U2-Robbins-C11: Vasculitis Flashcards
The development of atheromatous plaque formation with subsequent complications is observed in an experiment.
Atherosclerotic plaques are shown to change slowly but constantly in ways that can promote clinical events, including
acute coronary syndromes. In some cases, changes occurred that were not significantly associated with acute coronary
syndromes. Which of the following plaque alterations is most likely to have such an association?
□ (A) Thinning of the media
□ (B) Ulceration of the plaque surface
□ (C) Thrombosis
□ (D) Hemorrhage into the plaque substance
□ (E) Intermittent platelet aggregatio
(A) Atheromatous plaques can be complicated by various pathologic alterations, including hemorrhage, ulceration,
thrombosis, and calcification. These processes can increase the size of the plaque and narrow the residual arterial lumen.
Although atherosclerosis is a disease of the intima, in advanced disease, the expanding plaque compresses the media.
This causes thinning of the media, which weakens the wall and predisposes it to aneurysm formation.
A 60-year-old woman has reported increasing fatigue over the past year. Laboratory studies show a serum creatinine
level of 4.7 mg/dL and urea nitrogen level of 44 mg/dL. An abdominal ultrasound scan shows that her kidneys are
symmetrically smaller than normal. The high-magnification microscopic appearance of the kidneys is shown in the figure.
These findings are most likely to indicate which of the following underlying conditions?
□ (A) Escherichia coli septicemia
□ (B) Systemic hypertension
□ (C) Adenocarcinoma of the colon
□ (D) Tertiary syphilis
□ (E) Polyarteritis nodosa
(B) The figure shows an arteriole with marked hyaline thickening of the wall, indicative of hyaline arteriolosclerosis.
Diabetes mellitus also can lead to this finding. Sepsis can produce disseminated intravascular coagulopathy with arteriolar
hyaline thrombi. The debilitation that accompanies cancer tends to diminish the vascular disease caused by atherosclerosis. Syphilis can cause a vasculitis involving the vasa vasorum of the aorta. Polyarteritis can involve large to
medium-sized arteries in many organs, including the kidneys; the affected vessels show fibrinoid necrosis and
inflammation of the wall (vasculitis).
A 55-year-old woman visits her physician for a routine health maintenance examination. On physical examination, her
temperature is 36.8°C, pulse is 70/min, respirations are 14/min, and blood pressure is 160/105 mm Hg. Her lungs are clear
on auscultation, and her heart rate is regular. She feels fine and has had no major medical illnesses or surgical
procedures during her lifetime. An abdominal ultrasound scan shows that the left kidney is smaller than the right kidney. A
renal angiogram shows a focal stenosis of the left renal artery. Which of the following laboratory findings is most likely to
be present in this patient?
□ (A) Anti–double-stranded DNA titer 1 : 512
□ (B) C-ANCA titer 1 : 256
□ (C) Cryoglobulinemia
□ (D) Plasma glucose level 200 mg/dL
□ (E) HIV test positive
□ (F) Plasma renin 15 mg/mL/hr
□ (G) Serologic test for syphilis positive
(F) This is a classic example of a secondary form of hypertension for which a cause can be determined. In this case, the
renal artery stenosis reduces glomerular blood flow and pressure in the afferent arteriole, resulting in renin release by
juxtaglomerular cells. The renin initiates angiotensin II–induced vasoconstriction, increased peripheral vascular resistance,
and increased aldosterone, which promotes sodium reabsorption in the kidney, resulting in increased blood volume. Anti–
double-stranded DNA is a specific marker for systemic lupus erythematosus. ANCAs are markers for some forms of
vasculitis, such as microscopic polyangiitis or Wegener granulomatosis. Some patients with hepatitis B or C infection can
develop a mixed cryoglobulinemia with a polyclonal increase in IgG. Renal involvement in such patients is common, and
cryoglobulinemic vasculitis then leads to skin hemorrhages and ulceration. Hyperglycemia is a marker for diabetes
mellitus, which accelerates the atherogenic process and can involve the kidneys, promoting the development of
hypertension. HIV infection is not related to hypertension. Tertiary syphilis can produce endaortitis and aortic root dilation,
but hypertension is not a likely sequela.
A 7-year-old child has had abdominal pain and dark urine for 10 days. Physical examination shows purpuric skin lesions
on the trunk and extremities. Urinalysis shows hematuria and proteinuria. Serologic test results are negative for P-ANCAs
and C-ANCAs. A skin biopsy specimen shows necrotizing vasculitis of small dermal vessels. A renal biopsy specimen
shows immune complex deposition in glomeruli, with some IgA-rich immune complexes. Which of the following is the most
likely diagnosis?
□ (A) Giant cell arteritis
□ (B) Henoch-Schönlein purpura
□ (C) Polyarteritis nodosa
□ (D) Takayasu arteritis
□ (E) Telangiectasias
□ (F) Wegener granulomatosis
(B) In children, Henoch-Schönlein purpura is the multisystemic counterpart of the IgA nephropathy seen in adults. The
immune complexes formed with IgA produce the vasculitis that affects mainly arterioles, capillaries, and venules in skin,
gastrointestinal tract, and kidney. In older adults, giant-cell arteritis is seen in external carotid branches, principally the
temporal artery unilaterally. Polyarteritis nodosa is seen most often in small muscular arteries and sometimes veins, with
necrosis and microaneurysm formation followed by scarring and vascular occlusion. This occurs mainly in the kidney,
gastrointestinal tract, and skin of young to middle-aged adults. Takayasu arteritis is seen mainly in children and involves
the aorta (particularly the arch) and branches such as coronary and renal arteries, with granulomatous inflammation,
aneurysm formation, and dissection. Telangiectasias are small vascular arborizations seen on skin or mucosal surfaces.
Wegener granulomatosis, seen mainly in adults, involves small arteries, veins, and capillaries and causes mixed
inflammation and necrotizing and non-necrotizing granulomatous inflammation with geographic necrosis surrounded by
palisading epithelioid macrophages and giant cells.
A 30-year-old woman has had coldness and numbness in her arms and decreased vision in the right eye for the past 5
months. On physical examination, she is afebrile. Her blood pressure is 100/70 mm Hg. Radial pulses are not palpable, but
femoral pulses are strong. She has decreased sensation and cyanosis in her arms, but no warmth or swelling. A chest
radiograph shows a prominent border on the right side of the heart and prominence of the pulmonary arteries. Laboratory
studies show serum glucose, 74 mg/dL; creatinine, 1 mg/dL; total serum cholesterol, 165 mg/dL; and negative ANA test
result. Her condition remains stable for the next year. Which of the following is the most likely diagnosis?
