Pathology

Midterm
Review
• A 55-year-old man with history of uncontrolled
diabetes and hypertension presented to the
emergency department with a 3-day history of
nagging chest pain. Four hours earlier, the chest pain
got much worse and radiated to both arms and his
neck. It was accompanied by diaphoresis and
dyspnea.
• On exam: BP 160/100, HR 110, RR 24, O2 98% on
room air. Heart rate is regular and there is trace
bilateral edema. CBC and BMP are
unremarkable. CK-MB is 42, CK 300, Troponin T 0.89.
ECG shows 3 mm of ST elevation in leads V2-V4.
• The cardiac catherization lab treats him with
thrombolytic agents for a diagnosis of ST elevation
myocardial infarction. Approximately 20 minutes
after infusion begins, he experiences ventricular
tachycardia and dies
• Which of the following best describes the pathologic
findings?
A.Caseous necrosis
B.Coagulative necrosis
C.Fat necrosis
D.Fibrinoid necrosis
E. Gangrenous necrosis
• Which of the following best describes the nuclear
changes seen here?
A.Chromatin condensation
B.DNA cleavage into nucleosomal subunits
C.Karyorrhexis
D.Karyolysis
E.Pyknosis
• Increased eosinophilia of the dead myocytes is most
directly linked to which of the following molecular
events?
A.Cytoplasmic blebbling
B.Denaturation of cytoplasmic proteins
C.Increased cytoplasmic RNA
D.Generation of myelin figures
E.Loss of glycogen particles
• Which of the following is a feature of necrosis?
A.Caspase activation
B.Chromatin condensation
C.Cytoplasmic blebbing
D.DNA cleavage into nucleosomal subunits
E.Karyorrhexis
• Which of the following is the most likely explanation for
the onset of ventricular tachycardia following initiation
of thrombolytic therapy?
A.Direct toxic effect of the thrombolytic therapy
B.Reperfusion injury
C.Second thrombus in the same site
D.Systemic hypotension
E.Ventricular rupture
• A 67-year-old woman with a long history
of hypertension and a remote myocardial
infarction presented to the emergency
department with a two-hour history of left-
sided weakness. She reported that she
had a “fluttering” sensation in her chest
and that her cardiologist had
recommended treatment for atrial
fibrillation which she had refused. While in
the emergency department, she developed
left-sided hemiparesis. She was admitted
to the hospital for observation; however,
her condition worsened and she went into
a coma. She died 17 days after admission.
• Which of the following best describes the pathologic
findings?
A.Caseous necrosis
B.Coagulative necrosis
C.Fat necrosis
D.Liquefactive necrosis
E.Gangrenous necrosis
• Which of the following processes did the necrotic cells in
this specimen undergo?
A.Caspase activation
B.Cell shrinkage
C.Chromatin condensation
D.DNA cleavage into nucleosomal subunits
E.Loss of membrane integrity
• When the patient’s artery was initially occluded by
thrombus, ischemia led to a rapid decrease in
intracellular ATP levels. Which of the following is a
consequence of this process?
A.Efflux of calcium
B.Detachment of ribosomes
C.Increased pH
D.Influx of potassium
E.Decrease in anaerobic glycolysis
• In this ischemic environment, the mitochondria are
unable to maintain normal oxidative phosphorylation,
resulting in release of reactive oxygen species into the
cytoplasm. Which of the following is the most direct
consequence of this release?
A.Apoptosis
B.Failure of the Ca2+ pump
C.Increased phospholipid breakdown
D.Leakage of metabolites into the extracellular space
E.Lipid peroxidation of membranes
• A 64-year-old morbidly obese
woman was admitted to the
emergency department with a 6-
hour history of nausea, vomiting
and jaw pain. While she was in
the emergency department she
collapsed and died. Autopsy
revealed a massive myocardial
infarction as well as significant
liver pathology.
• Which of the following is the most likely cause of this
condition?
A.Decreased a-glycerophosphate activity
B.Impaired fatty acid oxidation
C.Increased apoprotein synthesis
D.Peripheral sequestration of fatty acids
E.Reduced acetate concentration
• A 53-year-old obese man presents to a
free clinic. He reports that he has had
“heartburn” for the last ten years that he
has been treating with an over-the-
counter proton pump inhibitor that has
offered partial relief. He has no other
symptoms. Endoscopy is performed with
biopsy. Following biopsy analysis, an
endoscopic mucosal resection is
performed. However, surgical margins
are found to be positive and a
subsequent partial esophagogastrectomy
is performed.
• Which of the following is the appropriate term for the
pathologic process that accounts for the presence of
goblet cells in this specimen?
A.Anaplasia
B.Dysplasia
C.Hyperplasia
D.Metaplasia
• Which of the following is the mechanism by which this
process is thought to occur?
A.Activation of intestinal epithelial nests
B.Chromosomal translocation
C.Migration of epithelial cells from different sites
D.Reprogramming of stem cells
• An 18-year-old woman presented to the
emergency department with a two-day
history of nausea, vomiting and
periumbilical and lower abdominal pain.
Earlier that day, she experienced shaking
chills and fever. Physical exam showed
local tenderness and rigidity with rebound
pain in the lower abdomen. Laboratory
tests revealed a white blood cell count of
21,900/ dL, C-reactive protein of
300 mg/L (normal <3.0 mg/dL) and an
erythrocyte sedimentation rate of 104
mm/h (normal 0-20 mm/h). A peripheral
smear showed immature neutrophils
(“band” cells). She underwent an
exploratory laparotomy.
• Which of the following is the most
prominent morphologic pattern of inflammation seen
in this case?
A.Fibrinous inflammation
B.Granulomatous inflammation
C.Purulent inflammation
D.Serous inflammation
E.Ulceration
• Which of the following accounts for the immature
neutrophils (“band” cells) seen in the peripheral smear?
A.Diapedesis
B.Eosinophilia
C.Leukopenia
D.Mastocytosis
E.Shift to the left
• The pain experienced by this patient is MOST
LIKELY the result of the formation of which of the
following two chemical mediators?
A.Complement C3b and IgG
B.Interleukin-1 and tumor necrosis factor
C.Histamine and serotonin
D.Prostaglandin and bradykinin
E.Leukotriene and HPETE
• The edematous appearance of the appendix
is primarily due to the effects of which of the following
inflammatory mediators?
A.C3b
B.Histamine
C.Hydroxyeicosatetraenoic acid (HETE)
D.Lipoxin A4
E.Thromboxane A2
 • A 54-year-old man presented to his
primary care physician with a one-year
history of intermittent upper abdominal
pain. Laboratory results were as follows:

RESULT (ref. range in

TEST
parentheses)

Hemoglobin 10 gm/dL (12.0 – 16.0 gm/dL)

Hct 37% (41-53%)

MCV 61 µm3 (80- 100 µm3)

MCHC 28 % Hb/cell (31- 36% Hb/cell)

Upper endoscopy was performed, which
revealed a solitary ulcerated lesion. Although Serum ferritin 2 ng/mL (12-150 ng/mL)
most cases of this disease are typically treated
medically, this patient underwent a partial
gastrectomy.
• Which of the following cell types is most
closely associated with a chronic (as opposed to acute)
process?
A.Eosinophils
B.Neutrophils
C.Mast cells
D.Monocytes
E.Plasma cells
• This specimen shows mixed acute and chronic inflammation.
Which of the following best reflects the order of events
which led to neutrophil infiltration of the tissue?
A.Adhesion, margination, migration through tissues,
migration across vessel wall, rolling.
B.Adhesion, margination, rolling, migration through tissues,
migration across vessel wall.
C.Margination, rolling, adhesion, migration across vessel wall,
migration through tissues.
D.Migration across vessel wall, margination, rolling, adhesion,
migration through tissues.
E.Rolling, adhesion, margination, migration through tissues,
migration across vessel wall.
• Initial rolling interactions are mediated by which of the
following?
A.Arachidonic acid metabolites
B.Cadherins
C.Integrins
D.Platelet endothelial cell adhesion molecule (PECAM-1)
E.Selectins
• In patients with this condition, plain radiographic
evidence of free air under the diaphragm in the upright
position is most suggestive of which of the following?
A.Chronic gastritis
B.Frank hemorrhage
C.Malignant transformation
D.Perforation
E.Reactive gastropathy
• A 27-year-old woman was brought to the
Emergency Department following a loss of
consciousness. On presentation, her BP was
94/57 mmHg in her right arm and 89/54
mmHg in her left arm. Her heart rate was
106 beats per minute. O2 sat was 93% on
RA. CV exam showed a tachycardic rate
with regular rhythm. Lungs were clear to
auscultation bilaterally. Neurological exam
showed no focal findings. She was sent for a
CT of her chest with contrast to evaluate for
pulmonary embolism. While she was
undergoing a chest CT, she became
hypotensive and unresponsive and died
Which of the following is MOST COMMONLY associated
with this diagnosis?
A. Antithrombin III deficiency
B. Atherosclerosis
C. Hypertension
D. Syphilis
E. Vitamin C deficiency
• Which of the following should be suspected in this
patient?
A.Bacterial sepsis
B.Cardiogenic shock
C.Connective tissue abnormalities
D.Fat embolism
E.Heroin use
• A 63-year-old man presented to the
emergency department with a two-
day history of severe chest pain and
dyspnea. He had been discharged
from the hospital one
week earlier following a colon
resection due to obstruction from a
colonic adenocarcinoma that had also
metastasized to the liver. While he
was in the emergency department,
he collapsed and died. Gross and
microscopic images from the autopsy
are provided.
• What do the firm, red, wedge-shaped areas of the lung
represent?
A.Angiosarcoma
B.Hemorrhage
C.Infarcts
D.Metastatic disease
E.Thrombosis
• In cases of deep venous thrombosis with embolism,
which vessels are MOST OFTEN occluded?
A.Bronchial arteries
B.Bronchial veins
C.Inferior vena cava
D.Pulmonary arteries
E.Pulmonary veins
F.Superior vena cava
• Pulmonary emboli are more common than pulmonary
infarcts. Which of the following explains this
observation?
A.Coagulation is slower in oxygenated tissue
B.Lung tissue has increased numbers of mitochondria
C.Lungs have a dual arterial supply
D.Oxygenation can occur across the bronchial wall
E.Venous drainage is accelerated in lung tissue
• A 28-year-old woman presents to the
Emergency Department with an acute onset of
severe dyspnea after disembarking from a
trans-Atlantic flight. She reports left-sided chest
pain on inspiration. She has no significant
