Histopathology SBAs Flashcards
A 65-year-old patient with advanced breast malignancy and a history of multiple
systemic emboli suffers a stroke. On examination, there are no cardiac murmurs
but an echocardiogram reveals small bland vegetations on the mitral valve.
Blood cultures are negative. What is the most likely diagnosis?
A Infective endocarditis
B Acute rheumatic fever
C Non-bacterial thrombotic endocarditis
D Chronic rheumatic valvular disease
E Libman–Sacks endocarditis
C Non-bacterial thrombotic endocarditis
Non-bacterial thrombotic endocarditis (NBTE; C) commonly affects
patients over 40 years of age and is often characterized by the absence
of inflammation or bacteria. Sterile fibrin and platelet vegetations are
present on cardiac valves, more commonly affecting left-sided heart
valves (mitral > aortic) and are also associated with numerous diseases,
especially advanced stage malignancy. NBTE is a source of thromboembolism
to the brain, heart, kidneys, and recurrent emboli are a hallmark
feature.
A 41-year-old man presents with severe central chest pain which he describes as
‘tearing’ in nature and radiating to the back. He is tall, with long limbs and long
thin fingers. He also has an aortic regurgitation murmur. Histologically there is
cystic medial necrosis in the aortic wall. In which syndrome are these findings
most likely?
A Ortner’s syndrome
B Ehlers–Danlos syndrome
C Down syndrome
D Turner syndrome
E Marfan syndrome
E Marfan syndrome
Cystic medial necrosis is a disorder particularly affecting the aorta,
causing focal degeneration of the elastic tissue and muscle fibres in the
media, with accumulation of basophilic ground substance. This leads
to cyst-like pools between the fibres disrupting the normally parallel
arrays. Clinically, aneurysm formation becomes more likely. It is
more frequent after 40 years of age and is twice as common in males.
There is evidence that links cystic medial necrosis to aortic dissection
in patients with a variety of syndromes, the most common of which is
Marfan’s syndrome (E). These patients are characteristically tall with
long limbs and long thin fingers
A 57-year-old overweight patient suffers an acute myocardial infarction and
subsequently dies. A post-morterm examination of the infarcted area shows
extensive cell infiltration including polymorphs and macrophages. There is also
extensive debris post necrosis and the cytoplasm is homogeneous making it
difficult to see the outlines of the myocardial fibres. There is no evidence of
collagenization or a scar. How long after the initial attack did the patient die?
A At the time of the attack (0–6 hours)
B Hours after the attack (6–24 hours)
C Days after the attack (1–4 days)
D Within the first 2 weeks of the attack (4–14 days)
E Weeks and months after (14 days +)
C Days after the attack (1–4 days)
At 1–4 days (C) following an acute MI, the start of an extensive
acute inflammatory response takes place with cell infiltration. Debris
is left by the necrosis in the previous stage and the cytoplasm is homogeneous
so that it is difficult to see the outlines of the myocardial fibres.
Infiltration of polymorphs, and later macrophages, takes place. Removal
of the debris takes place at about 5–10 days.
A 35-year-old woman presents to accident and emergency with nausea, severe
malaise, swelling and stiffness of the fingers. On examination, her blood pressure
is 155/95 mmHg and she has Raynaud’s phenomenon. Blood tests reveal positive
anti-topoisomerase antibodies and deranged serum creatinine and urea. A biopsy
result of her small arteries reveals an onion skin appearance. What is the most
likely diagnosis?
A Systemic lupus erythematosus
B Diffuse scleroderma
C Kawasaki’s disease
D Polyarteritis nodosa
E Limited scleroderma/CREST
B Diffuse scleroderma
Scleroderma exists as limited and diffuse forms. This patient has internal
involvement with the evidence of renal failure, which is consistent with
diffuse scleroderma (B), which is a rapidly progressing condition that
affects a large area of skin and one or more internal organs such as the
kidneys, oesophagus and heart.
A 46-year-old woman presents with gradual muscle weakness in her neck and
upper arms over the past 3 weeks. She is also said to have a purple ‘heliotrope’
rash on her upper eyelids, an erythematous scaling rash on her face and red
patches on the knees. She has also experienced some weight loss. Blood tests
reveal elevated skeletal muscle enzymes but electromyogram results were negative.
What is the most likely diagnosis?
