ans: The answer is C: Lymphocytosis. Peripheral blood
following cells? lymphocytosis is defi ned as an increase in the absolute
(A) Endothelial cells (D) Macrophages peripheral blood lymphocyte count above the normal range
(<4,000/μL in children and 9,000/μL in infants). The principal
causes of absolute peripheral blood lymphocytosis are (1) ___24. A 10yo boy trips at school and scrapes the palms of
acute viral infections (infectious mononucleosis, whooping his hands. The wounds are cleaned and covered with sterile
cough, and acute infection lymphocytosis), (2) chronic gauze. Which of the following terms best characterizes the
bacterial infections (tuberculosis, brucellosis), and (3) healing of these superfi cial abrasions?
lymphoproliferative diseases. The other choices are not (A) Fibrosis (D) Regeneration
features of acute viral infections. (B) Granulation tissue (E) Secondary intention
Diagnosis: Infectious mononucleosis (C) Primary intention

___22. A 25yo woman sustains a deep, open laceration over Ans: The answer is D: Regeneration. Superfi cial abrasions of
her right forearm in a motorcycle accident. The wound is the skin heal by a process of regeneration. It is mediated by
cleaned and sutured. Which of the following cell types stem cells or stabile cells that are able to progress through
mediates contraction of the wound to facilitate healing? the cell cycle and fully restore normal tissue organization and
(A) Endothelial cells (D) Myofibroblasts function. Cellular migration is the predominant means by
(B) Fibroblasts (E) Smooth muscle cells which the wound surface is reepithelialized. Fibrosis (choice
(C) Macrophages A) refers to aberrant healing with deposition of collagen-rich
scar tissue. Granulation tissue (choice B) forms during the
Ans: The answer is D: Myofi broblasts. The myofi broblast is repair of deep wounds. Primary and secondary intentions
the cell responsible for wound contraction as well as the (choices C and E) are features of healing in deeper wounds.
deforming pathologic process termed wound contracture. Diagnosis: Superficial abrasion
These cells express a-smooth muscle actin, desmin, and
vimentin, and they respond to pharmacologic agents that ___25. A 34yo woman has a benign nevus removed from her
cause smooth muscle to contract or relax. Myofi broblasts back under local anesthesia. Which of the following families
exert their contractile effects by forming syncytia, in which of cell adhesion molecules is the principal component of the
the myofi broblasts are bound together by tight junctions. By “provisional matrix” that forms during early wound healing?
contrast, fi broblasts (choice B) tend to be solitary cells, (A) Cadherins (D) Laminins
surrounded by collagen fibers. Endothelial cells (choice A) (B) Fibronectins (E) Selectins
respond to growth factors and form capillaries, which are (C) Integrins
necessary for the delivery of nutrients and infl ammatory
cells. Neither macrophages (choice C) nor smooth muscle Ans: The answer is B: Fibronectins. Fibronectins are adhesive
cells (choice E) mediate wound contraction. glycoproteins that are widely distributed in stromal
Diagnosis: Wound contraction connective tissue and deposited at the site of tissue injury.
During the initial phase of healing, fibronectin in the
___23. A 4yo boy falls on a rusty nail and punctures his skin. extravasated plasma is cross-linked to fibrin, collagen, and
The wound is cleaned and covered with sterile gauze. Which other extracellular matrix components by the action of
of the following is the initial event in the healing process? transglutaminases. This cross-linking provides a provisional
(A) Accumulation of acute infl ammatory cells stabilization of the wound during the first several hours.
(B) Deposition of proteoglycans and collagen Fibronectin, cell debris, and bacterial products are
(C) Differentiation and migration of myofibroblasts chemoattractants for a variety of cells that are recruited to
(D) Formation of a fibrin clot the wound site over the next several days. Selectins (choice
(E) Macrophage-mediated phagocytosis of cellular debris E) are sugar-binding glycoproteins that mediate the initial
adhesion of leukocytes to endothelial cells at sites of
Ans: The answer is D: Formation of a fibrin clot. The initial inflammation. They are found at the cell surface and are not
phase of the repair reaction, which typically begins with part of the extracellular matrix. Cadherins (choice A) and
hemorrhage, involves the formation of a fibrin clot that fills integrins (choice C) are cell adhesion molecules. Like the
the gap created by the wound. A thrombus (clot), referred to selectin family of cell adhesion proteins, they are found at
as a scab after drying out, forms on the wounded skin as a the cell surface and are not part of the extracellular
barrier to invading microorganisms. It also prevents the loss matrix.
of plasma and tissue fluid. Formed primarily from plasma Diagnosis: Wound healing
fibrin, the thrombus is rich in fibronectin. The thrombus also
contains contracting platelets, which are an initial source of ___26. A 29yo carpenter receives a traumatic laceration to
growth factors. Much later, the thrombus undergoes her left arm. Which of the following is the most important
proteolysis, after which it is penetrated by regenerating factor that determines whether this wound will heal by
epithelium. The scab then detaches. Accumulation of acute primary or secondary intention?
inflammatory cells (choice A) might occur after formation of (A) Apposition of edges (D) Skin site affected
the initial fi brin clot. Collagen formation (choice B) and (B) Depth of wound (E) Vascular supply
macrophage activity (choice E) occur much later. (C) Metabolic status
Myofibroblasts (choice C) begin to accumulate
in the wound around the 3rd day. Ans: The answer is A: Apposition of edges. Healing by primary
Diagnosis: Wound healing intention occurs in wounds with closely apposed edges and
minimal tissue loss. Such a wound requires only minimal cell choices may cause eye irritation, seasonal conjunctivitis is
proliferation and neovascularization to heal, and the result is typically caused by allergies to pollens that are released
a small scar. Healing by secondary intention occurs in a during a particular time of the year. Allergic rhinitis (hay
gouged wound, in which the edges are far apart and in which fever) is the most common type I hypersensitivity disease in
there is substantial tissue loss. This wound requires wound adults. It may be caused by pollen, house dust, animal
contraction, extensive cell proliferation, and dandruff, and many other allergens. Antigens inhaled react
neovascularization (granulation tissue) to heal. Granulation with the IgE attached to basophils in the nasal mucosa,
tissue is eventually resorbed and replaced by a large scar that thereby triggering the release of vasoactive substances
is functionally and esthetically unsatisfactory. The other stored in cytoplasmic granules. Histamine, the main mediator
choices are important determinants of the outcome of released from mast cells, increases the permeability of
wound healing, but they do not provide a point of distinction mucosal vessels, causing edema and sneezing.
between primary and secondary intentions healing. Diagnosis: Conjunctivitis, hypersensitivity reaction
Diagnosis: Healing by primary intention
___30. A 45yo woman presents with a 1-year history of dry
___27. A 30yo firefighter suffers extensive third-degree burns mouth and eyes. A biopsy of a minor salivary gland reveals
over his arms and hands. This patient is at high risk for infiltrates of lymphocytes forming focal germinal centers.
developing which of the following complications of wound Which of the following cellular organelles is a target for
healing? autoantibodies in this patient?
(A) Contracture (D) Keloid (A) Centromere (D) Peroxisome
(B) Dehiscence (E) Traumatic neuroma (B) Lysosome (E) Plasma membrane
(C) Incisional hernia (C) Nucleus

Ans: The answer is A: Contracture. A mechanical reduction in Ans: The answer is C: Nucleus. Sjögren syndrome (SS) is an
the size of a wound depends on the presence of autoimmune disorder characterized by keratoconjunctivitis
myofibroblasts and sustained cell contraction. An sicca and xerostomia in the absence of other connective
exaggeration of these processes is termed contracture and tissue disease. The production of autoantibodies, particularly
results in severe deformity of the wound and surrounding antinuclear antibodies directed against DNA or nonhistone
tissues. Contractures are particularly conspicuous in the proteins, typically occurs in patients with SS. Autoantibodies
healing of serious burns and can be severe enough to to soluble nuclear nonhistone proteins, especially the
compromise the movement of joints. antigens SS-A and SS-B, are found in half of patients with
Diagnosis: Contracture primary SS and are associated with more severe glandular
and extraglandular manifestations. Autoantibodies to DNA or
___28. A 9yo boy receives a deep laceration over his right histones are rare. Organ-specific autoantibodies, such as
eyebrow playing ice hockey. The wound is cleaned and those directed against salivary gland antigens, are distinctly
sutured. Which of the following describes the principal uncommon. Autoantibodies to centromere proteins (choice
function of macrophages that are present in the wound 24 to A) are seen in the CREST variant of progressive systemic
48 hours after injury? sclerosis.
(A) Antibody production (D) Phagocytosis Diagnosis: Sjögren syndrome
(B) Deposition of collagen (E) Wound contraction
(C) Histamine release ___31. An 8-month-old boy with a history of recurrent
pneumonia is
Ans: The answer is D: Phagocytosis. Macrophages arrive at found to have almost no circulating IgG. Cellular immunity is
the site of injury shortly after neutrophils, but they persist in normal. His brother had this same disease and died of
the wound for days longer. Macrophages remove debris and echovirus encephalitis. His parents and sisters have normal
orchestrate the formation of granulation tissue by releasing serum levels of IgG. What is the appropriate diagnosis?
cytokines and chemoattractants. None of the other choices (A) DiGeorge syndrome
are functions of tissue macrophages. For example, plasma (B) Isolated IgA defi ciency
cells produce antibodies (choice A), and myofi broblasts (C) Severe combined immunodefi ciency
mediate wound contraction (choice E). (D) Wiskott-Aldrich syndrome
Diagnosis: Laceration (E) X-linked agammaglobulinemia of Bruton

___29. A 35yo man asks for advice regarding seasonal eye Ans: The answer is E: X-linked agammaglobulinemia of
itching and runny nose. Recurrent conjunctivitis in this Bruton. The congenital disorder Bruton X-linked
patient is most likely caused by which of the following agammaglobulinemia appears in male infants at 5 to 8
mechanisms of disease? months of age, the period during which maternal antibody
(A) Autoimmunity (D) Hypersensitivity levels begin to decline. The infant suffers from recurrent
(B) Bacterial infection (E) Viral infection pyogenic infections and severe hypogammaglobulinemia.
(C) Chemical toxicity There is an absence of both mature B cells in peripheral
blood and plasma cells in lymphoid tissues. The genetic
Ans: The answer is D: Hypersensitivity. Although the incorrect defect, located on the long arm of the X chromosome, is an
inactivating mutation of the gene for B-cell tyrosine kinase, response does not explain the pathogenesis of delayed
an enzyme critical to B-lymphocyte maturation. Wiskott- hypersensitivity in this patient.
Aldrich syndrome (choice D) is also an X-linked genetic Diagnosis: Allergic contact dermatitis
disease but is characterized by defects in both B-cell and T-
cell functions (i.e., humeral and cellular immunity). DiGeorge ___34. A 28yo woman with a history of drug abuse presents
syndrome (choice A) is a developmental disorder with an infectious mononucleosis-like syndrome and
characterized by thymic and parathyroid aplasia. lymphadenopathy. Blood tests subsequently indicate that she
Diagnosis: X-linked agammaglobulinemia of Bruton is HIV-positive. Which of the following lymphocyte-associated
proteins mediates the entry of HIV into host cells in this
___32. A 20yo woman with a history of asthma and allergies patient?
undergoes skin testing to identify potential allergens in her (A) CD4 (D) GP120
environment. A positive skin reaction to ragweed in this (B) CD8 (E) LFA-1
patient would be mediated by which of the following classes (C) GP41
of immunoglobulin?