□ (A) Aortic dissection
□ (B) Kawasaki disease
□ (C) Microscopic polyangiitis
□ (D) Takayasu arteritis
□ (E) Tertiary syphilis
□ (F) Thromboangiitis obliterans
(D) Takayasu arteritis leads to “pulseless disease” because of involvement of the aorta (particularly the arch) and
branches such as coronary, carotid, and renal arteries, with granulomatous inflammation, aneurysm formation, and
dissection. Fibrosis is a late finding, and the pulmonary arteries also can be involved. Aortic dissection is an acute problem
that, in older adults, is driven by atherosclerosis and hypertension, although this patient is within the age range for
complications of Marfan syndrome, which causes cystic medial necrosis of the aorta. Kawasaki disease affects children
and is characterized by an acute febrile illness, coronary arteritis with aneurysm formation and thrombosis, skin rash, and
lymphadenopathy. Microscopic polyangiitis affects arterioles, capillaries, and venules with a leukocytoclastic vasculitis that
appears at a similar stage in multiple organ sites (in contrast to classic polyarteritis nodosa, which causes varying stages
of acute, chronic, and fibrosing lesions in small to medium-sized arteries). Tertiary syphilis produces an endaortitis with
proximal aortic dilation. Thromboangiitis obliterans (Buerger disease) affects small to medium-sized arteries of the
extremities and is strongly associated with smoking.
A 61-year-old man had a myocardial infarction 1 year ago, which was the first major illness in his life. He now wants to
prevent another myocardial infarction and is advised to begin a program of exercise and to change his diet. A reduction in
the level of which of the following serum laboratory findings 1 year later would best indicate the success of this diet and
exercise regimen?
□ (A) Cholesterol
□ (B) Glucose
□ (C) Potassium
□ (D) Renin
□ (E) Calcium
(A) Reducing cholesterol, particularly LDL cholesterol, with the same or increased HDL cholesterol level, indicates a
reduced risk of atherosclerotic complications. Atherosclerosis is multifactorial, but modification of diet (i.e., reduction in
total dietary fat and cholesterol) with increased exercise is the best method of reducing risk for most individuals. Glucose is
a measure of control of diabetes mellitus. Potassium, calcium, and renin values can be altered with some forms of
hypertension, one of several risk factors for atherosclerosis
A 23-year-old man experiences sudden onset of severe, sharp chest pain. On physical examination, his temperature is
36.9°C, and his lungs are clear on auscultation. A chest radiograph shows a widened mediastinum. Transesophageal
echocardiography shows a dilated aortic root and arch, with a tear in the aortic intima 2 cm distal to the great vessels. The
representative microscopic appearance of the aorta with elastic stain is shown in the figure. Which of the following is the
most likely cause of these findings?
□ (A) Scleroderma
□ (B) Diabetes mellitus
□ (C) Systemic hypertension
□ (D) Marfan syndrome
□ (E) Wegener granulomatosis
□ (F) Takayasu arteritis
(D) This is a description of cystic medial degeneration, which weakens the aortic media and predisposes to aortic
dissection. In a young patient such as this, a heritable disorder of connective tissues, such as Marfan syndrome, must be
strongly suspected. Scleroderma and Wegener granulomatosis do not typically involve the aorta. Atherosclerosis
associated with diabetes mellitus and hypertension are risk factors for aortic dissection, although these are seen at an
older age. Takayasu arteritis is seen mainly in children and involves the aorta (particularly the arch) and branches such as the coronary and renal arteries, causing granulomatous inflammation, aneurysm formation, and dissection
A 40-year-old man with a history of diabetes mellitus has had worsening abdominal pain for the past week. On physical
examination, his vital signs are temperature, 36.9°C; pulse, 77/min; respirations, 16/min; and blood pressure,
140/90 mm Hg. An abdominal CT scan shows the findings in the figure. Laboratory studies show his hemoglobin A1C is
10.5%. Which of the following is the most likely underlying disease process in this patient?
□ (A) Polyarteritis nodosa
□ (B) Obesity
□ (C) Diabetes mellitus
□ (D) Systemic lupus erythematosus
□ (E) Syphilis
(C) This patient has an atherosclerotic abdominal aortic aneurysm. His abdominal CT scan shows a 6-cm fusiformshaped
enlargement of the abdominal aorta. Diabetes mellitus, an important risk factor for atherosclerosis, must be
suspected if a younger man or premenopausal woman has severe atherosclerosis. His hemoglobin A1C value is consistent
with poorly controlled diabetes mellitus. Polyarteritis nodosa does not typically involve the aorta. Obesity, a “soft” risk
factor for atherosclerosis, also contributes to diabetes mellitus type 2; however, the extent of atherosclerotic disease in this
patient suggests early-onset diabetes mellitus, which is more likely to be type 1. Systemic lupus erythematosus produces
small arteriolar vasculitis. Syphilitic aortitis, a feature of tertiary syphilis, most often involves the thoracic aorta, but it is
rare, and most thoracic aortic aneurysms nowadays are likely to be caused by atherosclerosis
A 10-year-old boy is brought to the physician for a routine health maintenance examination. The physician notes a 2-cm spongy, dull red, circumscribed lesion on the upper outer left arm. The parents state that this lesion has been present
since infancy. The lesion is excised, and its microscopic appearance is shown in the figure. Which of the following is the
most likely diagnosis?
□ (A) Kaposi sarcoma
□ (B) Angiosarcoma
□ (C) Lymphangioma
□ (D) Telangiectasia
□ (E) Hemangioma
(E) The figure shows dilated, endothelium-lined spaces filled with RBCs. The circumscribed nature of this lesion and its
long, unchanged course suggest its benign nature. Kaposi sarcoma is uncommon in its endemic form in childhood, and it
is best known as a neoplastic complication associated with HIV infection. Angiosarcomas are large, rapidly growing
malignancies in adults. Lymphangiomas, seen most often in children, tend to be more diffuse and are not blood-filled. A
telangiectasia is a radial array of subcutaneous dilated arteries or arterioles surrounding a central core that can pulsate
A pharmaceutical company is developing an antiatherosclerosis agent. An experiment investigates mechanisms of
action of several potential drugs to determine their efficacy in reducing atheroma formation. Which of the following
mechanisms of action is likely to have the most effective antiatherosclerotic effect?
□ (A) Inhibits PDGF/Inhibits macrophage-mediated lipoprotein oxidation
□ (B) Inhibits PDGF/Promotes macrophage-mediated lipoprotein oxidation
□ (C) Promotes PDGF/Promotes macrophage-mediated lipoprotein oxidation
□ (D) Decreases HDL/Inhibits macrophage-mediated lipoprotein oxidation
□ (E) Increases HDL/Promotes macrophage-mediated lipoprotein oxidation
□ (F) Decreases ICAM-1/Promotes macrophage-mediated lipoprotein oxidation
□ (G) Increases ICAM-1/Inhibits macrophage-mediated lipoprotein oxidation
(A) Atherosclerosis is considered a complex reparative response that follows endothelial cell injury.