A Polymyositis
B Henoch–Schönlein purpura
C Dermatomyositis
D Kawasaki disease
E Sarcoidosis
C Dermatomyositis
Dermatomyositis (C) has the muscle components involved in polymyositis
but in addition it is accompanied by periorbital oedema and a characteristic
purple ‘heliotrope’ rash on the upper eyelids. Heliotrope is a pink/
purple colour that one only hears about in reference to dermatomyositis,
but is actually the colour of the heliotrope flaver. It is also commonly
present with an erythematous, scaling rash on the face, shoulders, upper
arms and chest, with red patches over the knuckles, elbows and knees.
Weight loss and arthralgia may also present
A 43-year-old man presents with a rest tremor, slowness of voluntary movement
and rigidity. It is reported that he has a mutation of the alpha-synuclein protein
and he is free of Lewy bodies on histological examination. What is the most
likely diagnosis?
A Familial Parkinson’s disease
B Alzheimer’s disease
C Multiple system atrophy
D Multiple sclerosis
E Idiopathic Parkinson’s disease
A Familial Parkinson’s disease
The alpha-synuclein protein is a major component of Lewy bodies. Its
true function is unknown but its accumulation has a toxic effect on
plasma membranes. In the rare cases of familial forms of Parkinson’s
disease (A), there is a mutation in the gene coding for alpha-synuclein
and this condition is free of Lewy bodies. Patients with these mutations
have a worse prognosis with earlier onset and non-responsiveness to
levodopa.
The activity of the plaques in a 25-year-old multiple sclerosis patient is described with the presence of oedema and macrophages, and some myelin breakdown. Which ICDNS (International Classification of Diseases of the Nervous System) plaque type classification best fits the description?
A Acute plaque
B Early chronic active plaque
C Late chronic active plaque
D Chronic inactive plaque
E Shadow plaque
B Early chronic active plaque
Early chronic active plaque (B): Oedema and macrophages, indicative of
an inflammatory disorder of the central nervous system, with some myelin
breakdown. Reactive astrocytosis is present
A 72-year-old woman is diagnosed with a disease that accounts for 50–75 per
cent of all cases of dementia. The four characteristic pathological features for her
diagnosis are severe brain atrophy, loss of neurons, senile plaques and neurofibllirary
tangles. What is the most likely diagnosis?
A Huntington’s disease
B Alzheimer’s disease
C Multiple system atrophy
D Dementia with Lewy bodies
E Parkinson’s disease
B Alzheimer’s disease
Alzheimer’s disease (AD) (B) accounts for 50–75 per cent of all cases
of dementia in Western countries. Dementia is the progressive loss of
cognitive function due to degeneration of the cerebral cortex. There is
severe brain atrophy particularly prominent in the hippocampus and
the frontal lobes and the brain weight is reduced to 1000 grams or
less (normal average being 1400 grams). Histological hallmarks of the
disease include senile plaques, which are complex spherical structures
involving the grey matter and the aggregation of beta-amyloid appears
to play a central role in developing the senile plaques. Neurofibrillary
tangles are abnormal tangles in neuronal cell bodies of insoluble
cytoskeletal-like tau protein. It is believed that the major antigenic component
is the phosphorylated tau.
A 32-year-old man has a past medical history of severe gastro-oesophageal
reflux disease. His most recent oesophageal biopsy shows a columnar epithelium
with goblet cells suggestive of a diagnosis of Barrett’s oesophagus. What form of
cell change is this also known as?
A Anaplasia
B Hyperplasia
C Metaplasia
D Dysplasia
E Neoplasia
C Metaplasia
The normal oesophagus is lined by stratified squamous epithelium and
the squamo-columnar junction lies 2 cm above the gastro-oesophageal
junction and is recognized by an irregular white line known as the Z
line. Barrett’s oesophagus occurs due to long standing reflux, and is the
re-epithelialization by metaplastic columnar epithelium with goblet cells
replacing normal squamous epithelium. This is known as metaplasia (C),
which is the conversion from one type of differentiated tissue to another.
It is reversible and often represents an adaptive response to environmental
stress. Surveillance is crucial with repeated biopsy to detect a
potential adenocarcinoma early, which is becoming more common than
squamous cell carcinomas.
A 38-year-old man is a known gastritis patient. The most recent endoscopy and
biopsy has detected that the area most severely affected is the pyloric antrum. He
also has susceptibility for developing a gastric MALT lymphoma in the future.
What is the most likely diagnosis?
A Menetrier’s disease (hyperplastic hypersecretory gastropathy)
B Acute gastritis
C Helicobacter-associated chronic gastritis
D Autoimmune chronic gastritis
E Reactive/reflux chronic gastritis
C Helicobacter-associated chronic gastritis
Helicobacter pylori-associated gastritis (C) is the most common form of
chronic gastritis, accounting for 90 per cent of cases, and it is known
that the pyloric antrum is the most severely affected area. An immune
response is established and the infection may potentially persist for
years. Around three-quarters of MALT (mucosa-associated lymphoid tissue)
lymphoma or MALToma cases are associated with H. pylori infection.