(A) IgA (D) IgG Ans: The answer is A: CD4. The HIV-1 genome consists of two
(B) IgD (E) IgM identical 9.7-kb single strands of RNA enclosed within a core
(C) IgE of viral proteins. The core is enveloped by a phospholipid
bilayer derived from the host cell membrane, in which are
Ans: The answer is C: IgE. Immediate-type hypersensitivity is found virally encoded glycoproteins (gp120 and gp41). In
manifested by a localized or generalized reaction that occurs addition to the gag, pol, and env genes—characteristic of
within minutes after exposure to an antigen or “allergen” to all replication-competent RNA viruses—HIV-1 contains six
which the person has previously been sensitized. In its other genes that code for proteins involved in replication.
generalized and most severe form, immediate The specifi c target cells for HIV-1 are CD4+ helper T
hypersensitivity reactions are associated with lymphocytes and mononuclear phagocytes, although
bronchoconstriction, airway obstruction, and circulatory infection of other cells occurs. The HIV envelope glycoprotein
collapse, as seen in anaphylactic shock. Type I gp120 (either on the free virus or on the surface of an
hypersensitivity reactions feature the formation of IgE infected cell) binds CD4 on the surface of helper T
antibodies that bind avidly to Fc-epsilon (Fc-ε) receptors lymphocytes. The binding of gp120 to CD4 allows gp41 to
on mast cells and basophils. The high-avidity binding of IgE insert into the cell membrane of the lymphocyte, thereby
accounts for the term cytophilic antibody. Once exposed to promoting fusion of the viral envelope with the lymphocyte.
a specifi c allergen that has resulted in the formation of IgE, Entry of HIV-1 into a target cell in vivo also requires viral
a person is sensitized. Subsequent responses to the allergen binding to a coreceptor, β-chemokine receptor 5 (CCR-5).
induce an immediate release of a cascade of Choices C and D (gp41 and gp120) are involved in viral
proinflammatory mediators. These mediators are responsible replication, but they are present on the viral envelope.
for smooth muscle contraction, edema formation, and the Choice E (LFA-1) is a member of the leukocyte integrin family
recruitment of eosinophils. None of the other that is involved in cell-cell adhesion.
immunoglobulin classes mediates immediate Diagnosis: Acquired immunodeficiency
hypersensitivity.
Diagnosis: Asthma ___35. A 12yo boy presents with a 5-day history of sore
throat. His temperature is 38.7°C (103°F). Physical
___33. A 20yo gardener presents to his family physician for examination reveals inflamed tonsils and swollen cervical
treatment of what he describes as “poison ivy.” The patient’s lymph nodes. Trafficking and recirculation of blood-borne
hands and arms appear red and are covered with oozing lymphocytes through the cervical lymph nodes in this patient
blisters and crusts. Which of the following best describes the occurs primarily at which of the following locations?
pathogenesis of these skin lesions? (A) Afferent lymphatic vessel (D) High endothelial
(A) Cytotoxic antibody production venules
(B) Delayed-type hypersensitivity (B) Efferent lymphatic vessel (E) Peyer patches
(C) Deposition of antigluten antibodies (C) Hassall corpuscles
(D) Deposition of circulating immune complexes
(E) IgE-mediated mast cell degranulation Ans: The answer is D: High endothelial venules (HEVs). B and
T lymphocytes circulate via the vascular system to secondary
Ans: The answer is B: Delayed-type hypersensitivity. “Poison lymphoid organs and tissues. Included among these tissues
ivy” is a type IV hypersensitivity reaction to plants of the Rhus are lymph nodes, mucosa-associated lymphoid tissues, and
genus. This T-lymphocyte–mediated allergic contact spleen. In the case of lymph nodes, lymphocyte traffi cking
dermatitis presents as urticaria and bullous eruption. Blisters occurs through specialized postcapillary venules termed
rupture and heal with crusts, usually without scarring. high endothelial venules (HEVs). HEVs express an array of
Deposition of antigluten antibodies (choice C) occurs in specific cell adhesion molecules (e.g., CD31) that allow
patients with dermatitis herpetiformis. IgE-mediated mast lymphocyte binding and diapedesis. The cuboidal shape of
cell degranulation (choice E) is part of the response to poison HEV cells reduces fl ow-mediated shear forces and
ivy (hypersensitivity reactions overlap), but this immediate specialized intercellular connections facilitate egress of
lymphocytes out of the vascular space. Afferent and efferent (B) Choristoma (E) Teratoma
lymphatic channels (choices A and B) do not possess HEVs. (C) Hamartoma
Hassall corpuscles (choice C) are found in the medulla of the
thymus. Peyer patches (choice E) are organized lymphoid Ans: The answer is A: Adenoma. Benign tumors arising from a
tissues found in the small intestine. glandular epithelium are termed adenomas. Patients with a
Diagnosis: Lymphadenopathy, streptococcal pharyngitis prolactin-secreting pituitary adenoma present with
amenorrhea and galactorrhea. Ectopic islands of normal
___36. A 62yo woman presents with a breast lump that she tissue are called choristomas (choice B). Localized, disordered
discovered 6 days ago. A breast biopsy shows lobular differentiation during development results in a hamartoma
carcinoma in situ. Compared to normal epithelial cells of the (choice C). Papillomas (choice D) do not occur in the pituitary.
breast lobule, these malignant cells would most likely show Benign tumors that arise from germ cells and contain all
decreased expression of which of the following proteins? three germ layers are termed teratomas (choice E).
(A) Desmin (D) P selectin Diagnosis: Pituitary adenoma, prolactinoma
(B) E-cadherin (E) Telomerase
(C) Lysyl hydroxylase ___39. A 65yo man dies after a protracted battle with
metastatic colon carcinoma. At autopsy, the liver is filled with
Ans: The answer is B: E-cadherin. Cadherins are Ca2+- multiple nodules of cancer, many of which display central
dependent transmembrane glycoproteins that mediated cell– necrosis (umbilication). Which of the following best explains
cell adhesion. E-cadherin is expressed on the surface of all the pathogenesis of tumor umbilication in this patient?
epithelia and mediates cell adhesion by “zipper-like” (A) Biphasic tumor (D) Ischemia and
interactions. Overall, cadherins suppress invasion and infarction
metastasis. Thus, it is perhaps not surprising that the (B) Chronic infl ammation (E) Stimulation of
expression of E-cadherin is reduced in most carcinomas. angiogenesis
Desmin (choice A) is an intermediate (C) Granulomatous infl ammation
fi lament protein found in cells of mesenchymal origin.
Lysyl hydroxylase (choice C) is involved in the Ans: The answer is D: Ischemia and infarction. Angiogenesis is
posttranslational modification of collagen. P selectin is a cell a requirement for the continued growth of cancers, whether
adhesion molecule that mediates the margination of primary or metastatic. In the absence of new vessels to
neutrophils during acute infl ammation. Telomerase (choice supply the nutrients and remove waste products, malignant
E) is increased in certain malignancies. tumors do not grow larger than 1 to 2 mm in diameter. In
Diagnosis: Breast cancer general, causes of tumor cell death in situ include (1)
programmed cell death (apoptosis); (2) inadequate blood
___37. A 60yo man who worked for 30 years in a chemical supply, with consequent ischemia; (3) a paucity of nutrients;
factory complains of blood in his urine. Urine cytology and (4) vulnerability to specifi c and nonspecifi c host
discloses dysplastic cells. A bladder biopsy demonstrates defenses. The CT scan provided for Question 21 shows
transitional cell carcinoma. Which of the following central necrosis (umbilication) in most of the metastatic
carcinogens was most likely involved in the pathogenesis of tumor nodules. None of the other choices are
bladder cancer in this patient? likely causes of tumor necrosis.
(A) Aniline dyes (D) Cisplatinum Diagnosis: Metastatic cancer
(B) Arsenic (E) Vinyl chloride
(C) Benzene ___40. A 59yo woman complains of “feeling light-headed”
and losing 5 kg (11 lb) in the last month. A CBC reveals a
Ans: The answer is A: Aniline dyes. Transitional cell carcinoma normocytic, normochromic anemia. The patient subsequently
is the most common malignant tumor of the urinary bladder, dies of metastatic cancer. Based on current epidemiologic
and the incidence of bladder cancer is increased in aniline data for cancer-associated mortality in women, which of the
dye workers. These azo dyes are converted to water-soluble following is the most likely primary site for this patient’s
carcinogens in the liver. They are excreted in the urine, malignant neoplasm?
where they primarily affect the transitional epithelium of the (A) Brain (D) Lung
bladder. Benzene exposure (choice C) is associated with (B) Breast (E) Urinary bladder
leukemia. Vinyl chloride exposure (choice E) has been (C) Colon
associated with hepatic angiosarcomas.
Diagnosis: Transitional cell carcinoma of bladder Ans: The answer is D: Lung. Lung carcinoma is the cause of
most cancer-related deaths in the United States and Western
___38. A 35yo woman complains of nipple discharge and Europe in men and women. The second most common cause
irregular menses of 5 months duration. Physical examination of death from cancer in women is breast cancer (choice B).
reveals a milky discharge from both nipples. MRI shows an One of the most common fi ndings in patients with cancer is
enlargement of the anterior pituitary. Which of the following anemia, but the mechanism for this paraneoplastic syndrome
is the most likely histologic diagnosis of this patient’s is not clear. The anemia is usually normocytic and
pituitary tumor? normochromic, although iron defi ciency anemia is common
(A) Adenoma (D) Papilloma in cancers that bleed into the gastrointestinal tract.
Diagnosis: Lung cancer of blood. Hematochezia (choice D) is passage of blood caused
by lower gastrointestinal hemorrhage. Hemoptysis (choice E)
___41. A 63yo woman with chronic bronchitis presents with is coughing up blood.
shortness of breath. A chest X-ray reveals a 2-cm “coin Diagnosis: Hemophilia, hemarthrosis
lesion” in the upper lobe of the left lung. A CT-guided lung
biopsy is obtained. Which of the following describes the ___44. A 50yo fire fighter emerges from a burning house with
histologic features of this lesion if the diagnosis is 3rd-degree burns over 70% of his body. The patient expires
hamartoma? 24 hours later. Which of the following was the most likely
(A) Benign neoplasm of epithelial origin cause of death?
(B) Disorganized normal tissue (A) Congestive heart failure
(C) Ectopic islands of normal tissue (B) Disseminated intravascular coagulation
(D) Granulation tissue (C) Hypovolemic shock
(E) Granulomatous inflammation (D) Pulmonary saddle embolism
(E) Toxic shock syndrome
Ans: The answer is B: Disorganized normal tissue. Localized,
disordered differentiation during embryonic development Ans: The answer is C: Hypovolemic shock. Hypovolemic shock
results in a hamartoma, a disorganized caricature of normal may be caused by hemorrhage, fl uid loss from severe burns,
tissue components. Such tumors, which are not strictly diarrhea, excessive urine formation, perspiration, or trauma.
neoplasms, contain varying combinations of cartilage, ducts In the case of burns or trauma, direct damage to the
or bronchi, connective tissue, blood vessels, and lymphoid microcirculation increases vascular permeability. Persons
tissue. Ectopic islands of normal tissue (choice C), called with third-degree burns weep large amounts of plasma. The
choristoma, may also be mistaken for true neoplasms. These other choices are unlikely causes of death in an acute burn
small lesions are represented by pancreatic tissue in the wall victim.
of the stomach or intestine, adrenal rests under the renal Diagnosis: Hyperthermia, hypovolemic shock
capsule, and nodules of splenic tissue in the peritoneal cavity.
