Chapter 8: Environmental & Nutritional Pathology

Question 1

A 65-year-old woman with a history of smoking presents
with a 3-week history of chest pain and bloody sputum. An
X-ray film of the chest reveals a hilar lung mass. The surgical
specimen reveals a squamous cell carcinoma growing within
the lumen of a bronchus (shown in the image). Which of
the following chemical agents may be associated with the
pathogenesis of the cancer in this patient?

Answer 1

1. Aromatic hydrocarbons.

Question 2

A 75-year-old man who had worked in a shipyard for 25 years
dies of a thoracic tumor. Autopsy reveals a pleural tumor that
encases the lung. Interstitial pulmonary fi brosis and multiple
pleural plaques are noted. Numerous, brown, beaded ferruginous
bodies are also found in the lungs (shown in the image).
Which of the following agents is most likely associated with
the pathogenesis of the cancer in this patient?

Answer 2

2. Asbestos

Question 3

A 47-year-old man presents with a 6-week history of increasing
fatigue and dark-colored stools. Complete blood count
shows hemoglobin of 8.6 g/dL and microcytic, hypochromic
RBCs. Upper gastrointestinal endoscopy reveals a peptic
ulcer along the lesser curvature of the stomach. This patient’s
anemia is most likely caused by defi ciency of which of the
following?

Answer 3

3. Iron

Question 4

A 49-year-old woman presents with a 2-month history of
yellow discoloration of her eyes, abdominal pain, weight loss,
and low-grade fever (38.4°C, 101°F). Physical examination
shows a distended abdomen, right upper quadrant tenderness,
and a palpable liver 2 cm below the costal margin. A liver
biopsy reveals alcoholic hepatitis. The patient recovers and
is strongly advised to abstain from alcohol. However, she
subsequently imbibes some antifreeze containing ethylene
glycol and develops acute failure of which organ?

Answer 4

4. kidney

Question 5

A neonate was noted to have mild growth retardation and
facial dysmorphology. The mother was a known abuser of
several substances. This infant’s problem most likely resulted
from maternal intake of which of the following?

Answer 5

5. Alcohol

Question 6

A 10-year-old boy presents with irritability and ataxia. He
is subsequently found to have anemia, basophilic stippling
of erythrocytes, and dark-gray pigmentation of the gums.
Exposure to which of the following chemical agents is most
likely associated with this disease?

Answer 6

6. Lead

Question 7

A 50-year-old man presents for a routine physical examination,
which demonstrates an enlarged liver. During the visit,
he describes memos from his supervisor at work regarding
chronic exposure to vinyl chloride. The patient has an elevated
risk for which of the following tumors?

Answer 7

7. Angiosarcoma of the liver.

Question 8

A severely depressed 32-year-old man commits suicide
by running his car motor in his closed garage for several
hours. The mechanism of death in this case of carbon
monoxide (CO) poisoning is through which of the following
mechanisms?

Answer 8

8. Displacement of oxygen on hemoglobin by CO.

Question 9

A Japanese fi sherman who lives in the vicinity of a plastics
factory develops severe neurologic symptoms, including
constriction of visual fi elds, paresthesias, ataxia, dysarthria,
and hearing loss. Public health authorities fi nd a number of
similar cases in the local village. Exposure to which of the
following chemical agents is most likely associated with the
pathogenesis of this man’s neurologic disease

Answer 9

9. Mercury

Question 10

A 12-year-old boy is rescued 2 days after becoming lost
in the Canadian woods in February. Physical examination
shows he has gangrene of his fi ngers and toes. Which of the
following mechanisms of cell injury played the most important
role in mediating necrosis in the fi ngers and toes of this
patient?

Answer 10

10. Membrane disruption by water crystals.

Question 11

A 35-year-old man is hospitalized with third-degree burns
after being rescued from a house fi re. Initially, he suffers from
shock and oliguria, but his renal function returns to normal
within a few days. Which of the following would be the most
likely cause of death if complications were to arise?

Answer 11

11. Sepsis

Question 12

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

Answer 12

12. Heat Stroke

Question 13

A 26-year-old electrician is found unconscious in his backyard
beside a metal ladder and an exposed electrical wire, suffering
from a deep burn on his right hand. Resuscitation attempts
are unsuccessful. Which of the following was the most likely
cause of death?

Answer 13

13. Cardiac arrhythmia.

Question 14

A sailor on a nuclear-powered submarine is seen by a physician
after a breach in the reactor containment system. Physical
examination is unremarkable, but the patient subsequently
develops profound pancytopenia. Hemoglobin is 7.8 g/dL,
WBC count is 900/μL, and platelets are 20,000/μL. How
many rads of acute total-body radiation did this patient most
likely receive?