MALT is a system of small lymphoid tissue that regulates mucosal
immunity and is present in a variety of organs in the body.
A 50-year-old known alcoholic man has persistent severe epigastric pain radiating
to the back and has experienced weight loss of 5 kg in 2 months. On initial
presentation, the patient is not jaundiced. On contrast enhanced CT scan there
are multiple calcific densities along the line of the main pancreatic duct. On
histological examination, there is evidence of parenchymal fibrosis and large
ducts containing insipissated secretions. What is the most likely diagnosis?
A Chronic pancreatitis
B Carcinoma in the head of the pancreas
C Diabetes mellitus type 2
D Acute pancreatitis
E Pseudocysts
A Chronic pancreatitis
Chronic pancreatitis (A) causes irreversible loss of function. Histology
shows chronic inflammation with parenchymal fibrosis, loss of pancreatic
parenchymal elements and duct strictures with formation of
intrapancreatic calculi. Jaundice may occur; it is a presenting feature in
only a small proportion of patients and would be secondary to common
bile duct obstruction during its course through the fibrosed head of the
pancreas. Grossly, the pancreas is replaced by firm fibrous tissue within
which are dilated ducts and areas of calcification
A 22-year-old man presents with polyuria and polydipsia. His fasting plasma
glucose is 7.3 mmol/L. He is Glutamic Acid Decarboxylase (GAD) antibody
positive. What is the most likely diagnosis?
A Diabetes mellitus type 1
B Diabetes insipidus
C Psychogenic polydipsia
D Diabetes mellitus type 2
E Zollinger–Ellison syndrome
A Diabetes mellitus type 1
Diabetes mellitus type (1) (A) is an autoimmune disorder of childhood/
adolescent onset that is characterized by antibody-mediated destruction
of beta-cells of the islets of Langerhans. Ninety to ninety-five per cent
of patients are HLA DR3 and HLA DR4 positive. Type 1 diabetes can present
with polyuria as in this case, or, if the polyuria is ignored, with diabetic
ketoacidosis. The peak incidence of type 1 diabetes is 12–14 years,
so the patient being young also makes this type 1 diabetes
A 37-year-old man, while abroad, was involved in a road traffic accident and
required a blood transfusion. He had an episode of acute hepatitis with the contraction
of a DNA virus of the Hepadna group. There is a small chance this may
progress to chronic hepatitis. What is the most likely viral hepatitis type?
A Hepatitis A
B Hepatitis B
C Hepatitis C
D Hepatitis D
E Hepatitis E
B Hepatitis B
Hepatitis B (B) is a DNA virus of the Hepadna group. Transmission is commonly
blood-borne but these can also be sexual and vertical transmission
from mother to child. Most commonly, the infection can be asymptomatic
with complete recovery, but also patients can develop acute or chronic
hepatitis B infection. These patients always have a risk of developing
chronic hepatitis. Hepatitis A (A) infection never causes chronic hepatitis.
A 42-year-old woman, who has a history of joint and skin symptoms, presents
with jaundice. Anti-mitochondrial antibodies are present and histologically there
is evidence of a progressive, chronic granulomatous inflammation of the bile
duct. What is the most likely diagnosis?
A Primary sclerosing cholangitis
B Autoimmune hepatitis
C Primary biliary cirrhosis
D α-1 Antitrypsin deficiency
E Alcoholic liver disease
C Primary biliary cirrhosis
Primary biliary cirrhosis (C) is the destruction of the intrahepatic bile duct, often associated with an immune component, with anti-mitochondrial antibodies present in 90 per cent of cases and associations with other autoimmune diseases such as rheumatoid arthritis or scleroderma. Primary sclerosing cholangitis (A) also presents with obstructive jaundice and probably has an autoimmune element to it, but is very unlikely to show any autoantibodies. Sixty per cent of cases are associated with ulcerative colitis.
A 23-year-old patient has an autosomal recessive disorder. The patient has
demonstrated parkinsonian symptoms such as a hand tremor and has developed
chronic hepatitis. On examination, he is found to have Kayser–Fleischer
rings. Blood levels of serum ceruloplasmin are low. What is the most likely
diagnosis?