Diagnosis: Hamartoma ___45. A 20yo man is brought to the ER after rupturing his
spleen in a motorcycle accident. His blood pressure on
___42. A 50yo alcoholic is rushed to the hospital with admission is 80/60 mm Hg. Analysis of arterial blood gasses
bleeding esophageal varices and expires. At autopsy, the demonstrates metabolic acidosis. This patient is most likely
patient’s protruding abdomen is found to contain a large suffering from which of the following conditions?
volume of serous fluid. What is the appropriate term used to (A) Acute pancreatitis (D) Hypovolemic shock
describe this fluid? (B) Cardiogenic shock (E) Septic shock
(A) Ascites (D) Hydrothorax (C) Hypersplenism
(B) Exudate (E) Lymphedema
(C) Hemorrhage Ans: The answer is D: Hypovolemic shock. Hypovolemic shock
is secondary to a pronounced decrease in blood or plasma
Ans: The answer is A: Ascites. A protruding belly and fluid volume, caused by the loss of fl uid from the vascular
accumulation in patients with cirrhosis represents ascites compartment. Hemorrhage, fl uid loss from severe burns,
(i.e., accumulation of serous fl uid in the abdominal cavity). It diarrhea, excessive urine formation, perspiration, and trauma
is are major mechanisms of fl uid loss that can lead to
primarily a consequence of portal hypertension and hypovolemic shock. Cardiogenic shock (choice B) is caused by
hypoalbuminemia. None of the other choices describe serous myocardial pump failure. Septic shock (choice E) is
fluid accumulation in the abdomen. improbable in this setting.
Diagnosis: Cirrhosis, portal Diagnosis: Hypovolemic shock

___43. A 23yo man with hemophilia is recently wheelchair ___46. An autopsy of a 70yo woman reveals a
bound. Which of the following best accounts for this subendocardial, circumferential infarct of the left ventricle.
development? This type of infarct is most commonly associated with which
(A) Hemarthrosis of the following?
(B) Hematemesis (A) Deep venous thrombosis
(C) Hematocephalus (B) Hypotensive shock
(D) Hematochezia (C) Pericardial tamponade
(E) Hemoptysis (D) Thrombotic occlusion of the right coronary artery
(E) Thrombotic occlusion of the circumflex artery
Ans: The answer is A: Hemarthrosis. Hemarthrosis refers to
bleeding into the joint cavity. It is associated with joint Ans: The answer is B: Hypotensive shock. Myocardial infarcts
swelling and is a crippling complication of hemophilia. are described as transmural (through the entire wall) or
Repeated bleeding may cause deformities and may limit the subendocardial. A transmural infarct results from complete
mobility of the joints. Hematemesis (choice B) is vomiting occlusion of a major extramural coronary artery.
blood. Hematocephalus (choice C) is an intracranial infusion Subendocardial infarction reflects prolonged ischemia caused
by partially occluding lesions of the coronary arteries when uncommon. Malignant hyperthermia (choice C) occurs in
the requirement for oxygen exceeds the supply. Such a surgical patients after anesthesia.
situation prevails in disorders such as shock, anoxia, or severe Diagnosis: Heat stroke
tachycardia. Thrombotic occlusion (choices D and E) is more
likely to cause transmural myocardial infarcts. ___50. A sailor on a nuclear-powered submarine is seen by a
Diagnosis: Myocardial infarction physician after a breach in the reactor containment system.
PE is unremarkable, but the patient subsequently develops
___47. A neonate was noted to have mild growth retardation profound pancytopenia. Hemoglobin is 7.8 g/dL, WBC count
and facial dysmorphology. The mother was a known abuser is 900/μL, and platelets are 20,000/μL. How many rads of
of several substances. This infant’s problem most likely acute total-body radiation did this patient most likely
resulted from maternal intake of which of the following? receive?
(A) Alcohol (D) Heroin (A) 1 (D) 300
(B) Cocaine (E) Marijuana (B) 3 (E) 3,000
(C) Ethylene glycol (C) 30

Ans: The answer is A: Alcohol. Fetal alcohol syndrome is the Ans: The answer is D: 300. Acute total-body irradiation of
most common acquired cause of mental retardation in the about 300 rads causes depression of the bone marrow, and
United States. The common features of the syndrome include symptoms related to granulocytopenia and
intrauterine growth retardation, facial dysmorphology, thrombocytopenia develop within 2 weeks. Anemia follows
neurologic impairment, and other congenital anomalies. In more slowly because red blood cells have a longer lifespan
cases with lesser manifestations, termed fetal alcohol effect, than leukocytes and platelets. Exposure to 3,000 rads (choice
children later suffer from mental retardation and minor E) is rapidly fatal owing to central nervous system damage.
dysmorphic features. Cocaine (choice B) may cause neonatal Diagnosis: Radiation sickness
diffi culties and heroin (choice D) intake may result in
neonates that are addicted to that opiate, but they are not ___51. A 40yo, malnourished woman presents with a 6-
associated with characteristic facial dysmorphology. month history of night blindness. Physical examination
Diagnosis: Fetal alcohol syndrome reveals keratomalacia and corneal ulceration. Which of the
following vitamin defi ciencies would be suspected in this
___48. A 10yo boy presents with irritability and ataxia. He is patient?
subsequently found to have anemia, basophilic stippling of (A) Vitamin A (D) Vitamin E
erythrocytes, and dark-gray pigmentation of the gums. (B) Vitamin B2 (riboflavin) (E) Folic acid
Exposure to which of the following chemical agents is most (C) Vitamin C
likely associated with this disease?
(A) Arsenic (D) Mercury Ans: The answer is A: Vitamin A. Vitamin A defi ciency causes
(B) Copper (E) Nickel squamous metaplasia at a number of sites. In the cornea, it
(C) Lead leads to xerophthalmia (dry eye), which may progress to
softening of the tissue (keratomalacia) and corneal
Ans: The answer is C: Lead. Chronic lead poisoning inhibits ulceration. Defi ciencies of the other vitamins are not related
deltaaminolevulinic acid dehydratase and ferrochelatase to these clinical and pathologic fi ndings.
(enzymes essential for heme synthesis), thereby causing Diagnosis: Vitamin A defi ciency, keratomalacia
microcytic hypochromic anemia. The inhibition of heme
synthesis leads to basophilic stippling of erythrocytes, which ___52. A 28yo radar technician aboard an aircraft carrier has
is due to residual ribosome clusters in the cytoplasm. Chronic been subjected to intense microwave radiation for 7 years.
exposure of children to lead also leads to cognitive loss. He has an elevated risk for developing which of the
Mercury (choice D) poisoning has neurologic sequelae, but following?
not these hematologic characteristics. (A) Aplastic anemia (D) Myelogenous leukemia
Diagnosis: Lead poisoning (B) Hodgkin disease (E) None of the above
(C) Lymphocytic leukemia
___49. A healthy adult runs a marathon in the summer and
develops hot dry skin, cessation of sweating, lactic acidosis, Ans: The answer is E: None of the above. The absorption of
hypocalcemia, and muscle necrosis (rhabdomyolysis). Which microwave energy produces only heat and is not associated
of the following is the appropriate diagnosis? with any known health risks.
(A) Dysautonomia (D) Myotonic dystrophy Diagnosis: Radiation injury
(B) Heat stroke (E) Polymyositis
(C) Malignant hyperthermia
Ans: The answer is B: Heat stroke. Exertional heat stroke ___53. Petechial hemorrhages were noticed on the upper
occurs in healthy men during unusually vigorous exercise, and lower extremities of a 5-day-old infant. Hemorrhagic
particularly when the ambient temperature is high. Lactic disease of the neonate was most likely caused by a defi
acidosis, hypocalcemia, and rhabdomyolysis may be severe ciency of which of the following vitamins?
problems. Myoglobinuric acute renal failure is not (A) Vitamin B2 (riboflavin) (D) Vitamin K
(B) Vitamin D (E) Pyridoxine Clostridium botulinum (choice A) produces a neurotoxin that
(C) Folic acid causes paralysis.
Diagnosis: Pseudomembranous colitis, Clostridium diffi cile
Ans: The answer is D: Vitamin K. Hemorrhagic disease of the
newborn may be caused by a defi ciency of vitamin K. ___56. A 24yo woman develops an expanding erythematous
Vitamin K is an important coagulation factor, which is skin lesion after hiking through the woods in Connecticut. The
necessary for the carboxylation and activation of rash disappears, but 1 year later, the patient develops
prothrombin, as well as of clotting factors VII, IX, and X. arthralgias and right facial nerve palsy. Which of the
Newborn infants frequently exhibit vitamin K defi ciency following is the most likely etiologic agent responsible for this
because the vitamin is not transported well across the patient’s symptoms?
placenta, and the sterile gut of the newborn does not have (A) Chlamydia (D) Rickettsia
bacteria to produce it. The other vitamin deficiencies do not (B) Mycobacterium (E) Spirochete
impair coagulation. (C) Protozoa
Diagnosis: Vitamin K deficiency, hemolytic disease of the
newborn Ans: The answer is E: Spirochete. Lyme disease is a chronic
infection that begins with a characteristic skin lesion and later
___54. A 24yo beating victim is brought to the ER with a 4-cm variably manifests cardiac, neurologic, and joint disturbances.
linear tear of the skin caused by blunt trauma. Which of the The causative agent is Borrelia burgdorferi, a large spirochete
following terms best describes this patient’s skin lesion? that is transmitted from its animal reservoir to humans by the
(A) Abrasion (D) Contusion bite of the deer tick (Ixodes). B. burgdorferi reproduces at the
(B) Avulsion (E) Laceration site of inoculation, spreads to regional lymph nodes, and is
(C) Blast injury eventually disseminated throughout the body. Untreated
Lyme disease is chronic, with periods of remission and
Ans: The answer is E: Laceration. A laceration is a linear tear exacerbation. Stage 1 is characterized by erythema
of the skin produced by a force that causes unidirectional chronicum migrans, a skin lesion that appears at the site of
displacement. A surgical incision is a controlled laceration. the tick bite. Stage 2 features migratory musculoskeletal pain
Internal organs may also be lacerated by trauma or by the and the development of cardiac or neurologic abnormalities
surgeon. An abrasion (choice A) is a skin defect caused by (meningitis and facial nerve palsy). Stage 3 begins months to
crushes or scrapes. Avulsion (choice B) is a tearing away or years after infection and involves joint, skin, and neurologic
forcible separation. A contusion (choice D) is a localized abnormalities. Over half of these patients develop a severe
mechanical injury with focal hemorrhage. arthritis of the hips and knees, which is indistinguishable
Diagnosis: Laceration from the symptoms of rheumatoid
arthritis.