medical history, but states that she takes oral
contraceptive pills. Physical exam shows 20
breaths per minute and a heart rate of 125
bpm. Her left calf is swollen and warm. A
duplex ultrasound demonstrates a deep venous
thrombosis. Laboratory analysis reveals a
positive activated protein C resistance test;
remaining studies are noncontributory.
• Which of the following is the most likely etiology for
her condition?
A.Antiphospholipid antibody syndrome
B.Factor V Leiden mutation
C.Glucose-6-phosphate dehydrogenase deficiency
D.Hyperhomocystenemia
E.von Willebrand disease
• Which of the following is true about this disease?
A.Homozygotes have a 50-fold increase in relative risk of
venous thrombosis
B.Inheritance is typically autosomal recessive
C.It is associated with increased prothrombin levels
D.Partial thromboplastin time is typically prolonged
E.There is an increased incidence in patients with
systemic lupus erythematosus
• Which of the following is the pathophysiology of this
disease?
A.Autoantibodies cause platelet aggregation
B.Factor V is resistant to cleavage
C.Prothrombin is resistant to cleavage
D.Thioester linkages form between homocysteine
metabolites and proteins
E.Ultra large von Willebrand multimers are found in the
serum
• A 48-year-old woman presents
to the emergency department
in labor. She has had no
prenatal care. Delivery of the
full-term infant is
uncomplicated. An image of the
neonate is provided.
• Which of the following processes best accounts for this
patient’s karyotype?
A.Amplification
B.Chromosomal deletion
C.Lyonization
D.Mosaicism
E.Premutation
• Which of the following is most strongly associated
with risk of having a child with this disease?
A.Advanced maternal age
B.In utero alcohol exposure
C.Insufficient folate
D.Oligohydramnios
E.Toxoplasma infection
• For which of the following is this patient
at greatest risk?
A.Alzheimer disease
B.Hyperlipidemia
C.Hypocalcemia
D.Infertility
E.Retinoblastoma
• A newborn baby is noted to have
meconium ileus. His mother notices
that when she kisses him, his skin
tastes salty. A sweat chloride test
was 110mEq/L (nl <60 mEq/L).
Throughout childhood, he
experiences persistent lung
infections, chronic cough and
obstructive pulmonary disease and,
later in life, he develops exocrine
pancreatic insufficiency with
manifestations of malabsorption. He
dies from cor pulmonale and an
autopsy is performed.
• Which of the following genes is most
frequently mutated in this disease?
A.APC
B.CFTR
C.COL3A1
D.FMR1
E.LDLR
• Which of the following best accounts for the pulmonary
findings in this patient?
A.Decreased chloride secretion in respiratory epithelium
B.High-volume surface fluid layer coating respiratory
mucosa cells
C.Hyperplasia of bronchial smooth muscle
D.Hypoplasia of bronchiolar cartilage
E.Increased water and sodium secretion in respiratory
epithelium
• Which of the following is most commonly found in
patients with this disease?
A.Cherry red macula
B.Hepatosplenomegaly and bone lesions
C.Increased plasma LDL
D.Light colored hair and skin
E.Pseudomonas aeruginosa infection
• A 43-year-old woman presented to her
primary care physician with a 3-month
history of bilateral hand and wrist pain,
stiffness and swelling. The stiffness is
worse in the morning. A clinical image
of her hands is provided.
• Laboratory tests were positive for
rheumatoid factor and anti-cyclic
citrullinated peptide antibodies. Over
the next 25 years, she had increasing
pain and deformity of her hands and
also experienced pain and swelling of
her feet. A plain radiograph study is
provided.
• Which of the following antibodies are MOST LIKELY to
be demonstrated in this patient?
A.Anti-citrullinated peptides
B.Anti-myeloperoxidase (MPO-ANCA)
C.Anti-proteinase-3 (PR3-ANCA)
D.Anti-smooth muscle
E.Anti-transglutaminase (anti-eTg)
• Which of the following is an important mediator and
therapeutic target of this disease?
A.Cryoglobulin
