Chapter 1: Cell Adaptation, cell injury and cell death

Question 1

Bone marrow cells from an organ donor are cultured in vitro
at 37°C in the presence of recombinant erythropoietin. A
photomicrograph of a typical “burst-forming unit” is shown
in the image. This colony, committed to the erythrocyte
pathway of differentiation, represents an example of which
of the following physiologic adaptations to transmembrane
signaling?

Answer 1

1.Hyperplasia`

Question 2

A 50-year-old chronic alcoholic presents to the emergency
room with 12 hours of severe abdominal pain. The pain
radiates to the back and is associated with an urge to vomit.
Physical examination discloses exquisite abdominal tenderness.
Laboratory studies show elevated serum amylase. Which of
the following morphologic changes would be expected in the
peripancreatic tissue of this patient?
A) Coagulative necrosis
(B) Caseous necrosis
(C) Fat necrosis
(D) Fibrinoid necrosis
(E) Liquefactive necrosis

Answer 2

2.Fat Necrosis

Question 3

A 68-year-old man with a history of gastroesophageal refl ux
disease suffers a massive stroke and expires. The esophagus at
autopsy is shown in the image. Histologic examination of the
abnormal tissue shows intestine-like epithelium composed of
goblet cells and surface cells similar to those of incompletely
intestinalized gastric mucosa. There is no evidence of nuclear
atypia. Which of the following terms best describes this
morphologic response to persistent injury in the esophagus of
this patient?

(A) Atypical hyperplasia
(B) Complex hyperplasia
(C) Glandular metaplasia
(D) Simple hyperplasia
(E) Squamous metaplasia

Answer 3

3.Glandular metaplasia

Question 4

A CT scan of a 43-year-old woman with a parathyroid adenoma
and hyperparathyroidism reveals extensive calcium deposits in
the lungs and kidney parenchyma. These radiologic fi ndings
are best explained by which of the following mechanisms of
disease?
(A) Arteriosclerosis
(B) Dystrophic calcifi cation
(C) Granulomatous infl ammation
(D) Metastatic calcifi cation
(E) Tumor embolism

Answer 4

4.Metastatic calcification

Question 5

A 75-year-old woman with Alzheimer disease dies of congestive
heart failure. The brain at autopsy is shown in the image. This
patient’s brain exemplifi es which of the following responses to
chronic injury?

Answer 5

5.Atrophy

Question 6

A 68-year-old woman with a history of heavy smoking and
repeated bouts of pneumonia presents with a 2-week history of
fever and productive cough. A chest X-ray reveals a right lower
lobe infi ltrate. A transbronchial biopsy confi rms pneumonia
and further demonstrates preneoplastic changes within the
bronchial mucosa. Which of the following best characterizes
the morphology of this bronchial mucosal lesion?

Answer 6

6. Abnormal pattern of cellular maturation.

Question 7

A 64-year-old man with long-standing angina pectoris and
arterial hypertension dies of spontaneous intracerebral
hemorrhage. At autopsy, the heart appears globoid. The
left ventricle measures 2.8 cm on cross section (shown in
the image). This adaptation to chronic injury was mediated
primarily by changes in the intracellular concentration of
which of the following components?

Answer 7

7. mRNA

Question 8

A 24-year-old woman contracts toxoplasmosis during her
pregnancy and delivers a neonate at 37 weeks of gestation
with a severe malformation of the central nervous system. MRI
studies of the neonate reveal porencephaly and hydrocephalus.
An X-ray fi lm of the head shows irregular densities in the basal
ganglia. These X-ray fi ndings are best explained by which of
the following mechanisms of disease?

Answer 8

8. Dystrophic calcification.

Question 9

A 30-year-old man with AIDS-dementia complex develops
acute pneumonia and dies of respiratory insuffi ciency. At
autopsy, many central nervous system neurons display
hydropic degeneration. This manifestation of sublethal
neuronal injury was most likely mediated by impairment of
which of the following cellular processes?

Answer 9

9. Plasma membrane sodium transport.

Question 10

A 62-year-old man is brought to the emergency room in a
disoriented state. Physical examination reveals jaundice,
splenomegaly, and ascites. Serum levels of ALT, AST, alkaline
phosphatase, and bilirubin are all elevated. A liver biopsy
demonstrates alcoholic hepatitis with Mallory bodies. These
cytoplasmic structures are composed of interwoven bundles
of which of the following proteins?

Answer 10

10. Intermediate filaments.

Question 11

A 65-year-old man suffers a heart attack and expires. Examination
of the lungs at autopsy reveals numerous pigmented
nodules scattered throughout the parenchyma (shown in the
image). What is the appropriate diagnosis?