Answer 14

14. 300

Question 15

Another sailor on the submarine (see Question 14) dies
10 days after the accident as a result of severe diarrhea and
dehydration. Which of the following doses (in rads) of acute
total-body radiation did this sailor most likely receive?

Answer 15

15. 1000

Question 16

A 66-year-old woman presents with a 6-month history of scaling
and abnormal pigmentation of the skin. Her past medical
history is signifi cant for the treatment of thyroid cancer 1 year
ago. Biopsy of lesional skin shows atrophy of the epidermis
and dense fi brosis of the dermis, which displays dilated superfi
cial blood vessels. These pathologic fi ndings are most likely
caused by previous exposure to which of the following?

Answer 16

16. Radiation therapy

Question 17

A 28-year-old radar technician aboard an aircraft carrier has
been subjected to intense microwave radiation for 7 years. He
has an elevated risk for developing which of the following?

Answer 17

17. None of the above

Question 18

A 15-year-old African boy has a history of tooth loss, gingivitis,
skin hemorrhages, multiple infections, and poor wound healing.
Physical examination shows that the child is in the 20th
percentile for height and 10th percentile for weight. This patient
most likely has which of the following underlying conditions

Answer 18

18. Scurvy

Question 19

A 24-year-old woman, who is a food faddist, eats only cornbased
foods. She presents with dermatitis, diarrhea, and
dementia. This patient most likely suffers from which of the
following conditions?

Answer 19

19. Pellagra

Question 20

A 45-year-old woman with longstanding Crohn disease and
severe fat malabsorption experiences a fracture of the femoral
neck after a minor contusion. This woman most likely has a
defi ciency of which of the following vitamins?

Answer 20

20. Vitamin D

Question 21

A homeless man, who is a chronic alcoholic, is brought to the
hospital in a wasted state. He is noted to have a neuropathy, diffi culty balancing, and dementia. He dies suddenly
of an arrhythmia, and at autopsy, lesions are found in
the mamillary bodies and the vicinity of the third ventricle.
The vitamin defi ciency associated with these signs and symptoms
is which of the following?peripheral

Answer 21

21. Vitamin B1

Question 22

A 40-year-old, malnourished woman presents with a 6-month
history of night blindness. Physical examination reveals keratomalacia
and corneal ulceration. Which of the following vitamin
defi ciencies would be suspected in this patient?

Answer 22

22. Vitamin A

Question 23

A 26-year-old woman presents to the emergency room with fever
and shaking chills. Her temperature is 38.7°C (103°F), pulse
120 per minute, and blood pressure 140/80 mm Hg. Physical
examination reveals a harsh systolic murmur. The patient develops
a headache, slips into a coma and expires. The aortic valve is
examined at autopsy (shown in the image). Which of the following
is the most important risk factor for this pathologic fi nding

Answer 23

23. IV Drug abuse

Question 24

50-year-old woman presents with easy fatigability, a smooth
sore tongue, numbness and tingling of the feet, and weakness
of the legs. A complete blood count shows a megaloblastic
anemia that is not reversed by folate therapy. Hemoglobin is
5.6 g/dL, WBC count is 5,100/μL, and platelets are 240,000/
μL. This patient most likely has a defi ciency of which of the
following vitamins?

Answer 24

24. Vitamin B12

Question 25

A starving, 4-year-old, African boy presents with apathy, generalized
edema, and an enlarged fatty liver. The physician
notes that, despite generalized growth failure, subcutaneous
fat is preserved. What is the appropriate diagnosis?

Answer 25

25. Kwashiorkor

Question 26

Petechial hemorrhages were noticed on the upper and lower
extremities of a 5-day-old infant. Hemorrhagic disease of the
neonate was most likely caused by a defi ciency of which of the
following vitamins?

Answer 26

26. Vitamin K

Question 27

A 6-year-old girl is examined at a clinic in central Africa.
Physical examination reveals wasting of muscle and fat, and a
protuberant abdomen. Her pulse, blood pressure, and temperature
are low. The face appears wrinkled. There is no evidence
of generalized edema. What is the appropriate diagnosis?

Answer 27

27. Marasmus

Question 28

A 40-year-old, chronically ill man from a Vietnamese village
presents with painful sores around his mouth. Physical examination
reveals prominent fi ssures at the angles of his mouth.
Cheilosis in this patient is most likely caused by a defi ciency
of which of the following vitamins?

