CELLULAR

INJURY

Question 1
A 48-year-old woman has a malignant lymphoma involving lymph nodes in the para-aortic region. She
is treated with a chemotherapeutic agent which results in the loss of individual neoplastic cells through
fragmentation of individual cell nuclei and cytoplasm. Over the next 2 months, the lymphoma decreases
in size, as documented on abdominal CT scans. By which of the following mechanisms has her neoplasm
primarily responded to therapy?
A

Coagulative necrosis

Mitochondrial poisoning

Phagocytosis

Acute inflammation

E
Apoptosis

(E) CORRECT. The induction of individual cell death occurs in the process of apoptosis. The drug effect
is targeted primarily at the neoplastic cells, not normal cells.

Question 2
A 53-year-old man has experienced severe chest pain for the past 6 hours. On physical examination he
is afebrile, but has tachycardia. Laboratory studies show a serum troponin I of 10 ng/mL. A coronary
angiogram is performed emergently and reveals >90% occlusion of the anterior interventricular (left
anterior descending) artery. In this setting, an irreversible injury to myocardial fibers will have
occurred when which of the following cellular changes occurs?
A

Glycogen stores are depleted

Cytoplasmic sodium increases

Nuclei undergo karyorrhexis

Intracellular pH diminishes

E
Blebs form on cell membranes

(C) CORRECT. Chromatin clumping is reversible, but dissolution of the entire nucleus is not, and when
the nucleus is lost, the cell will die. An acute coronary syndrome with myocardial infarction is described
here.

Question 3
While in a home improvement center warehouse buying paint, a 35-year-old man hears 'Look out
below!' and is then struck on the leg by a falling pallet rack, which strikes him on his left leg in the
region of his thigh. The skin is not broken. Within 2 days there is a 5 x 7 cm purple colour to the site of
injury. Which of the following substances has most likely accumulated at the site of injury to produce a
yellow-brown colour at the site of injury 16 days later?
A

Lipofuscin

Bilirubin

Melanin

Hemosiderin

E
Glycogen

(D) CORRECT. The iron in the heme pigment from the red blood cells in the hemorrhage beneath the
skin is incorporated into hemosiderin granules that impart the yellow to brown colour of the healing
contusion (bruise) from blunt force trauma.

Question 4
A 54-year-old man with a chronic cough has a squamous cell carcinoma diagnosed in his right lung.
While performing a pneumonectomy, the thoracic surgeon notes that the hilar lymph nodes are small,
0.5 to 1.0 cm in size, and jet black in colour throughout. Which of the following is the most likely cause
for this appearance to the hilar nodes?
A

Anthracotic pigment

Lipochrome deposits

Melanin accumulation

Hemosiderosis

E
Metastatic carcinoma

(A) CORRECT. The black colour comes from carbon pigments in dust particles inhaled over the years,
engulfed by macrophages, and sent via lymphatics to the lymph nodes. It looks bad but does not
compromise lung function. Smokers will have more anthracosis.

Question 5
A 50-year-old woman with a history of unstable angina suffers an acute myocardial infarction.
Thrombolytic therapy with tissue plasminogen activator (tPA) is administered to restore coronary

blood flow. In spite of this therapy, the degree of myocardial fiber injury may increase because of which
of the following cellular abnormalities?
A

Cytoskeletal intermediate filament loss

Decreased intracellular pH from anaerobic glycolysis

Increased free radical formation

Mitochondrial swelling

Nuclear chromatin clumping

F
Reduced protein synthesis

(C) CORRECT. Such toxic oxygen radicals are released from neutrophils when blood flow is restored
following ischemia. This is a reperfusion injury. Overall, there is likely to be more good than harm to
restoration of blood flow.