Answer 11

11. Anthracosis

Question 12

A 32-year-old woman with poorly controlled diabetes mellitus
delivers a healthy boy at 38 weeks of gestation. As a result of
maternal hyperglycemia during pregnancy, pancreatic islets in
the neonate would be expected to show which of the following
morphologic responses to injury?

Answer 12

12. Hyperplasia

Question 13

A 59-year-old female alcoholic is brought to the emergency
room with a fever (38.7°C/103°F) and foul-smelling
breath. The patient subsequently develops acute bronchopneumonia
and dies of respiratory insuffi ciency. A pulmonary
abscess is identifi ed at autopsy (shown in the image).
Histologic examination of the wall of this lesion would
most likely demonstrate which of the following pathologic
changes?

Answer 13

13. Liquefactive necrosis.

Question 14

A 20-year-old man from China is evaluated for persistent
cough, night sweats, low-grade fever, and general malaise.
A chest X-ray reveals fi ndings “consistent with a Ghon complex.”
Sputum cultures grow acid-fast bacilli. Examination of
hilar lymph nodes in this patient would most likely demonstrate
which of the following pathologic changes?

Answer 14

14. Caseous necrosis. Caseous necrosis is a characteristic
    of primary tuberculosis, in which the necrotic cells
    fail to retain their cellular outlines. They do not disappear by
    lysis, as in liquefactive necrosis (choice E), but persist indefi -
    nitely as amorphous, coarsely granular, eosinophilic debris.
    Grossly, this debris resembles clumpy cheese, hence the name
    caseous necrosis. Primary tuberculosis is often asymptomatic
    or presents with nonspecifi c symptoms, such as low-grade
    fever, loss of appetite, and occasional spells of coughing. The

Question 15

A 31-year-old woman complains of increased vaginal discharge
of 1-month duration. A cervical Pap smear is shown
in the image. Superfi cial epithelial cells are identifi ed with
arrows. When compared to cells from the deeper intermediate layer (top), the nuclei of these superfi cial cells exhibit which
of the following cytologic features?

Answer 15

15. Pyknosis.

Question 16

A 30-year-old woman suffers a tonic-clonic seizure and presents
with delirium and hydrophobia. The patient states that
she was bitten on the hand by a bat about 1 month ago. The
patient subsequently dies of respiratory failure. Viral particles
are found throughout the brainstem and cerebellum at
autopsy. In addition to direct viral cytotoxicity, the necrosis of
virally infected neurons in this patient was mediated primarily
by which of the following mechanisms?

Answer 16

16. Humoral and cellular immunity.

Question 17

A 52-year-old woman loses her right kidney following an automobile
accident. A CT scan of the abdomen 2 years later shows
marked enlargement of the left kidney. The renal enlargement
is an example of which of the following adaptations?

Answer 17

17. Hypertrophy

Question 18

An 82-year-old man has profound bleeding from a peptic
ulcer and dies of hypovolemic shock. The liver at autopsy displays
centrilobular necrosis. Compared to viable hepatocytes,
the necrotic cells contain higher intracellular concentrations
of which of the following?

Answer 18

18. Calcium

Question 19

A 28-year-old woman is pinned by falling debris during a hurricane.
An X-ray fi lm of the leg reveals a compound fracture
of the right tibia. The leg is immobilized in a cast for 6 weeks. When the cast is removed, the patient notices that her right leg
is weak and visibly smaller in circumference than the left leg.
Which of the following terms best describes this change in the
patient’s leg muscle?

Answer 19

19. Atrophy.

Question 20

A 70-year-old man is hospitalized after suffering a mild stroke.
While in the hospital, he suddenly develops crushing substernal
chest pain. Analysis of serum proteins and ECG confi rm
a diagnosis of acute myocardial infarction. The patient subsequently
develops an arrhythmia and expires. A cross section of
the left ventricle at autopsy is shown in the image. Histologic
examination of the affected heart muscle would demonstrate
which of the following morphologic changes?

Answer 20

20. Coagulative necrosis.

Question 21

Which of the following histologic features would provide
definitive evidence of necrosis in the myocardium of the
patient described in Question 20?

Answer 21

21. Nuclear fragmentation.

Question 22

A 90-year-old woman with mild diabetes and Alzheimer disease
dies in her sleep. At autopsy, hepatocytes are noted to
contain golden cytoplasmic granules that do not stain with
Prussian blue. Which of the following best accounts for pigment
accumulation in the liver of this patient?