B.Platelet-derived growth factor
C.Toll-like receptor
D.Transthyretin
E.Tumor necrosis factor
• A 33-year-old man presents to a
new primary care physician with a
6-month history of raised, reddish
purple lesions on his trunk. He
states that he has been having
sex with men for more than ten
years and that he has had
unprotected sex multiple times.
He says he went to a free clinic
one month ago and a laboratory
test was positive for HIV.
• Which of the following is most likely to be his CD4+ T
cell count?
A.<200 cells/uL
B.Between 500 and 1000 cells/uL
C.Between 1500 and 5000 cells/uL
D.> 10,000 cells/uL
• e is prescribed with an antiretroviral therapy that
includes a protease inhibitor. Which of the following is
the mechanism of action of this drug?
A.Enhances activation of CD8+ T cells
B.Inhibits fusion of HIV envelope to host cell membrane
C.Lowers affinity of CCR5 binding to gp120
D.Prevents formation of mature proteins
from gag and pol genes
E.Prevents integration of viral genome into host DNA
• A researcher is working on an experimental drug that kills
all HIV-infected CD4+ T cells in a mouse model. He notices
that even though all of these T cells are destroyed, he can
still detect the presence of HIV in the mouse. Which of the
following is the most likely reservoir for HIV in this
system?
A.B cells
B.Basophils
C.CD8+ T cells
D.Eosinophils
E.Macrophages
• 51-year-old man with a
long history of
tuberculosis presented to
his primary care physician
with a 4-week history of
bilateral ankle
edema. Physical
examination revealed an
enlarged liver and
urinalysis showed 2+
proteinuria. While he was
being evaluated, he
experienced a ventricular
arrhythmia and died.
Gross and microscopic
images are provided.
• The development of this particular disease in this
patient is MOST LIKELY due to deposition of which of
the following?
A.β-amyloid protein (Aβ)
B.Amyloid light chain protein (AL)
C.Amyloid-associated fibril protein (AA)
D.β2-microglobulin
E.Transthyretin
• Which of the following stains is most commonly used
to visualize the deposited substance?
A.Congo red
B.Oil Red O
C.Periodic acid-Schiff
D.Silver
E.Warthin-Starry
• Which of the following is the MOST COMMON cause of
this disease?
A.Familial Mediterranean fever
B.Hemodialysis
C.Plasma cell dyscrasia
D.Rheumatoid arthritis
E.Tuberculosis
• A 12-year-old boy with end-stage renal
failure due to congenital ureteral
obstruction received a living-donor renal
transplant from his grandfather which failed
eight years later due to noncompliance with
immunosuppressive medications. At age
25, he received a second, deceased-donor
renal transplant. His immunosuppressive
regimen included tacrolimus (FK 506),
azathioprine, and prednisone. His serum
creatinine level fell during the first week
post-transplant to almost normal levels, but
then began to rise again, reaching a level
of 5 mg/dL. A percutaneous renal biopsy
was performed.
• Which of the following would be the best test to
confirm the diagnosis?
A.Complete blood count with differential
B.Evaluation of serum complement levels
C.Examination of a peripheral blood smear
D.Immunohistochemical stains for cytomegalovirus
E.Screening for donor-specific antibodies
• Additional clinical information: Circulating antibodies against
both class I and class II histocompatibility antigens were
detected by serologic testing; one of the anti-class I
antibodies was donor-specific.
• Which of the following is the most likely cause of anti-HLA
antibodies in this patient?
A.Autoimmunity
B.Immune reaction to drug-bound self proteins
C.Immunization by cross-reacting gut flora
D.Production of anti-graft antibody by neoplastic plasma cell
clone
E.Sensitization by previous allograft
• This patient is at greatest risk for developing which of
the following?
A.Graft-versus-host disease
B.Hyper-IgM syndrome
C.IgA deficiency
D.Non-Hodgkin lymphoma
E.Wiskott-Aldrich syndrome