Question 6
A 12-year-old boy has had multiple episodes of ear pain accompanied by fever. On examination his right
tympanic membrane is red and bulging with yellow exudate. Laboratory studies of the exudate show
culture positive for Hemophilus influenzae. A year later he has conductive hearing loss on the right, and
a head CT scan shows a mass in the right middle ear. Which of the following materials is most likely to
be seen in the tissue curetted from his middle ear?
A

Lipofuscin pigment

Russell bodies

Neutrophil granules

Cholesterol crystals

E
Anthracotic pigment

(D) CORRECT. An inflammatory mass persisted, with cellular necrosis, and the lipid from the cell
membranes is broken down and cholesterol crystals form. The boy has the complication of otitis media
known as a cholesteatoma

Question 7
A 43-year-old man has complained of mild burning substernal pain following meals for the past 3 years.
Upper GI endoscopy is performed and biopsies are taken of an erythematous area of the lower
esophageal mucosa 3 cm above the gastroesophageal junction. There is no mass lesion, no ulceration,

and no hemorrhage noted. The biopsies show the presence of columnar epithelium with goblet cells.
Which of the following mucosal alterations is most likely represented by these findings?
A

Dysplasia

Hyperplasia

Carcinoma

Ischemia

E
Metaplasia

(E) CORRECT. Metaplasia is the substitution of one tissue normally found at a site for another. The
esophageal stratified squamous epithelium undergoes metaplasia in response to the ongoing
inflammation from reflux of gastric contents. This is common in the lower esophagus with
gastroesophageal reflux disease (GERD).

Question 8
A 71-year-old woman had the loss of consciousness that persisted for over an hour. When she becomes
arousable, she cannot speak nor move her right arm. A cerebral angiogram revealed an occlusion to her
left middle cerebral artery. Months later, a computed tomographic (CT) scan shows a large 5 cm cystic
area in her left parietal lobe cortex. This CT finding is most likely the consequence of resolution from
which of the following cellular events?
A

Liquefactive necrosis

Atrophy

Coagulative necrosis

Caseous necrosis

E
Apoptosis

(A) CORRECT. She had a 'stroke' with cerebral infarction and loss of brain tissue. The brain undergoes
liquefactive necrosis with infarction. As it resolves, macrophaes remove the dead cells and debria,
leaving a cystic area that forms in the region of infarction.

Question 9
A 19-year-old woman gives birth to her first child. She begins breast feeding the infant. She continues
breast feeding for almost a year with no difficulties and no complications. Which of the following
cellular processes that began in the breast during pregnancy allowed her to nurse the infant for this
period of time?

Stromal hypertrophy

Epithelial dysplasia

Steatocyte atrophy

Ductal epithelial metaplasia

E
Lobular hyperplasia

(E) CORRECT. There is an increase in the breast lobules under hormonal influence, primarily
progesterone with pregnancy, to provide for lactation.

Question 10
An 84-year-old man dies from complications of Alzheimer disease. At autopsy, his heart is small (250
gm) and dark brown on sectioning. Microscopically, there is light brown perinuclear pigment with H&E
staining of the cardiac muscle fibers. Which of the following substances is most likely increased in the
myocardial fibers to produce this appearance of his heart?
A

Hemosiderin from iron overload

Lipochrome from 'wear and tear'

Glycogen from a storage disease

Cholesterol from atherosclerosis

E
Calcium deposition following necrosis

(B) CORRECT. Lipochrome (lipofuscin) deposition in myocardial cell cytoplasm is a common finding,
though ordinarily there are small amounts of it, and it has little effect upon cardiac function. The 'brown
atrophy' of the heart in this case is a rare finding.

Question 11
In an experiment, a series of immunohistochemical stains are employed to identify different cellular
components. One particular stain identifies the presence of intermediate filaments within cells. This
cytokeratin stain is most likely to be useful for which of the following diagnostic purposes?
A

Cytoskeletal alterations indicate impending cell death

A neoplasm is determined to be a carcinoma

Contractile properties of the cells can be assessed

A history of chronic alcoholism can be confirmed

E
The degree of metaplasia or dysplasia can be assessed

(B) CORRECT. Carcinomas are derived from epithelium and contain cytokeratins, while sarcomas
derived from mesenchymal cells contain vimentin.

Question 12
A 20-year-old woman had Goodpasture syndrome which progressed to chronic renal failure. She is 165
cm tall and weighs 55 kg. She now has blood pressure measurements in the range of 150/90 to
180/110 mm Hg, but does not regularly take medications. Laboratory studies show her blood urea
nitrogen is over 100 mg/dL and she requires chronic dialysis. A chest x-ray shows an enlarged heart.
The size of her heart is most likely to be the result of which of the following processes involving the
myocardial fibers?
A

Hypertrophy

Fatty infiltration

Hyperplasia

Fatty degeneration

E
Edema

(A) CORRECT. The ongoing pressure load of the systemic hypertension led to myocardial fiber
hypertrophy and a heart that increased in size. Renal failure often leads to hypertension, and vice versa.