___55. A 65yo man undergoes cardiac bypass surgery and is Diagnosis: Lyme disease
placed on postoperative, broad-spectrum, antibiotic
prophylaxis. Several days later, he develops fever, abdominal ___57. A 28yo man presents with sudden onset of fever,
pain, and bloody diarrhea. Colonoscopic biopsy demonstrates chills, and a productive cough with blood-tinged sputum. His
a thick mucopurulent exudate. Which of the following is the past medical history is signifi cant for a splenectomy
most likely etiology of this patient’s gastrointestinal disorder? following a motor vehicle accident 3 years ago. An X-ray of
(A) Clostridium botulinum the chest demonstrates consolidation of the right middle
(B) Clostridium difficile lobe. Sputum culture shows Gram-positive diplococci. Which
(C) Clostridium perfringens of the following
(D) Clostridium tetani is the most likely cause of this patient’s respiratory infection?
(E) Escherichia coli 0157-H7 (A) Klebsiella pneumoniae
(B) Legionella pneumophila
Ans: The answer is B: Clostridium diffi cile. C. diffi cile is the (C) Mycoplasma pneumoniae
most common cause of diarrhea in patients on antibiotic (D) Staphylococcus aureus
therapy (e.g., clindamycin or cephalosporins) who are (E) Streptococcus pneumoniae
hospitalized for more than 3 days. Necrotizing enterocolitis
(pseudomembranous colitis) is a disease that may affect the Ans: The answer is E: Streptococcus pneumoniae. S.
colon in segments or in its entirety. The mucosa is covered by pneumoniae (pneumococcus) causes pyogenic infections
yellow-green, necrotic exudates (pseudomembranes). Food involving the lungs (pneumonia), middle ear (otitis media),
poisoning and necrotizing entercolitis are caused by the sinuses (sinusitis), and meninges (meningitis). It is one of the
enterotoxins of C. perfringens (choice C). About 48 hours most common causes of community-acquired pneumonia.
after the ingestion of contaminated meal, patients present Consolidation of lung parenchyma typically produces lobar
with abdominal pain and distention, vomiting, and passage pneumonia, which passes through four stages: (1) congestion
of bloody stools. C. perfringens is also the most common and edema, (2) red hepatization, (3) gray hepatization, and
cause of gas gangrene following wound infection or septic (4) resolution. During the acute phase, the alveoli are packed
abortion. C. tetani (choice D) produces a potent neurotoxin with neutrophils, fibrin, and debris. Pneumonia is caused by
that causes tetany and generalized muscle spasms. the other organisms with much lower frequency.
Diagnosis: Pneumococcal pneumonia
___60. A 2-month-old infant presents with fever to 38.6°C
___58. A 75yo woman died in February of respiratory failure (103°F)
after a febrile disease of 1 week in duration. An autopsy and neck rigidity. Cerebrospinal fluid shows numerous
shows necrotizing bronchitis and diffuse, hemorrhagic neutrophils, decreased glucose, and increased protein.
necrotizing pneumonia. Which of the following pathogens Grampositive cocci are present. Which of the following is the
was most likely responsible for this patient’s fatal pulmonary most likely cause of meningitis in this neonate?
infection? (A) Group B streptococcus
(A) Influenza virus (B) Haemophilus infl uenzae
(B) Norwalk-like viruses (C) Neisseria gonorrhoeae
(C) Respiratory syncytial virus (D) Neisseria meningitidis
(D) Rhinovirus (E) Staphylococcus aureus
(E) Rotavirus
Ans: The answer is A: Group B streptococcus. Several
Ans: The answer is A: Infl uenza virus. Infl uenza A and B are thousand neonatal infections with group B streptococci occur
RNA viruses. Infl uenza infections are common in the in the United States every year. About 30% of infected infants
wintertime, with the severity of the illness depending on the die. The other choices are much less common causes of
immune status of the individual. Patients typically present meningitis in this age group. Meningococci are Gram-
with fever, tachypnea, conjunctivitis, and pharyngeal infl negative organisms.
ammation. In severe cases, they may develop extreme Diagnosis: Neonatal bacterial meningitis
respiratory distress and prostration. Infl uenza affects all
segments of the population, but severe cases are more ___61. A 42yo man presents with a 1-week history of
commonly seen among the very young and the elderly. myalgia, low-grade fever, and swelling of the left calf. The
Rhinovirus (choice D) is the most frequent cause of the patient reports recently attending a fi reman’s pig-roast.
“common cold.” Norwalk-like virus (choice B) and rotavirus Laboratory data show elevated serum levels of creatine
(choice E) cause diarrhea in children. Infection with kinase. Examination of a muscle biopsy in this patient would
respiratory syncytial virus (choice C) is commonly most likely reveal an infi ltrate of which of the following cell
seen in children under 2 years of age. types?
Diagnosis: Influenza virus, pneumonitis (A) Eosinophils (D) Segmented neutrophils
(B) Mast cells (E) Smooth muscle cells
___59. A 37-year-old man is admitted to the hospital with a (C) Plasma cells
productive cough, fever, and night sweats. An X-ray fi lm of
the chest shows an ill-defined area of consolidation at the Ans: The answer is A: Eosinophils. Trichinosis is produced by
periphery of the right middle lobe and mediastinal the roundworm Trichinella spiralis. After mating, the females
lymphadenopathy. Sputum culture grows acid-fast bacilli. liberate larvae into the circulation. The larvae can invade
Lymph node biopsy in this patient would most likely show almost any tissue but survive only in skeletal muscle in an
which of the following encapsulated form. Elevated serum levels of creatine kinase
pathologic findings? indicate muscle cell necrosis. Early muscle involvement elicits
(A) Caseating granulomas an intense infl ammatory infi ltrate rich in eosinophils. The
(B) (B) Follicular hyperplasia other cells do not typically respond to acute parasitic
(C) Nodular amyloidosis infestations.
(D) Noncaseating granulomas Diagnosis: Trichinosis
(E) Purulent abscess
___62. A 22yo student living in a college dormitory presents
Ans: The answer is A: Caseating granulomas. Tuberculosis is a with a 4-week history of a nonproductive cough and previous
chronic, communicable disease in which the lungs are the low-grade fever. An X-ray fi lm of the chest shows patchy
prime target. The disease is caused principally by consolidation of the right lower lobe, with evidence of
Mycobacterium tuberculosis hominis (Koch bacillus), but interstitial involvement. Which of the following is the most
infection with other species occurs, notably M. tuberculosis likely etiology of this patient’s pulmonary infection?
bovis (bovine tuberculosis). Primary tuberculosis consists of (A) Klebsiella pneumoniae
lesions in the lower lobes and subpleural space, referred to (B) Mycobacterium tuberculosis
as the Ghon focus. The infection then drains to hilar lymph (C) Mycoplasma pneumoniae
nodes. The combination of Ghon focus and hilar (D) Staphylococcus aureus
lymphadenopathy is known as “Ghon complex.” The typical (E) Streptococcus pneumoniae
lesion of tuberculosis is a caseous granuloma, with a soft core
surrounded by epithelioid macrophages, Langhans giant cells, Ans: The answer is C: Mycoplasma pneumoniae. M.
lymphocytes, and peripheral fi brosis. Noncaseating pneumoniae produces an acute self-limited lower respiratory
granulomas (choice D) are a feature of sarcoidosis, among tract infection, primarily in children and young adults. Most
other causes. infections occur in groups of persons living in close contact.
Diagnosis: Primary tuberculosis M. pneumoniae tends to be milder than other bacterial
pneumonias and has, therefore, earned the appellation (D) Mönckeberg medial sclerosis
“walking pneumonia.” Fever usually persists for no more than (E) Polyarteritis nodosa
2 weeks, although a cough may linger for 6 weeks or more.
Chest X-ray commonly shows patchy consolidation of a single Ans: The answer is D: Mönckeberg medial sclerosis.
segment of a lower lung lobe. M. pneumoniae is responsible Mönckeberg medial sclerosis is characterized by calcifi cation
for about 20% of all pneumonias in developed countries. The of the media of large- and medium-sized arteries of older
other choices do not cause interstitial pneumonia. persons who are not otherwise affected by atherosclerosis
Diagnosis: Mycoplasma pneumoniae (choice B). On gross examination, the involved arteries are
hard and dilated. These arterial changes are usually
___63. A 30yo woman presents with a widespread skin rash asymptomatic. None of the other choices display calcifi
that she has had for 5 days. She is taking sulfa medication for cation.
recurrent cystitis. A skin biopsy shows leukocytoclastic Diagnosis: Mönckeberg medial sclerosis
vasculitis involving dermal venules. What is the appropriate
diagnosis? ___66. A 70yo, previously healthy man presents with right
(A) Buerger disease upper quadrant pain. Physical examination demonstrates
(B) Giant cell granulomatous arteritis hepatomegaly. A liver biopsy reveals a vascular lesion
(C) Henoch-Schönlein purpura composed of pleomorphic endothelial cells with
(D) Hypersensitivity angiitis hyperchromatic nuclei and numerous mitoses. Laboratory
(E) Polyarteritis nodosa tests for HIV infection are negative. Which of the following is
the most likely diagnosis?
Ans: The answer is D: Hypersensitivity angiitis. (A) Angiosarcoma (D) Hemangioma
Hypersensitivity angiitis refers to a broad spectrum of infl (B) Dermatofi broma (E) Kaposi sarcoma
ammatory lesions that represent a reaction to foreign (C) Glomus tumor
materials (e.g., bacterial products or more commonly drugs).
When the vascular lesions are confined to the skin, the terms Ans: The answer is A: Angiosarcoma. Angiosarcoma is a highly
leukocytoclastic vasculitis, cutaneous vasculitis, or cutaneous malignant tumor composed of masses of malignant
necrotizing venulitis are applied. The other choices are not endothelial cells. The most common locations are the skin,
caused by sulfa drugs. breast, bone, liver, and spleen. Angiosarcoma exhibits varying
Diagnosis: Hypersensitivity angiitis degrees of differentiation, ranging from tumors composed of
distinct vascular elements to undifferentiated tumors with
___64. A 40yo man presents with a 2-week history of nuclear pleomorphism, and frequent mitosis. Kaposi sarcoma
recurrent oral ulcers, genital ulcers, intermittent arthritic pain (choice E) is most commonly associated with AIDS patients
of the knees, and abdominal pain. Physical examination who are infected by HHV-8.
reveals shallow ulcerations of the mucosa of the glans penis, Diagnosis: Angiosarcoma
as well as oral aphthous ulcers and conjunctivitis. Which of
the following is the most likely diagnosis? 32___67. A 62yo man is discovered to have hyperlipidemia
(A) Behçet disease (D) Polyarteritis nodosa on screening tests after a routine physical examination.