Hypercholesterolemia (high LDL cholesterol level) is believed to cause subtle endothelial injury. The oxidation of LDL by
macrophages or endothelial cells has many deleterious effects. Oxidized LDL is chemotactic for circulating monocytes,
causes monocytes to adhere to endothelium, stimulates release of growth factors and cytokines, and is cytotoxic to
smooth muscle cells and endothelium. Smooth muscle proliferation in response to injury, important in the development of
atheromas, is driven by growth factors, including platelet-derived growth factor. HDL is believed to mobilize cholesterol
from developing atheromas; high HDL levels are protective. Intercellular adhesion molecule-1 (ICAM-1) and vascular cell
adhesion molecule-1 (VCAM-1) are adhesion molecules on endothelial cells that promote adhesion of monocytes to the
site of endothelial injury.
A 73-year-old man who has had progressive dementia for the past 6 years dies of bronchopneumonia. Autopsy shows
that the thoracic aorta has a dilated root and arch, giving the intimal surface a “tree-bark” appearance. Microscopic
examination of the aorta shows an obliterative endarteritis of the vasa vasorum. Which of the following laboratory findings
is most likely to be recorded in this patient’s medical history?
□ (A) High double-stranded DNA titer
□ (B) P-ANCA positive 1 : 1024
□ (C) Sedimentation rate 105 mm/hr
□ (D) Ketonuria 4+
□ (E) Antibodies against Treponema pallidum
(E) This description is most suggestive of syphilitic aortitis, a complication of tertiary syphilis, with characteristic
involvement of the thoracic aorta. Obliterative endarteritis is not a feature of other forms of vasculitis. High-titer doublestranded
DNA antibodies are diagnostic of systemic lupus erythematosus, and the test result for P-ANCA is positive in
various vasculitides, including microscopic polyangiitis. A high sedimentation rate is a nonspecific marker of inflammatory
diseases. Ketonuria can occur in individuals with diabetic ketoacidosis
For the past 3 weeks, a 70-year-old woman has been bedridden while recuperating from a bout of viral pneumonia
complicated by bacterial pneumonia. Physical examination now shows some swelling and tenderness of the right leg,
which worsens when she raises or moves the leg. Which of the following terms best describes the condition involving the
patient’s right leg?
□ (A) Lymphedema
□ (B) Disseminated intravascular coagulopathy
□ (C) Thrombophlebitis
□ (D) Thromboangiitis obliterans
□ (E) Varicose veins
(C) Thrombophlebitis is a common problem that results from venous stasis. There is little or no inflammation, but the
term is well established. Lymphedema takes longer than 3 weeks to develop and is not caused by bed rest alone.
Disseminated intravascular coagulopathy more often results in hemorrhage, and edema is not the most prominent
manifestation. Thromboangiitis obliterans is a rare form of arteritis that results in pain and ulceration of extremities.
Varicose veins are superficial and can thrombose, but they are not related to bed rest
A 49-year-old man is feeling well when he visits his physician for a routine health maintenance examination for the first
time in 20 years. On physical examination, his vital signs are temperature, 37°C; pulse, 73/min; respirations, 14/min; and
Robbins & Cotran Review of Pathology Pg. 200
time in 20 years. On physical examination, his vital signs are temperature, 37°C; pulse, 73/min; respirations, 14/min; and
blood pressure, 155/95 mm Hg. He has had no serious medical problems and takes no medications. Which of the following
is most likely to be the primary factor in this patient’s hypertension?
□ (A) Increased catecholamine secretion
□ (B) Renal retention of excess sodium
□ (C) Gene defects in aldosterone metabolism
□ (D) Renal artery stenosis
□ (E) Increased production of atrial natriuretic factor
(B) This patient has essential hypertension (no obvious cause for his moderate hypertension). Renal retention of
excess sodium, which is thought to be important in initiating this form of hypertension, leads to increased intravascular fluid
volume, increase in cardiac output, and peripheral vasoconstriction. Increased catecholamine secretion (as can occur in
pheochromocytoma) , gene defects in aldosterone metabolism, and renal artery stenosis all can cause secondary
hypertension. Hypertension secondary to all causes is much less common, however, than essential hypertension.
Increased production of atrial natriuretic factor reduces sodium retention and reduces blood volume.
A 50-year-old man has a 2-year history of angina pectoris that occurs during exercise. On physical examination, his
blood pressure is 135/75 mm Hg, and his heart rate is 79/min and slightly irregular. Coronary angiography shows a fixed
75% narrowing of the anterior descending branch of the left coronary artery. Which of the following types of cells is the
initial target in the pathogenesis of this arterial lesion?
□ (A) Monocytes
□ (B) Smooth muscle cells
□ (C) Platelets
□ (D) Neutrophils
□ (E) Endothelial cells
(E) Atherogenesis can be considered a chronic inflammatory response of the arterial wall to endothelial injury. The injury promotes participation by monocytes, macrophages, and T lymphocytes. Smooth muscle cells are stimulated to
proliferate. Platelets adhere to areas of endothelial injury. Neutrophils are not a part of atherogenesis, although they can
be seen in various forms of vasculitis. The process begins with endothelial cell alteration.
A study of atheroma formation leading to atherosclerotic complications evaluates potential risk factors for relevance in a
population. Three factors are found to play a significant role in the causation of atherosclerosis: smoking, hypertension,
and hypercholesterolemia. These factors are analyzed for their relationship to experimental models for atherogenesis.
Which of the following events is the most important direct biologic consequence of these factors?
□ (A) Endothelial injury and its sequelae
□ (B) Conversion of smooth muscle cells to foam cells
□ (C) Alterations of hepatic lipoprotein receptors
□ (D) Inhibition of LDL oxidation
□ (E) Alterations of endogenous factors regulating vasomotor tone
(A) Atherosclerosis is thought to result from a form of endothelial injury and the subsequent chronic inflammation and
repair of the intima. All risk factors, including smoking, hyperlipidemia, and hypertension, cause biochemical or mechanical
injury to the endothelium. Formation of foam cells occurs after the initial endothelial injury. Although lipoprotein receptor
alterations can occur in some inherited conditions, these account for only a fraction of cases of atherosclerosis, and other
lifestyle conditions do not affect their action. Inhibition of LDL oxidation should diminish atheroma formation. Vasomotor
tone does not play a major role in atherogenesis.
A 55-year-old woman has noted the increasing prominence of unsightly dilated superficial veins over both lower legs for
the past 5 years. Physical examination shows temperature of 37°C, pulse of 70/min, respirations of 14/min, and blood
pressure of 125/85 mm Hg. There is no pain, swelling, or tenderness in either lower leg. Which of the following
complications is most likely to occur as a consequence of this condition?