Answer 22

22. Advanced age.

Question 23

Which of the following mechanisms of disease best describes
the pathogenesis of pigment accumulation in hepatocytes in
the patient described in Question 22?

Answer 23

23. Peroxidation of membrane lipids.

Question 24

A 45-year-old man presents with increasing abdominal girth
and yellow discoloration of his skin and sclera. Physical examination
reveals hepatomegaly and jaundice. A Prussian blue
stain of a liver biopsy is shown in the image. What is the major

Answer 24

24. Hemosiderin.

Question 25

60-year-old man with chronic cystitis complains of urinary
frequency and pelvic discomfort. Digital rectal examination
is unremarkable. Biopsy of the bladder mucosa reveals foci
of glandular epithelium and chronic infl ammatory cells. No
cytologic signs of atypia or malignancy are observed. Which of
the following terms best describes the morphologic response
to chronic injury in this patient?

Answer 25

25. Metaplasia

Question 26

A 60-year-old man is rushed to the hospital with acute liver
failure. He undergoes successful orthotopic liver transplantation;
however, the transplanted liver does not produce much
bile for the fi rst 3 days. Poor graft function in this patient is
thought to be the result of “reperfusion injury.” Which of the
following substances was the most likely cause of reperfusion
injury in this patient’s transplanted liver?

Answer 26

26. Reactive oxygen species.

Question 27

A 68-year-old woman with a history of hyperlipidemia dies
of cardiac arrhythmia following a massive heart attack. Peroxidation
of which of the following molecules was primarily
responsible for causing the loss of membrane integrity in cardiac
myocytes in this patient?

Answer 27

27. Phospholipids

Question 28

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

Answer 28

28. Liquefactive necrosis.

Question 29

A 42-year-old man undergoes liver biopsy for evaluation of the
grade and stage of his hepatitis C virus infection. The biopsy
reveals swollen (ballooned) hepatocytes and moderate lobular
infl ammatory activity (shown in the image). The arrow identifi
es an acidophilic (Councilman) body. Which of the following
cellular processes best accounts for the presence of scattered
acidophilic bodies in this liver biopsy?

Answer 29

29. Apoptotic cell death.

Question 30

Which of the following biochemical changes characterizes the
formation of acidophilic bodies in the patient described in
Question 29?

Answer 30

30. Fragmentation of DNA.

Question 31

A 56-year-old woman with a history of hyperlipidemia and
hypertension develops progressive, right renal artery stenosis.
Over time, this patient’s right kidney is likely to demonstrate
which of the following morphologic adaptations to partial
ischemia?

Answer 31

31. Atrophy.

Question 32

A 5-year-old boy suffers blunt trauma to the leg in an automobile
accident. Six months later, bone trabeculae have formed
within the striated skeletal muscle at the site of tissue injury.
This pathologic condition is an example of which of the following
morphologic adaptations to injury?

Answer 32

32. Metaplasia.

Question 33

A 43-year-old man presents with a scaly, erythematous lesion
on the dorsal surface of his left hand. A skin biopsy reveals
atypical keratinocytes fi lling the entire thickness of the epidermis
(shown in the image). The arrows point to apoptotic bodies.
Which of the following proteins plays the most important
role in mediating programmed cell death in this patient’s skin
cancer?

Answer 33

33. Cytochrome c.

Question 34

A 16-year-old girl with a history of suicidal depression swallows
a commercial solvent. A liver biopsy is performed
to assess the degree of damage to the hepatic parenchyma.
Histologic examination demonstrates severe swelling of the
centrilobular hepatocytes (shown in the image). Which of the following mechanisms of dz best accounts for reversible changes in the liver biopsy

Answer 34

34. Decreased stores of intracellular ATP.

Question 35

A 40-year-old man is pulled from the ocean after a boating
accident and resuscitated. Six hours later, the patient develops
acute renal failure. Kidney biopsy reveals evidence of karyorrhexis
and karyolysis in renal tubular epithelial cells. Which
of the following biochemical events preceded these pathologic
changes?

Answer 35

35. Decrease in intracellular pH.

Question 36

A 58-year-old man presents with symptoms of acute renal failure.
His blood pressure is 220/130 mm Hg (malignant hypertension).
While in the emergency room, the patient suffers a
stroke and expires. Microscopic examination of the kidney at
autopsy is shown in the image. Which of the following morphologic
changes accounts for the red material in the wall of
the artery?

Answer 36

36. Fibrinoid necrosis.

Question 37

A 10-year-old girl presents with advanced features of progeria
(patient shown in the image). This child has inherited mutations
in the gene that encodes which of the following types of
intracellular proteins?