(B) Genital herpes (E) Syphilis Laboratory studies show total serum cholesterol of 285
(C) Gonorrhea mg/dL, LDL of 215 mg/dL, HDL of 38 mg/dL, and triglycerides
of 300 mg/ dL. This patient is most at risk of developing an
Ans: The answer is A: Behçet disease. Behçet disease is a aneurysm in which of the following anatomic locations?
systemic vasculitis characterized by oral aphthous ulcers, (A) Abdominal aorta (D) Coronary artery
genital ulceration, and ocular infl ammation, with occasional (B) Ascending aorta (E) Renal artery
involvement of the nervous, gastrointestinal, and (C) Circle of Willis
cardiovascular systems. The mucocutaneous lesions show a
nonspecific vasculitis of arterioles, capillaries, and venules. Ans: The answer is A: Abdominal aorta. Abdominal aortic
The cause of the necrotizing inflammation of small blood aneurysms, which are defined as an increase in aortic
vessels is not known, but an association with specifi c HLA diameter of 50% or more, are the most frequent aneurysms,
subtypes suggests an immune basis. Herpes (choice B) does usually developing after the age of 50 years. The most
not present with arthritis. common cause of these abdominal aortic aneurysms is
Diagnosis: Behçet disease atherosclerosis. Aneurysms secondary to atherosclerosis are
less common in the other anatomic locations listed.
___65. A 60yo man has his left forearm amputated because Diagnosis: Atherosclerosis
he has invasive rhabdomyosarcoma. The pathologist notes
calcification in the wall of the radial artery, which otherwise ___68. A 76yo woman presents with a 1-hour history of
appears unremarkable. Which of the following is the substernal chest pain. Shortly after admission the patient
appropriate diagnosis? expires. At autopsy, extensive calcium deposits are noted in
(A) Churg-Strauss disease the coronary and other arteries affected by severe
(B) Complicated atherosclerotic plaque atherosclerosis. Which of the following terms best describes
(C) Fibromuscular dysplasia these autopsy fi ndings?
(A) Dystrophic calcification (C) Small cell carcinoma
(B) Hyperplastic calcification (D) Squamous cell carcinoma
(C) Hypertrophic calcification (E) Transitional cell carcinoma
(D) Metastatic calcification
(E) Physiologic calcification Ans: The answer is D: Squamous cell carcinoma. The vast
majority of laryngeal cancers are squamous cell carcinomas
Ans: The answer is A: Dystrophic calcification. Dystrophic and occur principally in smokers. Adenocarcinoma (choice A),
calcification is a response to cell injury. Serum levels of leiomyosarcoma (choice B), and small cell carcinoma (choice
calcium are normal, and the calcium deposits are located in C) are rarely encountered in the larynx.
previously damaged tissue. This patient suffered from Diagnosis: Laryngeal cancer
coronary artery atherosclerosis. The pathogenesis of the
atherosclerotic plaque is a dynamic process that usually ___65. A 20yo woman presents with a 2-year history of
occurs over decades, leading to erosion, ulceration or fi difficulty swallowing and increasing fatigue. A CBC shows
ssuring of the surface of the plaque; plaque hemorrhage; iron-deficiency anemia. Upper endoscopy reveals an annular
mural thrombosis; and calcifi cation. Calcification is thought narrowing in the upper third of the esophagus. A mucosal
to depend on a balance of mineral deposition and resorption biopsy shows no evidence of inflammation or neoplasia.
in areas of vascular necrosis. These apposing metabolic Which of the following is the most likely diagnosis?
processes are regulated by osteoblast-like and osteoclast-like (A) Achalasia (D) Esophageal web
cells in the vessel wall. Metastatic calcifi cation (choice D) is (B) Barrett esophagus (E) Schatzki ring
associated with hypercalcemia. Physiologic calcification (C) Diverticulum
(choice E) occurs in normal bone.
Diagnosis: Atherosclerosis, dystrophic calcification Ans: The answer is D: Esophageal web. Esophageal rings and
webs cause dysphagia. Webs are thin mucosal membranes
___63. A 65yo coal miner is admitted for evaluation of that project into the lumen of the esophagus. Rings are
chronic lung disease. The patient admits to smoking one pack thicker than webs and contain smooth muscle. The clinical
of cigarettes a day for 40 years. On physical examination, he symptoms of esophageal webs and rings include dysphagia,
is noticed to have a barrel chest and use accessory muscles esophageal substernal pain, and aspiration or regurgitation of
for inspiration. His face is puffy and red. He has 2+ pitting foods and liquids. Plummer-Vinson syndrome is characterized
edema of the lower extremities. A chest X-ray is compatible by a cervical esophageal web, mucosal lesions of the mouth
with diffuse and pharynx, and iron-deficiency anemia. Carcinoma of the
fi brosis, with some nodularity in central areas. Which of the oropharynx and upper esophagus are complications of
following is the most likely diagnosis? Plummer-Vinson syndrome. The other choices are not
(A) Anthracosilicosis (D) Psittacosis associated with anemia. Schatzki ring (choice E) occurs near
(B) Asbestosis (E) Sarcoidosis the gastroesophageal junction.
(C) Diffuse alveolar damage Diagnosis: Esophageal web

Ans: The answer is A: Anthracosilicosis. Coal dust is __66. A 45yo woman presents with general discomfort and
composed of amorphous carbon and other constituents of increasing tightness in the skin of her face. She reports
the earth’s surface, including variable amounts of silica. intermittent pain in the tips of her fi ngers when exposed to
Amorphous carbon by itself is not fi brogenic owing to its the cold. Physical examination shows “stone facies” and
inability to kill alveolar macrophages. It is simply a nuisance edema of the fingers and hands. Serologic tests for
dust that causes an innocuous anthracosis. By contrast, silica antinuclear and anti–Scl-70 antibodies are both positive.
is highly fi brogenic, and the inhalation of rock particles may Which of the following
therefore lead to the lesions of anthracosilicosis. Coal gastrointestinal manifestations is expected in this patient?
workers’ pneumoconiosis is also known as “black lung (A) Adenocarcinoma of the esophagus
disease” due to massive deposits of carbon particles. The (B) Dysphagia
characteristic pulmonary lesions of complicated coal workers’ (C) Esophageal rupture
pneumoconiosis include palpable coaldust nodules scattered (D) Esophageal varices
throughout the lung as 1- to 4-mm black foci. Nodules consist (E) Squamous cell carcinoma of the esophagus
of dust-laden macrophages associated with a fibrotic stroma.
Coal miners are not predisposed to the other choices. Ans: The answer is B: Dysphagia. This patient exhibits signs of
Diagnosis: Coal workers’ pneumoconiosis scleroderma (progressive systemic sclerosis), which is
characterized by vasculopathy and excessive collage
___64. A 56yo man with a history of cigarette smoking deposition in the skin and internal organs. Patients often
presents with diffi culty swallowing and a muffl ed voice. suffer from intermittent episodes of ischemia of the fi ngers,
Laryngoscopy reveals a 2-cm laryngeal mass. If this mass is a marked by pallor, paresthesias, and pain (Raynaud
malignant neoplasm, which of the following is the most likely phenomenon). Anti–Scl-70 antibodies to nuclear
histologic diagnosis? topoisomerase are virtually specifi c for this autoimmune
(A) Adenocarcinoma disease. Scleroderma can involve any portion of the
(B) Leiomyosarcoma gastrointestinal tract, although esophageal dysfunction
is the most common and troublesome complication. from superfi cial erosions. Defects in the mucosa may extend
The disease affects principally the lower esophageal into the deeper tissues to form an ulcer. The necrosis is
sphincter, which may become so impaired that the lower accompanied by an acute infl ammatory response and
esophagus and upper stomach are no longer distinct hemorrhage, which may be severe enough to result in
functional entities. In some affected patients, there may be a exsanguination and hypovolemic shock. The other choices
lack of peristalsis in the entire esophagus. The other choices are not associated with the use of NSAIDs.
are not associated with scleroderma. Diagnosis: Acute erosive gastritis
Diagnosis: Scleroderma
___69. A 5yo is brought to the physician after her parents
__67. A 45yo man presents with long-standing heartburn and noticed red blood in her stool. Physical examination reveals
dyspepsia. An X-ray fi lm of the chest shows a retrocardiac, mucocutaneous pigmentation. Small bowel radiography
gas-filled structure. This patient most likely has which of the discloses multiple, small- to medium-sized polyps that are
following conditions? diagnosed pathologically as hamartomas. Which of the
(A) Boerhaave syndrome following is the most likely diagnosis?
(B) Esophageal varices (A) Congenital teratoma
(C) Esophageal webs (B) Hyperplastic polyp
(D) Hiatal hernia (C) Peutz-Jeghers polyp
(E) Mallory-Weiss syndrome (D) Tubular adenoma
(E) Villous adenoma
Ans: The answer is D: Hiatal hernia. Hiatal hernia is a
protrusion of the stomach through an enlarged esophageal Ans: The answer is C: Peutz-Jeghers polyp. Peutz-Jeghers
hiatus in the diaphragm. Two basic types of hiatal hernia are syndrome is an autosomal dominant, hereditary disorder
observed. In sliding hiatal hernias, an enlargement of the characterized by intestinal hamartomatous polyps and
hiatus and laxity of the circumferential connective tissue mucocutaneous melanin pigmentation, which is particularly
allows a cap of gastric mucosa to move upward above the evident on the face, buccal mucosa, hands, feet, and perianal
diaphragm. Paraesophageal hiatal hernias are characterized and genital regions. The polyps seen in Peutz-Jeghers
by herniation of a portion of the gastric fundus alongside the syndrome are hamartomatous, characterized by a branching
esophagus through a defect in the diaphragmatic connective network of smooth muscle fi bers continuous with the
tissue membrane that defines the esophageal hiatus. muscularis mucosa that support the glandular epithelium of
Symptoms of hiatal hernia, particularly heartburn and the polyp. Congenital teratoma (choice A) does not involve
regurgitation, are attributed to the reflux of gastric contents, the intestine. The other choices are principally colonic polyps
which is primarily related to incompetence of the lower that derive from the luminal epithelium.
esophageal sphincter. Classically, the symptoms are Diagnosis: Gastrointestinal polyp, Peutz-Jeghers polyp
exacerbated when the affected person is recumbent. Large
herniations carry a risk of gastric volvulus or intrathoracic __70. A 60yo woman complains of increasing abdominal girth
gastric dilation. Boerhaave syndrome (choice A) represents of 4 weeks in duration. Physical examination discloses ascites,
rupture of the esophagus as a result of vomiting. Mallory- and cytologic examination of the fl uid reveals malignant
Weiss syndrome (choice E) refers to mucosal cells. Exploratory laparotomy shows multiple tumor nodules
laceration of the upper stomach and lower esophagus in the on the serosal surface of the intestines. Which of the
setting of severe retching. following is the most likely diagnosis?
Diagnosis: Paraesophagic hiatal hernia (A) Carcinoid tumor
(B) Gastrointestinal stromal tumor
__68. A 50yo woman with long-standing rheumatoid arthritis (C) Liposarcoma
complains of weakness and fatigue. She states that her stools (D) MALToma
have recently become black after taking a new nonsteroidal (E) Metastatic carcinoma
anti-infl ammatory drug (NSAID). Gastroscopy shows
numerous superficial, bleeding mucosal defects. Which of the Ans: The answer is E: Metastatic carcinoma. Metastatic
following is the most likely diagnosis? carcinoma is by far the most common malignant disorder
(A) Acute erosive gastritis affecting the peritoneum. Ovarian, gastric, and pancreatic
(B) Early gastric cancer carcinomas are particularly likely to seed the peritoneum, but
(C) Helicobacter pylori gastritis any intra-abdominal carcinoma can spread to the
(D) Ménétrier disease peritoneum. Metastatic carcinoma to the abdomen presents
(E) Peptic ulcer disease in the form of multiple serosal nodules and ascites fluid that
Ans: The answer is A: Acute erosive gastritis. Acute contains malignant cells.
hemorrhagic gastritis is characterized by necrosis of the Diagnosis: Metastatic carcinoma
mucosa and is commonly associated with the intake of
aspirin, other NSAIDs, alcohol, or ischemic injury. The factor __71. A 4yo girl is brought to the physician because her
common to all forms of acute hemorrhagic gastritis is parents noticed that she has been having pale, fatty, foul-
thought to be the breakdown of the mucosal barrier, which smelling stools. The patient is at the 50th percentile for
permits acid-induced injury. Mucosal injury causes bleeding height and 10th percentile for weight. Her symptoms
respond dramatically to a gluten-free diet. Which of the unrelated to neonatal jaundice. Elevated serum levels of
following is the most likely diagnosis? carotene (choice B) refl ects hypervitaminosis A.