□ (A) Stasis dermatitis
□ (B) Gangrenous necrosis of the lower legs
□ (C) Pulmonary thromboembolism
□ (D) Disseminated intravascular coagulation
□ (E) Atrophy of the lower leg muscles
(A) Venous stasis results in hemosiderin deposition and dermal fibrosis, with brownish discoloration and skin
roughening. Focal ulceration can occur over the varicosities, but extensive gangrene similar to that seen in arterial
atherosclerosis does not occur. The varicosities involve only the superficial set of veins, which can thrombose, but are not
the source of thromboemboli, as are the larger, deep leg veins. The thromboses in superficial leg veins do not lead to
disseminated intravascular coagulopathy. The varicosities do not affect muscle; however, lack of muscular support for
veins to “squeeze” blood out for venous return can predispose to formation of varicose veins.
A 35-year-old man is known to have been HIV-positive for the past 10 years. Physical examination shows several skin
lesions with the appearance shown in the figure. These lesions have been slowly increasing for the past year. Which of
the following infectious agents is most likely to play a role in the development of these skin lesions?
□ (A) Human herpesvirus-8
□ (B) Epstein-Barr virus
□ (C) Cytomegalovirus
□ (D) Hepatitis B virus
□ (E) Adenovirus
(A) Human herpesvirus-8 has been associated with Kaposi sarcoma and can be acquired as a sexually transmitted
disease. Kaposi sarcoma is a complication of AIDS. Individuals with HIV infection can be infected with various viruses,
including Epstein-Barr virus (EBV) and cytomegalovirus (CMV), but these have no etiologic association with Kaposi
sarcoma. EBV is a factor in the development of non-Hodgkin lymphoma, and CMV can cause colitis or retinitis or can be
disseminated. Hepatitis B virus can be seen in HIV-infected patients as well, particularly patients with a risk factor of
injection drug use. Adenovirus, which, although rare, can be seen in HIV-infected individuals, tends to be a respiratory or
gastrointestinal infection.
A 50-year-old man complains of a chronic cough that has persisted for the past 18 months. Physical examination shows
nasopharyngeal ulcers, and the lungs have diffuse crackles bilaterally on auscultation. Laboratory studies include a serum
urea nitrogen level of 75 mg/dL and a creatinine concentration of 6.7 mg/dL. Urinalysis shows 50 RBCs per high-power
field and RBC casts. His serologic titer for C-ANCA is elevated. A chest radiograph shows multiple, small, bilateral
pulmonary nodules. A nasal biopsy specimen shows mucosal and submucosal necrosis and necrotizing granulomatous
inflammation. A transbronchial lung biopsy specimen shows a vasculitis involving the small peripheral pulmonary arteries
and arterioles. Granulomatous inflammation is seen within and adjacent to small arterioles. Which of the following is the
most likely diagnosis?
□ (A) Fibromuscular dysplasia
□ (B) Glomus tumors
□ (C) Granuloma pyogenicum
□ (D) Hemangiomas
□ (E) Kaposi sarcoma
□ (F) Polyarteritis nodosa
□ (G) Takayasu arteritis
□ (H) Wegener granulomatosis
(H) Wegener granulomatosis is a form of hypersensitivity reaction to an unknown antigen characterized by necrotizing
granulomatous inflammation that typically involves the respiratory tract, small to medium-sized vessels, and glomeruli,
although many organ sites may be affected; pulmonary and renal involvement can be life-threatening. C-ANCAs are found
in more than 90% of cases. Fibromuscular dysplasia is a hyperplastic medial disorder, usually involving renal and carotid
arteries; on angiography, it appears as a “string of beads” caused by thickened fibromuscular ridges adjacent to less
involved areas of the arterial wall. Glomus tumors are usually small peripheral masses. Granuloma pyogenicum is an
inflammatory response that can produce a nodular mass, often on the gingiva or the skin. Hemangiomas are typically
small, solitary, red nodules that can occur anywhere. Kaposi sarcoma can produce plaquelike to nodular masses that are
composed of irregular vascular spaces lined by atypical-appearing endothelial cells; skin involvement is most common, but
visceral organ involvement can occur. Polyarteritis nodosa most often involves small muscular arteries, and sometimes
veins; it causes necrosis and microaneurysm formation followed by scarring and vascular occlusion, mainly in the kidney,
gastrointestinal tract, and skin of young to middle-aged adults. Takayasu arteritis is seen mainly in children and involves
the aorta (particularly the arch) and branches such as the coronary and renal arteries, with granulomatous inflammation,
aneurysm formation, and dissection. Telangiectasias are small vascular arborizations seen on skin or mucosal surfaces.
While cleaning debris out of the gate in an irrigation canal, a 50-year-old man cuts his right index finger on a sharp
metal shard. The cut stops bleeding within 3 minutes, but 6 hours later he notes increasing pain in the right arm and goes
to his physician. On physical examination, his temperature is 38°C. Red streaks extend from the right hand to the upper
arm, and the arm is swollen and tender when palpated. Multiple tender lumps are noted in the right axilla. A blood culture
grows group A hemolytic streptococci. Which of the following terms best describes the process that is occurring in this
patient’s right arm?
□ (A) Capillaritis
□ (B) Lymphangitis
□ (C) Lymphedema
□ (D) Phlebothrombosis
□ (E) Polyarteritis nodosa
Robbins & Cotran Review of Pathology Pg. 202
□ (F) Thrombophlebitis
□ (G) Varices
(B) The red streaks represent lymphatic channels through which an acute infection drains to axillary lymph nodes, and
these drain to the right lymphatic duct and into the right subclavian vein (lymphatics from the lower body and left upper
body drain to the thoracic duct). Capillaritis is most likely to be described in the lungs. Lymphedema occurs with blockage
of lymphatic drainage and develops over a longer period without significant acute inflammation. Phlebothrombosis and
thrombophlebitis describe thrombosis in veins with stasis and inflammation, typically in the pelvis and lower extremities.
Polyarteritis involves small to medium-sized muscular arteries, typically the renal and mesenteric branches. Varices are
veins dilated from blockage of venous drainage
An experiment studies early atheromas. Lipid streaks on arterial walls are examined microscopically and biochemically
to determine their cellular and chemical constituents and the factors promoting their formation. Early lesions show
increased attachment of monocytes to endothelium. The monocytes migrate subendothelially and become macrophages;
these macrophages transform themselves into foam cells. Which of the following is most likely to produce these effects?
□ (A) C-reactive protein
□ (B) Homocysteine
□ (C) Lp(a)
□ (D) Oxidized LDL
□ (E) Platelet-derived growth factor
□ (F) VLDL
(D) Oxidized LDL can be taken up by a special “scavenger” pathway in macrophages; it also promotes monocyte
chemotaxis and adherence. Macrophages taking up the lipid become foam cells that begin to form the fatty streak.