A Wilson’s disease
B Genetic haemochromatosis
C α-1 Antitrypsin deficiency
D Reye’s syndrome
E Budd–Chiari syndrome
A Wilson’s disease
Wilson’s disease (A) is an autosomal recessive metabolic disorder that is
caused by a mutation in the copper transport ATPase gene on chromosome
13. It results in failure of the liver to secrete the copper–ceruloplasmin
complex into the plasma. This creates an overspill of copper
into the blood that typically causes liver disease, central nervous system
disease resembling Parkinson’s disease and the characteristic development
of brown discolouration around the cornea (Kayser–Fleischer
rings).
An 8-year-old Down syndrome boy presents with constipation, distended abdomen,
vomiting and overflow diarrhoea. The cause is believed to be absence of
ganglion cells in the myenteric plexus causing the failure of the dilation of the
distal colon. What is the most likely diagnosis?
A Stenosis
B Hirschsprung’s disease
C Atresia
D Intussusception
E Volvulus
B Hirschsprung’s disease
Congenital aganglionic megacolon, also known as Hirschsprung’s disease
(B), is believed to be due to the absence of ganglion cells in the
myenteric plexus causing the failure of the dilation of the distal colon.
Macroscopically, there is narrowing of an abnormally innervated bowel
segment yet dilation and muscular hypertrophy of the bowel segment
proximal to this. Microscopically, there is an absence of normal myenteric
and submucosal plexus ganglion cells. The condition often presents
in early childhood with symptoms of colonic obstruction. There has
been a reported association of this condition with Down syndrome.
A 25-year-old white man is experiencing bloody diarrhoea and mucous discharge.
Macroscopic analysis shows abnormality in the colon and rectum only and is
continuous with a normal bowel wall thickness. The pattern of inflammation is confined to the mucosa of the bowel wall and no evidence of granulomas exists.
What is the most likely diagnosis?
A Crohn’s disease
B Ulcerative colitis
C Ischaemic colitis
D Pseudomembranous colitis
E Viral gastroenteritis
B Ulcerative colitis
Ulcerative colitis (B) is inflammation affecting the rectum and colon only in a contiguous fashion. There are many extra-intestinal manifestations including arthritis, myositis, uveitis/iritis, erythema nodosum, pyoderma gangrenosum and primary sclerosing cholangitis
A 39-year-old man is diagnosed with a colon cancer proximal to the splenic
flexure that is poorly differentiated and highly aggressive. There are no associated
adenomata. It is an autosomal dominant condition that involves gene mutations
of DNA mismatch repair genes. What is the most likely diagnosis?
A Familial adenomatous polyposis
B Gardner’s syndrome
C Colorectal carcinoma
D Hereditary non-polyposis colorectal cancer
E Hamartomatous polyps
D Hereditary non-polyposis colorectal cancer
Hereditary non-polyposis colorectal cancer (HNPCC) (D) is an uncommon
autosomal dominant disease but the cancers are poorly differentiated and
highly aggressive, therefore screening for identification of carriers for surveillance
is necessary.
A 25-year-old woman presents to clinic with an inability to conceive and a past
history of Chlamydia trachomatis infection. On ultrasonography, she is diagnosed
with hydrosalpinx. Hydrosalpinx is the most likely complication of which of the
below options?
A Endometriosis
B Adenomyosis
C Cervical intraepithelial neoplasia
D Salpingitis
E Human papillomavirus
D Salpingitis
Salpingitis (pelvic inflammatory disease; D) is inflammation of the fallopian
tubes that is almost always caused by infection, in particular
sexually transmitted infections including chlamydia, mycoplasma and
gonococcus. Other related infections, such as an actinomyces infection,
are associated with intrauterine contraceptive device use. Hydrosalpinx,
a complication of salpingitis, is the dilation of the fallopian tube that is
thin-walled and contains clear fluid. This is believed to be a sequel to
previous inflammatory damage to the tube. The scarring sequelae are
believed to include plical fusion, adhesions to the ovary, tubo-ovarian
abscess, peritonitis, hydrosalpinx, infertility and ectopic pregnancy.
A 42-year-old Afro-Caribbean woman is nulliparous and trying to conceive. She
has been experiencing dysmenorrhoea. Ultrasound scan shows multiple rounded
nodules within the myometrium. What is the most likely diagnosis?
A Cervical intraepithelial neoplasia
B Vulval carcinoma
C Leiomyoma
D Endometrial carcinoma
E CGIN (endocervical glandular dysplasia)
C Leiomyoma
Leiomyoma (C), also called fibroids, is a benign smooth muscle tumour
arising in the myometrium. They are the most common of all pelvic
tumours, presenting often in women over 30 years of age and are more
common in nulliparous and Afro-Caribbean women. The presentation
often involves multiple large rounded nodules. They are well circumscribed
with a pseudocapsule that may become pedunculated forming
polyps.