(A) Celiac sprue Diagnosis: Neonatal (physiologic) jaundice
(B) Cystic fi brosis of the pancreas
(C) Ménétrier disease __74. A 47yo man suffers from long-standing peptic ulcer
(D) Tropical sprue disease, which is largely unresponsive to pharmacologic
(E) Whipple disease therapy. Endoscopic examination reveals multiple, nonhealed
ulcerations of the duodenum and jejunum. Which of the
Ans: The answer is A: Celiac sprue. Celiac sprue, which is also following is the most likely diagnosis?
referred to as gluten-sensitive enteropathy, is characterized (A) Carcinoid syndrome
by (1) generalized malabsorption, (2) small intestinal mucosal (B) Insulinoma
lesions, and (3) prompt clinical and histopathologic response (C) Pancreatic adenocarcinoma
to the withdrawal of gluten-containing food. Critical factors in (D) Verner-Morrison syndrome
the development of celiac sprue include genetic (E) Zollinger-Ellison syndrome
predisposition and gliadin exposure. The hallmark of celiac
disease is a fl at mucosa, with blunting of villi, damaged Ans: The answer is E: Zollinger-Ellison syndrome. Zollinger-
epithelial cells, intraepithelial T cells, and increased plasma Ellison syndrome is characterized by intractable gastric
cells in the lamina propria. The other choices do not respond hypersecretion, severe peptic ulceration of the duodenum
to a gluten-free diet. and sometimes the jejunum, and elevated levels of gastrin in
Diagnosis: Celiac sprue blood. The tumor responsible for Zollinger-Ellison syndrome
is pancreatic gastrinoma composed of G cells. Gastrinomas
_72. An 85yo man complains of abdominal pain and bright are most often located in the pancreas, but they may arise in
red blood in his stool. An X-ray fi lm of the abdomen shows other parts of the gastrointestinal tract, notably the
fecal impaction in the rectosigmoid region. Which of the duodenum. Most gastrinomas are malignant. Carcinoid
following pathologic lesions is most likely to be found in this syndrome (choice A) is a systemic paraneoplastic disease
patient? caused by the release of hormones from carcinoid tumors
(A) Curling ulcer into venous blood. Clinical features of carcinoid tumors (e.g.,
(B) Cushing ulcer fl ushing, bronchial wheezing, watery diarrhea, and
(C) Melanosis coli abdominal colic) are presumably caused by the release of
(D) Peptic ulcer serotonin, bradykinin, and histamine.
(E) Stercoral ulcer Diagnosis: Gastrinoma, Zollinger-Ellison syndrome

Ans: The answer is E: Stercoral ulcer. Incomplete evacuation __75. A 35yo woman presents with 6-month history of skin
of the feces, usually in association with debilitating disease or rash and fatigue. Physical examination shows pallor and a
old age, may lead to the formation of a large mass of stool necrotizing erythematous skin rash of her lower body.
that cannot be passed, termed fecal impaction. Stercoral Laboratory studies reveal mild anemia and fasting blood
ulcers result from pressure necrosis of the mucosa caused by glucose of 160 mg/dL. A CT scan of the abdomen
the fecal mass. Complications include rectal bleeding and demonstrates a 2-cm mass in the pancreas. Which of the
perforation. The other ulcers do not occur in the rectum. following is the most likely
Diagnosis: Stercoral ulcer diagnosis?
(A) Carcinoid tumor
__73. A 3-day old neonate born after a 32-week gestation (B) Gastrinoma
develops yellow skin. Physical examination of the infant is (C) Glucagonoma
unremarkable. Which of the following is most likely to be (D) Insulinoma
increased in this neonate’s serum? (E) Pancreatic polypeptide-secreting tumor
(A) Alanine aminotransferase
(B) Carotene Ans: The answer is C: Glucagonoma. Necrotizing migratory
(C) Conjugated bilirubin erythema develops in association with the hypersecretion of
(D) Galactosyltransferase glucagon by alpha cell–containing tumors (glucagonomas).
(E) Unconjugated bilirubin These patients also have mild hyperglycemia and anemia.
The other choices do not present with these clinical signs and
Ans: The answer is E: Unconjugated bilirubin. Approximately symptoms.
70% of normal newborns exhibit transient unconjugated Diagnosis: Glucagonoma
hyperbilirubinemia. Immaturity of the liver leads to
inadequate conjugation of bilirubin. This physiologic jaundice __76. A 45yo woman complains of right upper quadrant
is more pronounced in premature infants due to inadequate abdominal pain, weight loss, dry mouth, increased urine
hepatic clearance of bilirubin and increased erythrocyte production, and foul-smelling fatty stools. She has a recent
turnover. Fetal bilirubin levels in utero remain low because history of mild diabetes mellitus. Abdominal ultrasound
bilirubin crosses the placenta, where it is conjugated and examination reveals gallstones and a solitary 1.5-cm mass in
excreted by the mother’s liver. The other enzymes are the pancreas. Which of the following hormones would most
likely be elevated (C) Minimal change disease, focal segmental
in the blood of this patient? glomerulosclerosis
(A) Calcitonin (D) Pyelonephritis, acute tubular necrosis
(B) Gastrin (E) Wilms tumor, renal cell carcinoma
(C) Insulin
(D) Somatostatin Ans: The answer is C: Minimal change disease, focal
(E) Vasoactive intestinal polypeptide segmental glomerulosclerosis. Minimal change
glomerulopathy causes 90% of the nephrotic syndrome in
The answer is D: Somatostatin. Delta cell tumors young children and 15% in adults. Proteinuria is generally
(somatostatinomas) produce a syndrome consisting of mild more selective (albumin > globulins) than in the nephrotic
diabetes mellitus, gallstones, steatorrhea, and syndrome caused by other diseases, but there is too much
hypochlorhydria. These effects result from the inhibitory overlap for this selectivity to be used as a diagnostic criterion.
action of somatostatin on the secretion of hormones by cells This disease is characterized pathologically by fusion
of the endocrine pancreas, acinar cells of the pancreas, and (effacement) of visceral epithelial foot processes; however,
certain hormone-secreting cells in the gastrointestinal tract. this can be visualized only by electron microscopy. Minimal
Somatostatin also inhibits the pituitary release of growth change glomerulopathy is successfully treated with
hormone. None of the other choices are associated with mild corticosteroids and does not progress to renal failure.
diabetes or cholelithiasis. Focal segmental glomerulosclerosis (FSGS) is the cause of
Diagnosis: Somatostatinoma, cholelithiasis nephrotic syndrome in 10% of children and 30% of adults.
FSGS is the term applied to a heterogeneous group of
__77. A 49yo man with a history of heavy smoking presents glomerular diseases that have different causes, including
with a 5-year history of shortness of breath and cough and mutations, viruses, drugs, and serum factors. Henoch-
production of abundant foul-smelling sputum. A pulmonary Schönlein purpura and lupus nephritis (choice A) generally
work-up demonstrates chronic bronchiectasis. Laboratory present with nephritic syndrome and rash, among other signs
studies reveal hypoalbuminemia and hyperlipidemia. and symptoms. Wilms tumor (choice E) is not a cause of
Urinalysis shows heavy proteinuria (>4 g per day). Which of nephrotic syndrome.
the following is the appropriate diagnosis? Diagnosis: Minimal change nephrotic syndrome
(A) Amyloid nephropathy
(B) Berger disease (IgA nephropathy) __79. A 14yo girl presents with a 5-day history of
(C) Focal segmental glomerulosclerosis hypertension, oliguria, and hematuria. She was seen 2 weeks
(D) Minimal change glomerulopathy earlier for a severe throat infection with group A (β-
(E) Wegener granulomatosis hemolytic) streptococci. A kidney biopsy displays
glomerulonephritis. Immunofluorescence staining for which
Ans: The answer is A: Amyloid nephropathy. Amyloidosis is a of the following proteins would provide the strongest
wellknown complication of chronic infl ammatory disorders, evidence that this patient’s glomerulonephritis is mediated
such as chronic suppurative bronchiectasis, rheumatoid by immune complexes?
arthritis, or osteomyelitis. These conditions stimulate the (A) Complement
production of amyloid from the serum amyloid A (SAA) (B) Fibrinogen
protein, an acutephase reactant secreted by the liver. The (C) Hageman factor (clotting factor XII)
kidneys, liver, spleen, and adrenals are the most common (D) Plasminogen
organs involved. Renal amyloidosis leads to nephrotic (E) Thrombin
syndrome (as in this case) and renal failure. Nephrotic
syndrome caused by deposition of SAA amyloid is clinically Ans: The answer is A: Complement. In acute postinfectious
indistinguishable from that related to AL amyloid. The other glomerulonephritis, immune complexes localize in glomeruli
choices have not been linked to chronic infl ammatory by deposition from the circulation or by formation in situ
conditions. Wegener granulomatosis (choice E) affects the as bacterial antigens bind circulating antibodies. The renal
lungs and kidneys, but bronchiectasis is not a feature of this biopsy shows complement fi xation. Complement activation
disease. is so extensive that over 90% of patients with postinfectious
Diagnosis: Amyloid nephropathy, bronchiectasis glomerulonephritis develop hypocomplementemia.