Smoking, diabetes mellitus, and hypertension all promote free radical formation, and free radicals increase degradation of
LDL to its oxidized form. About one third of LDL is degraded to the oxidized form; a higher LDL level increases the amount
of oxidized LDL available for uptake into macrophages. C-reactive protein is a marker for inflammation, which can increase
with more active atheroma and thrombus formation and predicts a greater likelihood of acute coronary syndromes.
Increased homocysteine levels promote atherogenesis through endothelial dysfunction. Lp(a), an altered form of LDL that
contains the apo B-100 portion of LDL linked to apo A, promotes lipid accumulation and smooth muscle cell proliferation.
Platelet-derived growth factor promotes smooth muscle cell proliferation. VLDL is formed in the liver and transformed in
adipose tissue and muscle to LDL.
A 12-year-old boy died of complications of acute lymphocytic leukemia. The gross appearance of the aorta at autopsy
is shown in the figure. Histologic examination of the linear pale marking is most likely to show which of the following
features?
□ (A) Cap of smooth muscle cells overlying a core of lipid debris
□ (B) Collection of foam cells with necrosis and calcification
□ (C) Granulation tissue with a lipid core and areas of hemorrhage
□ (D) Lipid-filled foam cells and small numbers of T lymphocytes
□ (E) Cholesterol clefts surrounded by proliferating smooth muscle cells and foam cells
(D) The slightly raised, pale lesions shown in the figure are called fatty streaks and are seen in the aorta of almost all
children older than 10 years. They are thought to be precursors of atheromatous plaques. T cells are present early in the
pathogenesis of atherosclerotic lesions and are believed to activate monocytes, endothelial cells, and smooth muscle cells
by secreting cytokines. Fatty streaks cause no disturbances in blood flow and are discovered incidentally at autopsy. All of
the other lesions described are seen in fully developed atheromatous plaques. The histologic features of such plaques
include a central core of lipid debris that can have cholesterol clefts and can be calcified. There is usually an overlying cap
of smooth muscle cells. Hemorrhage is a complication seen in advanced atherosclerosis. Foam cells, derived from smooth
muscle cells or macrophages that have ingested lipid, can be present in all phases of atherogenesis.
A 59-year-old man has experienced chest pain at rest for the past year. On physical examination, his pulse is 80/min
and irregular. The figure shows the microscopic appearance representative of the patient’s left anterior descending artery.
Which of the following laboratory findings is most likely to have a causal relationship to the process illustrated?
□ (A) Low Lp(a)
□ (B) Positive VDRL
Robbins & Cotran Review of Pathology Pg. 203
□ (C) Low HDL cholesterol
□ (D) Elevated platelet count
□ (E) Low plasma homocysteine
(C) The figure shows an arterial lumen that is markedly narrowed by atheromatous plaque complicated by calcification.
Hypercholesterolemia with elevated LDL and decreased HDL levels is a key risk factor for atherogenesis. Levels of Lp(a)
and homocysteine, if elevated, increase the risk of atherosclerosis. Syphilis (positive VDRL test result) produces
endarteritis obliterans of the aortic vasa vasorum, which weakens the wall and predisposes to aneurysms. Although
platelets participate in forming atheromatous plaques, their number is not of major importance. Thrombocytosis can result
in thrombosis or hemorrhage
After falling down a flight of stairs, a 59-year-old woman experiences mild intermittent right hip pain. Physical
examination shows a 3-cm contusion over the right hip. The area is tender to palpation, but she has full range of motion of
the right leg. A radiograph of the pelvis and right upper leg shows no fractures, but does show calcified, medium-sized
arterial branches in the pelvis. This radiographic finding is most likely to represent which of the following?
□ (A) Long-standing diabetes mellitus
□ (B) Benign essential hypertension
□ (C) An incidental observation
□ (D) Increased risk for gangrenous necrosis
□ (E) Unsuspected hyperparathyroidism
(C) Older adults with calcified arteries often have Mönckeberg medial calcific sclerosis, a benign process that is a form
of arteriosclerosis with no serious sequelae. Such arterial calcification is far less likely to be a consequence of
atherosclerosis with diabetes mellitus or with hypercalcemia. Hypertension is most likely to affect small renal arteries, and
calcification is not a major feature, although hypertension also is a risk factor for atherosclerosis
For more than a decade, a 45-year-old man has had poorly controlled hypertension ranging from 150/90 mm Hg to
160/95 mm Hg. Over the past 3 months, his blood pressure has increased to 250/125 mm Hg. On physical examination,
his temperature is 36.9°C. His lungs are clear on auscultation, and his heart rate is regular. There is no abdominal pain on
palpation. A chest radiograph shows a prominent border on the left side of the heart. Laboratory studies show that his
serum creatinine level has increased during this time from 1.7 mg/dL to 3.8 mg/dL. Which of the following vascular lesions
is most likely to be found in this patient’s kidneys?
□ (A) Hyperplastic arteriolosclerosis
□ (B) Granulomatous arteritis
□ (C) Fibromuscular dysplasia
□ (D) Polyarteritis nodosa
□ (E) Hyaline arteriolosclerosis
(A) This patient has malignant hypertension superimposed on benign essential hypertension. Malignant hypertension
can suddenly complicate less severe hypertension. The arterioles undergo concentric thickening and luminal narrowing. A
granulomatous arteritis is most characteristic of Wegener granulomatosis, which often involves the kidney. Fibromuscular
dysplasia can involve the main renal arteries, with medial hyperplasia producing focal arterial obstruction. This process
can lead to hypertension, but not typically malignant hypertension. Polyarteritis nodosa produces a vasculitis that can
involve the kidney. Hyaline arteriolosclerosis is seen with long-standing essential hypertension of moderate severity.
These lesions give rise to benign nephrosclerosis. The affected kidneys become symmetrically shrunken and granular
because of progressive loss of renal parenchyma and consequent fine scarring
After a mastectomy with axillary node dissection for breast cancer 1 year ago, a 47-year-old woman has developed
persistent swelling and puffiness in the left arm. Physical examination shows firm skin over the left arm and “doughy”
underlying soft tissue. The arm is not painful or discolored. She developed cellulitis in the left arm 3 months ago. Which of
the following terms best describes these findings?
□ (A) Thrombophlebitis
□ (B) Subclavian arterial thrombosis
□ (C) Tumor embolization
□ (D) Lymphedema
□ (E) Vasculitis
(D) A mastectomy with axillary lymph node dissection leads to disruption and obstruction of lymphatics in the axilla.
Such obstruction to lymph flow gives rise to lymphedema, a condition that can be complicated by cellulitis.