Answer 28

28. Vitamin B2 (riboflavin)

Question 29

A 32-year-old woman is a vegan (i.e., a strict vegetarian who
eats no animal products of any kind). She is weak and pale,
and laboratory studies show a macrocytic, normochromic
anemia (hemoglobin = 6.2 g/dL). This patient most likely has
which of the following vitamin defi ciencies?

Answer 29

29. Vitamin B12

Question 30

A 46-year-old man complains of weakness, dyspnea on exertion,
and palpitations. His temperature is 37°C (98.6°F), pulse
95 per minute, respirations 24 per minute, and blood pressure
120/80 mm Hg. Physical examination reveals pulmonary
rales and peripheral edema. Laboratory studies show normal
serum cholesterol (180 mg/dL) and elevated fasting blood

Answer 30

30. Chronic alcoholism.

Question 31

A 28-year-old pregnant woman weighs 86.4 kg (190 lb) and
gives birth after 39 weeks of gestation to a small baby weighing
2,300 g (5 lb, 1 oz). The baby has no congenital anomalies.
Which of the following maternal factors in this case may
be associated with the infant’s low birth weight?

Answer 31

31. Smoking.

Question 32

A 52-year-old man presents with sudden crushing chest pain
and tachycardia. He admits to cigarette smoking, consumption
of alcohol, and abuse of illicit drugs. An ECG is consistent
with ischemic change in the anteroseptal region of the heart.
Laboratory studies show elevated serum levels of CK-MB and
troponin I. Serum cholesterol is 240 mg/dL. Which of the following
most likely contributed to this patient’s condition?

Answer 32

32. Cigarette smoking

Question 33

A 52-year-old man presents with a chronic cough and shortness
of breath. He admits to smoking two packs of cigarettes a day
for 30 years. Pulmonary function tests reveal chronic obstructive
pulmonary disease. In counseling this patient, you advise
him to stop smoking immediately. You also mention that, in
addition to emphysema, which of the following organs carries
a signifi cantly increased risk of smoking-related cancer?

Answer 33

33. pancreas

Question 34

A homeless, poorly nourished man collapses on the street and
cannot be revived by the emergency medical technicians. A
social service agency notes that he had a long history of abusing
many illicit drugs. An autopsy is performed and reveals a
moderately enlarged heart, with patent coronary arteries and
no valvular abnormalities. Microscopic examination shows
patchy fi brosis of the myocardium. Which of the following
substances most likely caused this cardiomyopathy?

Answer 34

34. cocaine

Question 35

A 52-year-old, obese man (BMI = 34 kg/m2) presents to his
physician with complaints of hoarseness for 2 months. He has
worked in a chemical factory for 25 years and gives a history
of smoking, consumption of one or two beers a day, and
occasional use of illicit drugs. Physical examination reveals
enlarged and fi rm cervical lymph nodes. Direct laryngoscopy
reveals a fi xed and enlarged left vocal cord, which appears
ulcerated. A biopsy of the lesion is interpreted by the pathologist
as squamous cell carcinoma. What is the most likely cause
of this man’s disease?

Answer 35

35. cigarette smoking

Question 36

A 48-year-old man complains of weakness and easy fatigability
for 6 weeks. He has worked for 20 years in a chemical factory
that produces a variety of plastics and other synthetic compounds.
A complete blood count shows a hemoglobin level
of 8.2 g/dL, WBC count of 45,000/μL, and a platelet count
of 40,000/μL. Examination of a bone marrow aspirate reveals
numerous malignant myeloblasts, and a diagnosis of acute
myeloid leukemia is made. Exposure to which of the following
agents is the most likely cause of this patient’s hematologic
disease?

Answer 36

36. Benzene.

Question 37

A 48-year-old woman complains she has had weakness, fatigue,
and easy bruisability for 2 months. She had worked as a technician
in a nuclear energy plant for 15 years and was involved
in an accident during which she was exposed to considerable
radiation. Physical examination reveals an enlarged liver and
spleen. What disease should you suspect as a likely cause of
her condition?

Answer 37

37. Chronic myelogenous leukemia

Question 38

A 16-year-old girl has suffered from severe celiac disease for
years and reports continued steatorrhea. She suddenly develops
abdominal pain in the right lower quadrant. A complete
blood count shows a hemoglobin level of 14 g/dL, WBC of
18,000/μL, with 84% neutrophils, and a platelet count of
280,000/μL. A diagnosis of appendicitis is made, and tests
before surgery reveal a prolonged prothrombin time of 17
seconds (control = 2). What is the most likely cause of her
coagulation problem?

Answer 38

38. vitamin K deficiency

Question 39

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

Answer 39

39. laceration