Complement and other infl ammatory mediators attract and
__78. A 12yo boy complains of swelling of his feet for the activate neutrophils and monocytes, which stimulate the
past 3 weeks. He is otherwise healthy, with no known proliferation of mesangial and endothelial cells, resulting in
previous illness. Vital signs are normal. Physical examination diffuse proliferative glomerulonephritis. Typically, the level of
reveals pitting edema of the lower legs and a swollen serum C3 is depressed during the acute syndrome but
abdomen. Urinalysis shows 4+ protein but no RBCs or WBCs. returns to normal within 1 to 2 weeks. The other choices
Which of the involve the coagulation system and are not components of
following are the most likely diagnoses to consider in your immune complexes.
evaluation of this patient? Diagnosis: Postinfectious glomerulonephritis, nephritic
(A) Henoch-Schönlein purpura, lupus nephritis syndrome
(B) Malignant hypertension, renal vein thrombosis
__80. A 20yo woman is involved in an automobile accident
and loses a large amount of blood. In response to hypoxia, Ans: The answer is C: Hemolytic uremic syndrome (HUS). HUS
interstitial peritubular cells of the kidney would be expected features microangiopathic hemolytic anemia and acute renal
to release which of the following hormones? failure, with little or no evidence for signifi cant vascular
(A) Aldosterone disease outside the kidneys. It is the most common cause of
(B) Angiotensin acute renal failure in children. Major causes for HUS are Shiga
(C) Angiotensinogen toxin– producing strains of Escherichia coli, which are
(D) Erythropoietin ingested in contaminated food. The toxin injures endothelial
(E) Renin cells, thereby setting in motion the sequence of events that
produces thrombotic microangiopathy. Patients present with
Ans: The answer is D: Erythropoietin. Erythropoietin is hemorrhagic diarrhea and rapidly progressive renal failure.
released by the interstitial peritubular cells of the kidney in Postinfectious glomerulonephritis (choice A) follows
response to hypoxia and activates specifi c receptors on the streptococcal infections and is not characterized by acute
cell membrane of erythroid progenitor cells in the bone renal failure.
marrow. This effect rescues progenitor cells from Diagnosis: Hemolytic uremic syndrome
programmed cell death, promotes colony growth, and
restores normal red blood cell mass. Renin (choice E) is __83. A 5yo girl presents with the sudden onset of diffuse
released by the juxtaglomerular apparatus. arthralgias and skin rash. Physical examination shows a
Diagnosis: Anemia, hypoxia violaceous maculopapular rash on the lower torso. Urinalysis
discloses oliguria and 2+ hematuria. Urine cultures are
__81. A 54yo woman with squamous cell carcinoma of the negative. This child’s clinical presentation is commonly
lung develops bilateral pitting edema of the lower associated with which of the following diseases?
extremities. Laboratory studies show hyperlipidemia, (A) Berger disease
hypoalbuminemia, and 4+ proteinuria. Urinalysis reveals no (B) Goodpasture syndrome
infl ammatory cells or RBCs. Renal biopsy in this patient (C) Hemolytic uremic syndrome
would most likely show which of the following patterns of (D) Henoch-Schönlein purpura
glomerulopathy? (E) Polyarteritis nodosa
(A) Berger disease (IgA nephropathy)
(B) Goodpasture syndrome Ans: The answer is D: Henoch-Schönlein purpura. Henoch-
(C) Membranous glomerulopathy Schönlein purpura is the most common type of childhood
(D) Minimal change glomerulopathy vasculitis and is caused by vascular localization of immune
(E) Nodular glomerulosclerosis complexes containing predominantly IgA. The glomerular
lesion is identical with that of IgA nephropathy. Hemolytic
Ans: The answer is C: Membranous glomerulopathy. Many uremic syndrome (choice C) is caused by exposure to Shiga
malignant neoplasms may be accompanied by a variety of toxin-producing strains of Escherichia coli and is not
paraneoplastic syndromes, among which is membranous associated with angiopathy outside of the kidney. The other
nephropathy. Other causes of secondary membranous choices are not typically associated with rash.
nephropathy include autoimmune diseases (e.g., systemic Diagnosis: Henoch-Schönlein purpura
lupus erythematosus), infectious diseases (e.g., hepatitis B),
and therapeutic agents (e.g., penicillamine). Immune __84. The parents of a 6-month-old girl palpate a mass on the
complex deposition is found in all of these conditions. IgA left side of the child’s abdomen. Urinalysis shows high levels
nephropathy and Goodpasture syndrome (choices A and B) of vanillylmandelic acid. A CT scan reveals an abdominal
are not paraneoplastic disorders Minimal change tumor and bony metastases. Which of the following is the
glomerulopathy (choice D) is usually found in children and is most likely diagnosis?
not a paraneoplastic disorder. Nodular glomerulosclerosis (A) Dysgerminoma
(choice E) refl ects diabetic lesions. (B) Ganglioneuroma
Diagnosis: Membranous nephropathy, paraneoplastic (C) Immature teratoma
syndrome (D) Neuroblastoma
(E) Wilms tumor
__82. A 6yo child develops fever, abdominal pain, and bloody Ans: The answer is D: Neuroblastoma. Abdominal masses in
diarrhea. Several other children in the neighborhood had children include Wilms tumor (choice E), neuroblastoma, and
similar symptoms. The common feature was traced to eating multicystic renal dysplasia. Of these, only neuroblastoma
hamburgers at a fast food restaurant. The clinical course is secretes catecholamines and causes elevation of
complicated by the development of acute renal failure. vanillylmandelic acid in the urine.
Which of the following is the most likely diagnosis? Diagnosis: Neuroblastoma
(A) Acute postinfectious glomerulonephritis
(B) Churg-Strauss syndrome __85. A 35yo woman with end-stage renal disease of
(C) Hemolytic uremic syndrome unknown etiology is transplanted with a cadaver kidney. The
(D) Malignant hypertension patient develops oliguia shortly after transplantation and a
(E) Polyarteritis nodosa renal biopsy shows immediate (hyperacute) rejection.
Immunosuppression improves renal function. Which of the serous fluid. What is the appropriate diagnosis?
following represents the principle target for immune attack A) Epididymitis
directed against (B) Hematocele
this patient’s allograft? (C) Hydrocele
(A) ABO antigens (D) Spermatocele
(B) Bacterial antigens (E) Varicocele
(C) Glomerular basement membrane antigens
(D) β2-Microglobulin Ans: The answer is C: Hydrocele. The term hydrocele refers to
(E) Urothelium a collection of serous fl uid in the scrotal sac between the
two layers of the tunica vaginalis. The cavity is lined by
Ans: The answer is A: ABO antigens. Incompatible ABO mesothelium. Congenital hydrocele refl ects a patent
histo-blood group antigens, which are expressed on processus vaginalis testis or its incomplete obliteration. It is
endothelial cells and erythrocytes, are absolute barriers to a the most common cause of scrotal swelling in infants and is
successful transplant. ABO-incompatible grafts encounter often associated with inguinal hernia. Acquired hydrocele in
preformed circulating antibodies, which bind to endothelial adults is secondary to some other disease affecting the
cells and cause immediate (hyperacute) rejection. By scrotum, such as infection, tumor, or trauma. The diagnosis
contrast, the most common patterns of acute and chronic may be made by ultrasound examination
rejection are caused primarily by donor-recipient differences or by transilluminating the fl uid in the cavity. Hematocele
in HLA molecules encoded by the major histocompatibility (choice B) is caused by an accumulation of blood between
complex. These molecules are expressed on most cell surface the layers of tunica vaginalis. It may develop after trauma
membranes. Other causes of transplant rejection tend to be or hemorrhage into hydrocele. Testicular tumors and
chronic, because they do not involve preformed antibodies. infections may also lead to a hematocele. Spermatocele
None of the other choices mediates hyperacute graft (choice D) contains milky fl uid and does not occur in this age
rejection. group.
Diagnosis: Graft-versus-host disease Diagnosis: Congenital hydrocele

__86. A 20yo pregnant woman (gravida II, para I) complains __88. A 20yo man presents with dysuria, urgency, and
of lower pelvic discomfort, fever, and pain during urination urethral discharge. Physical examination shows suppurative
for the past 2 days. She also reports seeing blood in her urethritis, with redness and swelling at the urethral meatus.
urine. Which of the following is the most likely cause of Which of the following is the most likely etiology of urethritis
hematuria in this patient? in this patient?
(A) Acute cystitis (A) Borrelia recurrentis
(B) Acute pyelonephritis (B) Chlamydia trachomatis
(C) Bladder calculi (C) Haemophilus ducreyi
(D) Postinfectious glomerulonephritis (D) Neisseria gonorrhoeae
(E) Urothelial cell carcinoma of the bladder (E) Treponema pallidum

Ans: The answer is A: Acute cystitis. Acute cystitis is an infl Ans: The answer is D: Neisseria gonorrhoeae. Urethritis is the
ammation of the urinary bladder that is particularly common most common manifestation of sexually transmitted diseases
in women and is a frequent nosocomial infection in in men, in whom it typically presents with urethral discharge.
hospitalized patients. In most cases, cystitis refl ects Both gonococcal and nongonococcal urethritis have an acute
ascending infection of the lower urinary tract. Factors related onset and are related to recent sexual intercourse. The
to bladder infection include bladder calculi, bladder outlet infection manifests with urethral discharge, typically purulent
obstruction, diabetes mellitus, immunodefi ciency, prior and greenish yellow. Symptoms include pain or tingling at the
instrumentation or catheterization, radiation therapy, and meatus of the urethra and pain on micturition (dysuria).
chemotherapy. The risk of cystitis in females is increased Redness and swelling of the urethral meatus are usually seen
because of a short urethra, especially during pregnancy. in both sexes. In gonococcal urethritis, the urethral discharge
Examination of the urine usually reveals infl ammatory cells, contains N. gonorrhoeae, which can be identified
and the causative agent can be identifi ed by urine culture. microscopically in smears of the urethral exudates. The other
Acute pyelonephritis (choice B) is more likely to present with choices do not present with urethral suppurative discharge.
fl ank pain, without gross hematuria. Bladder calculi (choice Diagnosis: Gonorrhea, urethritis
C) and urothelial cell carcinoma of the bladder (choice E)
would be unlikely causes of gross hematuria in this patient’s __89. A 60yo man with a history of nodular prostatic
age group. hyperplasia and recurrent cystitis presents with pain in the
Diagnosis: Cystitis, acute scrotum. His temperature is 38°C (101°F). Physical
examination reveals a small, tender nodule attached to the
_87. A 9-month-old boy is brought to the physician by his testis. Which of the following is the most likely diagnosis?
mother, who noticed that her son had developed scrotal (A) Epididymitis
swelling. Physical examination reveals a scrotal mass. The (B) Orchitis
lesion can be transilluminated and is composed of clear (C) Spermatocele
(D) Urethritis (A) Anorchia
(E) Varicocele (B) Cryptorchidism
(C) Klinefelter syndrome
Ans: The answer is A: Epididymitis. Epididymitis is an infl (D) Macroorchidism
ammation of the epididymis, usually caused by bacteria, (E) Male pseudohermaphroditism
which may be acute or chronic. Bacterial epididymitis in
young men most often occurs in an acute form as a The answer is B: Cryptorchidism. Cryptorchidism, clinically
complication of gonorrhea or as a sexually acquired infection known as undescended testis, is a congenital abnormality in
with Chlamydia. It is characterized by suppurative infl which one or both testes are not found in their normal
ammation. In older men, E. coli from associated urinary tract position in the scrotum. It is the most common urologic
infections is the most common causative agent. Patients condition requiring surgical treatment in infants. In 5% of
present with intrascrotal pain and tenderness, with or male infants born at term and 30% of those born
without associated fever. Varicocele (choice E) is incorrect prematurely, the testes are not located in the scrotum or are
because it does not typically present with pain and fever. easily retracted. In the large majority of these infants, the
Neither orchitis (choice B) nor urethritis (choice D) would testis will descend into the scrotum during the fi rst year of
present with a nodular scrotal mass. life. The descent of the testis may be arrested at any point
Diagnosis: Epididymitis from the abdominal cavity to the upper scrotum. According
to their location, the cryptorchid testes can be classifi ed as
__90. A 65yo man presents with a 4-month history of a abdominal, inguinal, or upper scrotal. Anorchia (choice A)
scrotal mass. Which of the following is the most likely refers to congenital absence of testes. Macroorchidism
diagnosis? (choice D) is a pathologic fi nding in adult patients with fragile
(A) Choriocarcinoma X syndrome.