Thrombophlebitis from venous stasis is a complication seen more commonly in the lower extremities. An arterial
thrombosis can lead to a cold, blue, painful extremity. Tumor emboli are generally small but uncommon. Vasculitis is not a
surgical complication
A study is conducted to investigate the pathogenesis of atherosclerosis. The investigators have developed genetically
modified mice that have hypercholesterolemia and spontaneously develop atherosclerosis. Next, the investigators
selectively delete individual genes to determine the factors that are crucial to the development of atherosclerosis. Deletion
of the gene encoding for which of the following is most likely to reduce the experimentally observed atherosclerosis in
these modified mice?
□ (A) Von Willebrand factor
□ (B) Homocysteine
□ (C) T-cell receptor
□ (D) Endothelin
□ (E) Fibrillin
□ (F) LDL receptor
□ (G) Factor VIII
□ (H) Apolipoprotein
(C) Deletion of T-cell receptor genes prevents T-cell development (because engagement of T-cell receptors during
development in the thymus is essential for T cell survival). Early in the course of atheroma formation, the T cells adhere to VCAM-1 on activated endothelial cells and migrate into the vessel wall. These T cells, activated by some unknown
mechanism, secrete various proinflammatory molecules that recruit and activate monocytes and smooth muscle cells and
perpetuate chronic inflammation of the vessel wall. The loss of T cells reduces atherosclerosis. Von Willebrand factor is
required for normal platelet adhesion to collagen, and its absence leads to abnormal bleeding. Homocysteine can damage
endothelium, and its absence may protect against atherosclerosis, but there is no evidence that homocysteine is the major
factor in initiating endothelial damage. That role, most likely, belongs to cholesterol. Endothelin is a vasoconstrictor with no
known role in atherogenesis. Fibrillin loss causes weakness of the arterial media, with risk for dissection, as seen in
Marfan syndrome. A reduction in LDL receptors or decreased apolipoprotein promotes atherogenesis in familial
hypercholesterolemia. Decreased factor VIII leads to abnormal bleeding.
An 80-year-old man with a lengthy history of smoking survived a small myocardial infarction several years ago. He now
reports chest and leg pain during exercise. On physical examination, his vital signs are temperature, 36.9°C; pulse, 81/min;
respirations, 15/min; and blood pressure, 165/100 mm Hg. Peripheral pulses are poor in the lower extremities. There is a
7-cm pulsating mass in the midline of the lower abdomen. Laboratory studies include two fasting serum glucose
measurements of 170 mg/dL and 200 mg/dL. Which of the following vascular lesions is most likely to be present in this
patient?
□ (A) Aortic dissection
□ (B) Arteriovenous fistula
□ (C) Atherosclerotic aneurysm
□ (D) Glomus tumor
□ (E) Polyarteritis nodosa
□ (F) Takayasu arteritis
□ (G) Thromboangiitis obliterans
(C) Abdominal aneurysms are most often related to underlying atherosclerosis. This patient has multiple risk factors for
atherosclerosis, including diabetes mellitus, hypertension, and smoking. When the aneurysm reaches this size, there is a
significant risk of rupture. An aortic dissection is typically a sudden, life-threatening event with dissection of blood out of
the aortic lumen, typically into the chest, without a pulsatile mass. The risk factors for atherosclerosis and hypertension
underlie aortic dissection. An arteriovenous fistula can produce an audible bruit on auscultation. Glomus tumors are
usually small peripheral masses. Polyarteritis nodosa can produce small microaneurysms in small arteries. Takayasu
arteritis typically involves the aortic arch and branches in children. Thromboangiitis obliterans (Buerger disease) is a rare
condition with occlusion of the muscular arteries of the lower extremities in smokers
A 61-year-old man has smoked two packs of cigarettes per day for the past 40 years. He has experienced increasing
dyspnea for the past 6 years. On physical examination, his vital signs are temperature, 37.1°C; pulse, 60/min; respirations,
18/min and labored; and blood pressure, 130/80 mm Hg. On auscultation, expiratory wheezes are heard over the chest
bilaterally. His heart rate is regular. A chest radiograph shows increased lung volume, with flattening of the diaphragms,
greater lucency to all lung fields, prominence of pulmonary arteries, and a prominent border on the right side of the heart.
Laboratory studies include blood gas measurements of Po2 of 80 mm Hg, Pco2 of 50 mm Hg, and pH of 7.35. He dies of
pneumonia. At autopsy, the pulmonary arteries have atheromatous plaques. Which of the following is most likely to have
caused these findings?
□ (A) Chronic renal failure
□ (B) Coronary atherosclerosis
□ (C) Cystic fibrosis
□ (D) Diabetes mellitus
□ (E) Familial hypercholesterolemia
□ (F) Obesity
□ (G) Phlebothrombosis
□ (H) Pulmonary emphysema
(H) The pulmonary vasculature is under much lower pressure than the systemic arterial circulation and is much less
likely to have endothelial damage, which promotes atherogenesis. Atherosclerosis in systemic arteries is more likely to
occur where blood flow is more turbulent, a situation that occurs at arterial branch points, such as in the first few
centimeters of the coronary arteries or in the abdominal aorta. Factors driving systemic arterial atherosclerosis (e.g.,
hyperlipidemias, smoking, diabetes mellitus, and systemic hypertension) do not operate in the pulmonary arterial
vasculature. Pulmonary hypertension, the driving force behind pulmonary atherosclerosis, occurs when pulmonary
vascular resistance increases as the pulmonary vascular bed is decreased by either obstructive (e.g., emphysema, as in
this patient) or restrictive (e.g., as in scleroderma with pulmonary interstitial fibrosis) diseases. Cystic fibrosis leads to
widespread bronchiectasis, not emphysema, but cystic fibrosis is still an obstructive lung disease with the potential to
produce pulmonary hypertension. Obesity leads to pulmonary hypoventilation, which acts as a restrictive lung disease, but
pulmonary hypoventilation does not increase lung volumes, as in this patient. Phlebothrombosis affects veins and leads to
possible pulmonary thromboembolism, which increases pulmonary pressures, but more acutely than in this patient.
A 75-year-old man has experienced headaches for the past 2 months. On physical examination, his vital signs are
temperature, 36.8°C; pulse, 68/min; respirations, 15/min; and blood pressure, 130/85 mm Hg. His right temporal artery is
prominent, palpable, and painful to the touch. His heart rate is regular, and there are no murmurs. A temporal artery biopsy
is performed, and the segment of temporal artery excised is grossly thickened and shows focal microscopic granulomatous
inflammation. He responds well to corticosteroid therapy. Which of the following complications of this disease is most likely to occur in untreated patients?
□ (A) Renal failure
□ (B) Hemoptysis
□ (C) Malignant hypertension
□ (D) Blindness
□ (E) Gangrene of the toes
(D) This patient has clinical features suggesting giant-cell (temporal) arteritis. This form of arteritis typically involves
large to medium-sized arteries in the head (especially temporal arteries), but also vertebral and ophthalmic arteries.