Answer 37

37. Lamin

Question 38

A 32-year-old woman develops an Addisonian crisis (acute
adrenal insuffi ciency) 3 months after suffering massive hemorrhage
during the delivery of her baby. A CT scan of the
abdomen shows small adrenal glands. Which of the following
mechanisms of disease best accounts for adrenal atrophy in
this patient?

Answer 38

38. Lack of trophic signals.

Question 39

A 47-year-old man with a history of heavy smoking complains
of chronic cough. A “coin lesion” is discovered in his right
upper lobe on chest X-ray. Bronchoscopy and biopsy fail to
identify a mass, but the bronchial mucosa displays squamous
metaplasia. What is the most likely outcome of this morphologic
adaptation if the patient stops smoking?

Answer 39

39. Reversion to normal.

Question 40

A 60-year-old farmer presents with multiple patches of
discoloration on his face. Biopsy of lesional skin reveals actinic
keratosis. Which of the following terms best describes this
response of the skin to chronic sunlight exposure?

Answer 40

40. Dysplasia.

Question 41

A 59-year-old woman smoker complains of intermittent blood
in her urine. Urinalysis confi rms 4+ hematuria. A CBC reveals
increased red cell mass (hematocrit). A CT scan demonstrates a
3-cm renal mass, and a CT-guided biopsy displays renal cell carcinoma.
Which of the following cellular adaptations in the bone
marrow best explains the increased hematocrit in this patient?

Answer 41

41. Hyperplasia.

Question 42

A 33-year-old woman has an abnormal cervical Pap smear.
A cervical biopsy reveals that the epithelium lacks normal
polarity (shown in the image). Individual cells display hyperchromatic
nuclei, a larger nucleus-to-cytoplasm ratio, and
disorderly tissue arrangement. Which of the following adaptations
to chronic injury best describes these changes in the
patient’s cervical epithelium?

Answer 42

42. Dysplasia.

Question 43

A 24-year-old woman accidentally ingests carbon tetrachloride
(CCl4) in the laboratory and develops acute liver failure.
Which of the following cellular proteins was directly involved
in the development of hepatotoxicity in this patient?

Answer 43

43. Mixed function oxygenase.

Question 44

A 30-year-old woman presents with a 2-month history of
fatigue, mild fever, and an erythematous scaling rash. She
also notes joint pain and swelling, primarily involving the
small bones of her fi ngers. Physical examination reveals erythematous
plaques with adherent silvery scales that induce
punctate bleeding points when removed. Biopsy of lesional
skin reveals markedly increased thickness of the epidermis
(shown in the image). Which of the following terms best
describes this adaptation to chronic injury in this patient with
psoriasis?

Answer 44

44. Hyperplasia.

Question 45

A 24-year-old woman with chronic depression ingests a bottle
of acetaminophen tablets. Two days later, she is jaundiced
(elevated serum bilirubin) and displays symptoms of encephalopathy,
including impairment in spatial perception. In the
liver, toxic metabolites of acetaminophen are generated by
which of the following organelles?

Answer 45

45. Smooth endoplasmic reticulum.

Question 46

A 45-year-old woman presents with a 2-month history of
fatigue and recurrent fever. She also complains of tenderness
below the right costal margin and dark urine. Physical examination
reveals jaundice and mild hepatomegaly. The serum is
positive for hepatitis B virus antigen. Which of the following
best describes the mechanism of indirect virus-mediated
hepatocyte cell death in this patient?

Answer 46

46. Immune recognition of viral antigens on the

cell surface.

Question 47

You are asked to present a grand rounds seminar on the role of
abnormal proteins in disease. In this connection, intracellular
accumulation of an abnormally folded protein plays a role in
the pathogenesis of which of the following diseases?

Answer 47

47. C: a1-Antitrypsin defi ciency.

Question 48

A 38-year-old woman shows evidence of early cataracts, hair
loss, atrophy of skin, osteoporosis, and accelerated atherosclerosis.
This patient has most likely inherited mutations in both
alleles of a gene that encodes which of the following types of
intracellular proteins?

Answer 48

48. Helicase

Question 49

A 28-year-old man with a history of radiation/bone marrow
transplantation for leukemia presents with severe diarrhea.
He subsequently develops septic shock and expires. Microscopic
examination of the colon epithelium at autopsy reveals
numerous acidophilic bodies and small cells with pyknotic
nuclei. Which of the following proteins most likely played
a key role in triggering radiation-induced cell death in this
patient’s colonic mucosa?

Answer 49

49. p53