(B) Embryonal carcinoma Diagnosis: Cryptorchidism
(C) Leydig cell tumor
(D) Malignant lymphoma __93. A 60yo woman with a history of chronic cystitis is
(E) Seminoma referred to a urologist because of hematuria. Cystoscopy
reveals a mass in the dome of the bladder. Biopsy shows
The answer is D: Malignant lymphoma. Malignant lymphoma tumor cells arranged as gland-like structures. Special stains
is the most frequently encountered neoplasm in the testes of demonstrate mucin in the cytoplasm of the tumor cells. What
men older than 60 years. It usually occurs in the context of is the appropriate diagnosis?
systemic disease, but a few cases of primary lymphoma of (A) Adenocarcinoma
the testis have been reported. Most patients with (B) Inverted papilloma
lymphomatous involvement of the testis have a poor (C) Squamous cell carcinoma
prognosis. The other testicular tumors tend to occur in (D) Urothelial cell carcinoma
younger men. (E) Urothelial cell carcinoma in situ
Diagnosis: Malignant lymphoma
Ans: The answer is A: Adenocarcinoma. Adenocarcinoma of
__91. A 16yo boy from Africa presents with a 5-day history of the bladder accounts for only 1% of all malignant tumors of
fever and testicular pain. Physical examination shows the bladder. It originates from foci of cystitis glandularis or
swollen, tender parotid glands and testes. Which of the intestinal metaplasia or from remnants of urachal epithelium
following is the most likely responsible pathogen? in the bladder dome. Most bladder adenocarcinomas are
(A) Haemophilus ducreyi deeply invasive at the time of initial presentation and are not
(B) Human immunodefi ciency virus curable. The other choices do not feature mucin production.
(C) Human papillomavirus Squamous cell carcinoma of the bladder (choice C) develops
(D) Mumps virus in foci of squamous metaplasia, usually due to
(E) Streptococcus pyogenes schistosomiasis.
Diagnosis: Adenocarcinoma of bladder
Ans: The answer is D: Mumps virus. Orchitis occurs in 20% of __94. A 58yo woman complains of recent swelling in her
adult males with mumps, but widespread immunization vagina. There is a past medical history of prenatal exposure
against mumps has reduced the incidence of the disorder in to diethylstilbestrol. Physical examination reveals a 3-cm firm
the United States. Viral infection is characterized by testicular mass in the anterior wall of the upper vagina. Biopsy of the
pain and gonadal swelling, most commonly unilateral. The vaginal mass will most likely show which of the following
other choices do not involve either the parotid gland or the pathologic fi ndings?
testis. (A) Clear cell adenocarcinoma
Diagnosis: Mumps orchitis (B) Endodermal sinus tumor
(C) Granular cell tumor
__92. A 3-month-old boy is brought to the physician because (D) Mucinous adenocarcinoma
his parents cannot fi nd one of his testicles. Physical (E) Squamous cell carcinoma
examination confi rms the parents’ observation. Which of the
following is the most likely diagnosis? Ans: The answer is A: Clear cell adenocarcinoma. Of women
exposed in utero to diethylstilbestrol, 0.1% develop clear cell examination shows a markedly enlarged vulva, inguinal
adenocarcinoma. The tumor is most common between ages lymph node enlargement, and rectal stricture. Biopsy of an
17 and 22 years and is most frequent on the anterior wall inguinal lymph node reveals necrotizing granulomas,
of the upper third of the vagina. Almost all clear cell neutrophilic infiltrates, and inclusion bodies within
adenocarcinomas are associated with vaginal adenosis, but macrophages. Which of the following is the most likely
very few women with adenosis develop this cancer. The etiology of infertility
abundant clear cytoplasm, refl ecting the presence of in this patient?
glycogen, accounts for the name “clear cell.” The other (A) Chlamydia trachomatis
choices are not associated with prenatal exposure to (B) Gardnerella vaginalis
diethylstilbestrol. (C) Molluscum contagiosum
Diagnosis: Clear cell adenocarcinoma of vagina (D) Mycobacterium tuberculosis
(E) Treponema pallidum
__95. A 60yo woman presents with a 3-week history of a
painful genital lesion and bleeding. Physical examination Ans: The answer is A: Chlamydia trachomatis.
reveals an exophytic, ulcerated 1-cm polypoid mass near the Lymphogranuloma venereum is a sexually transmitted
external end of the urethra. What is the most likely infection that is endemic in tropical countries but rare in
diagnosis? developed ones. The disease is caused by C. trachomatis,
(A) Bartholin gland cyst which is a Gram-negative obligate, intracellular rickettsia.
(B) Caruncle This organism has been found in the genital tract of about 8%
(C) Condyloma acuminatum of asymptomatic women and in 20% of women presenting
(D) Lichen sclerosis with symptoms of a lower genital tract infection. After a few
(E) Lymphogranuloma venereum days to a month, a small painless vesicle forms at the site of
inoculation. It heals rapidly, and in many instances, the
Ans: The answer is B: Caruncle. This polypoid infl ammatory vesicle is not even noticed. The second stage presents with
lesion near the female urethral meatus elicits pain and bilaterally enlarged inguinal lymph nodes that may rupture
bleeding. It occurs exclusively in women, most frequently and form suppurative fi stulas. In some untreated patients, a
after menopause. Urethral caruncle presents as an exophytic, third stage appears, which causes lymphatic obstruction
often ulcerated, polypoid mass of 1 to 2 cm in diameter. and resulting genital elephantiasis and rectal strictures.
Microscopically, the lesion exhibits acutely and chronically Mycobacterium tuberculosis (choice D) induces
infl amed granulation tissue and ulceration and hyperplasia granulomatous infl ammation but does not feature inclusion
of transitional-cell or squamous epithelium. The other bodies. Gardnerella vaginalis (choice B) causes nonspecifi c
choices do not typically involve the urethral meatus. vaginitis. Molluscum contagiosum (choice C) does not involve
Diagnosis: Caruncle the lymph nodes. Treponema pallidum (choice E) does not
cause granulomas.
__96. A 59yo woman presents with a 2-year history of vulvar Diagnosis: Lymphogranuloma venaereum
itching and burning. Physical examination reveals a red, moist
lesion of the labium major. Biopsy reveals clusters of pale __98. A 35yo woman presents with a 6-week history of
vacuolated cells within the epidermis that stain positively for vaginal discharge, which is occasionally blood tinged. Pelvic
periodic acid-Schiff (PAS) and carcinoembryonic examination reveals a 2-cm pedunculated, lobulated, and
antigen (CEA). Which of the following is the most likely smooth cervical growth; it is excised. Histologic examination
diagnosis? of the specimen would most likely reveal which of the
(A) Extramammary Paget disease following?
(B) HPV-induced papilloma (A) Condyloma acuminatum
(C) Verrucous carcinoma (B) Embryonal rhabdomyosarcoma
(D) Vulvar intraepithelial neoplasia (C) Endocervical polyp
(E) Vulvar melanoma (D) Leiomyosarcoma
(E) Microglandular hyperplasia
Ans: The answer is A: Extramammary Paget disease. Paget Ans: The answer is C: Endocervical polyp. Endocervical polyp,
disease of the vulva is named after similar-appearing tumors the most common cervical growth, appears as a single
in the nipple and extramammary sites, such as the axilla and smooth or lobulated mass, typically smaller than 3 cm in
perianal region. The typical Paget cell has a pale, vacuolated greatest dimension. It typically manifests as vaginal bleeding
cytoplasm that contains glycosaminoglycans. It stains with or discharge. The lining epithelium is mucinous, with varying
PAS and mucicarmine and expresses CEA. The disorder degrees of squamous metaplasia, but may feature erosions
usually occurs on the labia majora in older women. Women and granulation tissue in women with symptoms. Simple
with Paget disease of the vulva complain of pruritus or a excision or curettage is curative. Cancer rarely arises in an
burning sensation for many years. The other choices do not endocervical polyp (0.2% of cases). The other choices are rare
feature these specific histologic findings. causes of an endocervical polyp.
Diagnosis: Extramammary Paget disease Diagnosis: Endocervical polyp

__97. A 31yo Haitian woman is evaluated for infertility. Pelvic __99. A 60-yo women presents with a 2-week history of
uterine bleeding. Gynecologic examination reveals an SCORES OF THOSE WHO PASSED:
enlarged uterus. The hysterectomy specimen shows a large Laiza- 52
polypoid mass involving the endometrium and myometrium. Abrar - 71
Histologic examination reveals malignant glands and Jiff - 50
malignant stromal elements, including striated muscle and Hobart -answer key
cartilage. What is the appropriate diagnosis? Chichi- answer key
(A) Carcinosarcoma Kyle - 68
(B) Endometrioid adenocarcinoma Grazelle -52
(C) Leiomyosarcoma Brenly - answer key
(D) Pleomorphic adenoma Andy - answer key
(E) Rhabdomyosarcoma Je-An - answer key
Apple - answer key
Ans: The answer is A: Carcinosarcoma. Carcinosarcoma is an Jonel - answer key
aggressive, mixed mesodermal tumor, in which the epithelial Obsioma - 53
and stromal components are both highly malignant. These Diane - answer key
neoplasms are derived from multipotential stromal cells. The Gabrinez - answer key
overall 5-year rate survival is 25%. Pleomorphic adenoma Pauline - answer key
(choice D) is a mixed tumor of salivary gland. The other Daday - answer key
choices do not feature biphasic components. Alyssa - 53
Diagnosis: Carcinosarcoma Jo - answer key
Remay - 58
__100. A 25yo woman is referred to the gynecologist for Uan - 68
treatment of infertility. The patient is obese (BMI = 32 kg/m2) Justin - 53
and has pronounced facial hair. She states that she has Thea - 62
always had irregular menstrual periods. On gynecologic Fritz - 56
examination, both ovaries are found to be symmetrically Melizza - 57
enlarged. This patient’s ovaries would likely show which of Neale - answer key
the following Marq - 59
pathologic fi ndings? Tin - 62
(A) Bilateral endometriomas July - answer key
(B) Cystic teratoma Jared - 65
(C) Mucinous cystadenoma
(D) Serous cystadenoma
(E) Subcapsular cysts

Ans: The answer is E: Subcapsular cysts. Polycystic ovary

syndrome, also known as Stein-Leventhal syndrome,
describes (1) clinical manifestations related to the secretion
of excess androgenic hormones, (2) persistent anovulation,
and (3) ovaries containing many small subcapsular cysts. It
was described initially as a syndrome of secondary
amenorrhea, hirsutism,
and obesity. The clinical presentation is now recognized to
be far more variable and includes amenorrheic women who
appear otherwise normal and, even rarely, have ovaries
lacking
polycystic features. Up to 7% of women experience the
polycystic ovary syndrome, making this condition a common
cause of infertility. Unopposed acyclic estrogen secretion
in women with polycystic ovary syndrome results in an
increased incidence of endometrial hyperplasia and
adenocarcinoma.
On gross examination, both ovaries are enlarged. On
cut section, the cortex is thickened and discloses numerous
cysts (typically 2 to 8 mm in diameter) arranged peripherally
around a dense core of stroma. The other choices are not
typically
associated with Stein-Leventhal syndrome.
Diagnosis: Polycystic ovary syndrome