Involvement of the latter can lead to blindness. Because involvement of the kidney, lung, and peripheral arteries of the
extremities is much less common, renal failure, hemoptysis, and gangrene of toes are unusual. There is no association
between hypertension and giant-cell arteritis.
A 30-year-old woman has smoked one pack of cigarettes per day since she was a teenager. She has had painful
thromboses of the superficial veins of the lower legs for 1 month and episodes during which her fingers become blue and
cold. Over the next year, she develops chronic, poorly healing ulcerations of her feet. One toe becomes gangrenous and
is amputated. Histologically, at the resection margin, there is an acute and chronic vasculitis involving medium-sized
arteries, with segmental involvement. Which of the following is the most appropriate next step in treating this patient?
□ (A) Hemodialysis
□ (B) Smoking cessation
□ (C) Corticosteroid therapy
□ (D) Antibiotic therapy for syphilis
□ (E) Insulin therapy
(B) This patient has features of thromboangiitis obliterans (Buerger disease). This disease, which affects small to
medium-sized arteries of the extremities, is strongly associated with smoking. Renal involvement does not occur.
Immunosuppressive therapy is not highly effective. Syphilis produces an aortitis. Although peripheral vascular disease with
atherosclerosis is a typical finding in diabetes mellitus, vasculitis is not.
A 40-year-old man has experienced malaise, fever, and a 4-kg weight loss over the past month. On physical
examination, his blood pressure is 145/90 mm Hg, and he has mild diffuse abdominal pain, but no masses or
hepatosplenomegaly. Laboratory studies include a serum urea nitrogen concentration of 58 mg/dL and a serum creatinine
level of 6.7 mg/dL. Renal angiography shows right renal arterial thrombosis, and the left renal artery and branches show
segmental luminal narrowing with focal aneurysmal dilation. During hemodialysis 1 week later, the patient experiences
abdominal pain and diarrhea and is found to have melena. Which of the following serologic laboratory findings is most
likely to be positive in this patient?
□ (A) C-ANCA
□ (B) ANA
□ (C) HIV
□ (D) HBsAg
□ (E) Scl-70
□ (F) RPR
(D) Segmental involvement of medium-sized arteries with aneurysmal dilation in the renal vascular bed and presumed
mesenteric vasculitis (e.g., abdominal pain, melena) is most likely caused by classic polyarteritis nodosa. Polyarteritis can
affect many organs at different times. Although the cause of polyarteritis is unknown, about 30% of patients have hepatitis
B surface antigen in serum. Presumably, hepatitis B surface antigen-antibody complexes damage the vessel wall. In
contrast to the situation with microscopic polyangiitis, there is less of an association with ANCA. A collagen vascular
disease with a positive ANA test result, such as systemic lupus erythematosus, may produce a vasculitis, but not in the
pattern seen here; the affected vessels are smaller. Vasculitis with HIV infection is uncommon. The Scl-70 autoantibody is
indicative of scleroderma, which can produce renal failure. The rapid plasma reagin (RPR) is a serologic test for syphilis; an endaortitis of the vasa vasorum can occur in syphilis
A 30-year-old schoolteacher is known to be a strict disciplinarian in the classroom. She has angina pectoris of 6
months’ duration. On physical examination, her blood pressure is 135/85 mm Hg. She is 168 cm (5 ft 5 in) tall and weighs
82 kg (BMI 29). Coronary angiography shows 75% narrowing of the anterior descending branch of the left coronary artery.
Angioplasty with stent placement is performed. Which of the following is the major risk factor associated with these
findings?
□ (A) Obesity
□ (B) Type A personality
□ (C) Diabetes mellitus
□ (D) Sedentary lifestyle
□ (E) Age
(C) Diabetes mellitus is a significant risk factor for early, accelerated, and advanced atherosclerosis. If a
premenopausal woman or a young man has severe coronary atherosclerosis, diabetes must be suspected as a
predisposing factor. “Soft” risk factors that can play a lesser role in the development of atherosclerosis include obesity,
stress, and lack of exercise
A 46-year-old man visits his physician because he has noted increasing abdominal enlargement over the past 15
months. Physical examination shows several skin lesions on the upper chest that have central pulsatile cores. Pressing on
a core causes a radially arranged array of subcutaneous arterioles to blanch. The size of the lesions, from core to
periphery, is 0.5 to 1.5 cm. Laboratory studies show serum glucose of 119 mg/dL, creatinine of 1.1 mg/dL, total protein of
5.8 g/dL, and albumin of 3.4 g/dL. Which of the following underlying diseases is most likely to be present in this patient?
□ (A) Wegener granulomatosis
□ (B) Micronodular cirrhosis
□ (C) Marfan syndrome
□ (D) AIDS
□ (E) Diabetes mellitus
(B) These lesions are spider telangiectasias, which are a feature of micronodular cirrhosis, typically as a consequence
of chronic alcoholism. Spider telangiectasias are thought to be caused by hyperestrogenism (estrogen excess) that results
from hepatic damage. Vasculitis does not tend to produce skin telangiectasias. The vascular involvement in Marfan
syndrome is primarily in the aortic arch with cystic medial necrosis. The most common vascular skin lesion in patients with
AIDS is Kaposi sarcoma, which is a neoplasm that manifests as one or more irregular, red-to-purple patches, plaques, or
nodules. Diabetes mellitus, with its accelerated atherosclerosis, is most likely to result in ischemia or gangrene
A 22-year-old woman complains of itching with burning pain in the perianal region for the past 4 months. Physical
examination shows dilated and thrombosed external hemorrhoids. Which of the following underlying processes is most
likely to be present in this patient?
□ (A) Rectal adenocarcinoma
□ (B) Pregnancy
□ (C) Polyarteritis nodosa
□ (D) Filariasis
□ (E) Micronodular cirrhosis
(B) The hemorrhoidal veins can become dilated from venous congestion. This situation is most common in patients
with chronic constipation, but the pregnant uterus presses on pelvic veins to produce similar congestion, which promotes
hemorrhoidal vein dilation. Carcinomas are not likely to obstruct venous flow. Polyarteritis does not affect veins. Filarial
infections can affect lymphatics, including those in the inguinal region, and produce lymphedema. Portal hypertension with
cirrhosis is most likely to dilate submucosal esophageal veins, but hemorrhoidal veins occasionally can be affected.
Cirrhosis would be rare, however, at this patient’s age
A clinical study is performed that includes a group of subjects whose systemic blood pressure measurements are
consistently between 145/95 mm Hg and 165/105 mm Hg. They are found to have increased cardiac output and increased
peripheral vascular resistance. Renal angiograms show no abnormal findings, and CT scans of the abdomen show no
masses. Laboratory studies show normal levels of serum creatinine and urea nitrogen. The subjects take no medications.
Which of the following laboratory findings is most likely to be present in this group of subjects?
□ (A) Lack of angiotensin-converting enzyme
□ (B) Decreased urinary sodium
□ (C) Elevated plasma renin
□ (D) Hypokalemia
□ (E) Increased urinary catecholamines
(B) The findings in this population group suggest essential hypertension, which has several postulated theories for its
cause. One theory is that there are defects in renal sodium homeostasis that reduce renal sodium excretion. The kidney
retains sodium and water, increasing intravascular fluid volume, which drives increased cardiac output. Cardiac output is
compensated by increasing peripheral vascular resistance, causing an increase in blood pressure. If angiotensinconverting
enzyme (ACE) were absent, blood pressure would decrease because angiotensin I would not be converted to
angiotensin II (drugs that act as ACE inhibitors are antihypertensives). An elevated plasma renin level is typical of
renovascular hypertension, which can occur with narrowing of a renal artery. Hypertensive patients with hypokalemia also
can have hyperaldosteronemia, which can be caused by an aldosterone-secreting adrenal adenoma. Increased urinary
catecholamines can indicate increased catecholamine output from a pheochromocytoma
A 3-year-old child from Osaka, Japan, developed a fever and a rash and swelling of her hands and feet over 2 days.
On physical examination, her temperature is 37.8°C. There is a desquamative skin rash, oral erythema, erythema of the
palms and soles, edema of the hands and feet, and cervical lymphadenopathy. The child improves after a course of
intravenous immunoglobulin therapy. Which of the following is most likely to be a complication of this child’s disease if it is
untreated?
□ (A) Asthma
□ (B) Glomerulonephritis
□ (C) Intracranial hemorrhage
□ (D) Myocardial infarction
□ (E) Pulmonary hypertension
(D) This child has mucocutaneous lymph node syndrome, or Kawasaki disease, which involves large, medium-sized,
and small arteries. Cardiovascular complications occur in 20% of cases and include thrombosis, ectasia, and aneurysm
formation of coronary arteries. Asthma can be seen in association with Churg-Strauss vasculitis. Glomerulonephritis is a
feature of Wegener granulomatosis and of autoimmune diseases such as systemic lupus erythematosus. Intracranial
hemorrhage can occur with septic emboli to peripheral cerebral arteries, producing mycotic aneurysms that can rupture.
Pulmonary hypertension can complicate Takayasu arteritis
An epidemiologic study seeking to determine possible risk factors for neoplasia is reviewing patient cases of neoplasms reported to tumor registries. Analysis of the data shows that one type of neoplasm is seen in two widely disparate
situations: (1) the liver of individuals exposed to polyvinyl chloride and (2) the soft tissue of the arm ipsilateral to a prior
radical mastectomy. The pathology reports about the neoplasms in these two groups of patients show a similar gross
appearance—an irregular, infiltrative, soft reddish mass—and a similar microscopic appearance—pleomorphic spindle
cells positive for CD31. Which of the following neoplasms is most likely to be described by these findings?
□ (A) Angiosarcoma
□ (B) Hemangioendothelioma
□ (C) Hemangioma
□ (D) Hemangiopericytoma
□ (E) Kaposi sarcoma
□ (F) Lymphangioma
(A) Angiosarcomas are aggressive malignancies. Knowledge of the association with vinyl chloride has virtually
eliminated this occupational exposure. In the past, when radical mastectomies were more common, angiosarcomas arose
in the setting of chronic lymphedema of the arm; the tumor probably arose from dilated lymphatics. Most angiosarcomas
are sporadic neoplasms that occur rarely in older adults. Hemangioendotheliomas exhibit biologic behavior intermediate
between the very localized, slow-growing hemangioma and the aggressive angiosarcoma; they may recur after excision.
Hemangiopericytomas are rare soft-tissue neoplasms that can metastasize. Kaposi sarcoma (KS) was previously a rare
endemic neoplasm involving the lower extremities; however, with the advent of AIDS, KS has become associated with HIV
infection. KS is driven by human herpesvirus-8 infection. Lymphangiomas are benign, and when formed of capillary-like
channels, are usually small and localized. Cavernous lymphangiomas can be ill-defined, however, and difficult to remove
A cohort study is performed involving healthy adult men and women born 20 years ago. They are followed to assess
development of atherosclerotic cardiovascular diseases. Multiple laboratory tests are performed yearly during this study.
An elevation in which of the following test results is most likely to indicate the greatest relative risk for development of one
of these diseases?
□ (A) Anti-proteinase 3 (PR3)
□ (B) C-reactive protein (CRP)
□ (C) Cryoglobulin
□ (D) Erythrocyte sedimentation rate (ESR)
□ (E) Platelet count
(B) CRP is an acute phase reactant that increases in response to inflammation. It causes endothelial cell activation,
promotes thrombosis, and increases leukocyte adhesiveness in developing atheromas. Since atherogenesis is partly an
inflammatory process, the CRP is an independent predictor of cardiovascular risk. PR3 is one type of antineutrophil
cytoplasmic autoantibody (ANCA) associated with some vasculitides such as microscopic polyangiitis. Cryoglobulins may
be found with some forms of immune complex mediated vasculitis. The ESR (“sed rate”) is a very nonspecific indicator of
inflammation and therefore the internist’s least favorite test; the ESR is best known to be markedly elevated with giant cell
arteritis. Though platelets play a role in atheroma formation, the actual number of platelets is not a predictor of
atherogenesis.
A 67-year-old woman with glucose intolerance, hypertension, central obesity, and hyperlipidemia has increasing
dyspnea from worsening congestive heart failure. Echocardiography shows a left ventricular ejection fraction of 25%.
Percutaneous transluminal coronary angioplasty is performed with placement of a left anterior descending arterial stent
containing paclitaxel. Which of the following long-term pathologic complications in her coronary artery is this drug-eluting
stent most likely to prevent?
□ (A) Angiosarcoma
□ (B) Bacillary angiomatosis
□ (C) Cystic medial degeneration
□ (D) Giant cell arteritis
□ (E) Proliferative restenosis
□ (F) Thromboangiitis obliterans
(E) She has metabolic syndrome, a risk for coronary atherosclerosis. Following angioplasty, there is often intimal
thickening that causes restenosis. The wire stent holds the lumen open and the paclitaxel limits smooth muscle
hyperplasia. Atherosclerosis is not a risk for neoplasia. Bacillary angiomatosis is caused by Bartonella organisms (catscratch
disease) and most often produces a red skin nodule. Cystic medial degeneration is a feature of Marfan syndrome
with aortic dissection. Giant cell arteritis most often involves external carotid branches such as temporal arteries; it is not
related to atherosclerosis. Thromboangiitis obliterans is a rare form of vasculitis involving lower extremities in smokers