Question 13
A 29-year-old man goes on a snorkeling trip to Looe Key Marine Sanctuary and later spends time on the
beach at Bahia Honda State Park. The next day he has a darker complexion. His skin does not show
warmth, erythema, or tenderness. His skin tone fades to its original appearance within a month. Which
of the following substances contributes the most to the biochemical process leading to these skin
changes?
A

Iron oxide

Lipofuscin

Tyrosine

Homogentisic acid

E
Glycogen
(C) CORRECT. The tanning process in skin is stimulated by ultraviolet light exposure. Melanocytes have
the enzyme tyrosinase to oxidize tyrosine to dihydroxyphenylalanine in the pathway for melanin
production. Natural skin tone is related to the level of tyrosinase enzyme activity.

Question 14
A study is performed to identify predisposing risks for tissue cellular changes. In some persons
epithelial metaplasia occurs. In which of the following situations is the process of epithelial metaplasia
most likely to take place?
A

Tanning of the skin following sunlight exposure

Lactation following pregnancy

Vitamin A deficiency

Acute myocardial infarction

E
Urinary obstruction from an enlarged prostate

(C) CORRECT. Vitamin A is necessary to maintain epithelia, and squamous metaplasia of the respiratory
tract may occur if there is vitamin A deficiency. The stratified squamous epithelium does not function as
well as the normal pseudostratified columnar respiratory epithelium, and there is an increased risk for
respiratory infections.

Question 15
In an experiment, a disease process is found which leads to scattered loss of individual cells, with the
microscopic appearance of karyorrhexis and cell fragmentation. The overall tissue structure remains
intact. This process is most typical for which of the following diseases?
A

Viral hepatitis

Brown atrophy of the heart

Renal transplant rejection

Chronic alcoholic liver disease

E
Barbiturate overdose

(A) CORRECT. Viral infection leads to apoptosis with individual hepatocyte necrosis, either from effects
of viral replication or from the body's cell mediated immune response with cytotoxic T lymphocytes.


Question 16
A 60-year-old woman has noted a dark red-black appearance to her great toe and second and third toes
of her left foot for the past month. On physical examination, the toes are cold and have no sensation to
touch. The dorsalis pedis and posterior tibial pulses are not palpable on the left. A transmetatarsal
amputation is performed. These findings are most typical for a patient with which of the following
conditions?
A

Diabetes mellitus

Gout

Blunt force trauma

AIDS

E
Rheumatoid arthritis

(A) CORRECT. Gangrenous necrosis is described. Occlusive peripheral atherosclerotic vascular disease
is typical for diabetes mellitus. Many arteries are involved, reducing collateral flow. This is diabetic
gangrene.

Question 17
A study is performed involving the microscopic analysis of tissues obtained from surgical procedures.
Some of these tissues have the microscopic appearance of an increased cell size of multiple cells within
the tissue, due to an increase in the amount of cell cytoplasm, with nuclei remaining uniform in size.
Which of the following conditions is most likely to have resulted in this finding?
A

Uterine myometrium in pregnancy

Female breast at puberty

Liver following partial resection

Ovary following menopause

E
Cervix with chronic inflammation

(A) CORRECT. This cellular hypertrophy with increase in cell size (not hyperplasia with increase in cell
number) accounts for most of the marked increase in size of the uterus during pregnancy. Following
pregnancy and reduction in hormonal stimulation, the uterus returns back to its normal size.


Question 18
A 17-year-old adolescent receives whole body radiation as part of a preparatory regimen for bone
marrow transplantation to treat acute lymphocytic leukemia. Which of the following cells and tissues in
the body is most likely to remain unaltered by the effects of this therapeutic radiation?
A

Primary follicles of ovary

Small intestinal epithelium

Erythropoietic cells of bone marrow

Spermatogonia of testicular tubules

E
Neurons of cerebral cortex
(E) CORRECT. Neurons are terminally differentiated cells that do not actively divide or proliferate, so at
therapeutic doses of radiation, they are relatively radioresistant. However, at higher radiation doses,
cerebral injury does occur from damage mainly to white matter and to the vasculature.

Question 19
A 79-year-old man has a large myocardial infarction involving much of the left ventricular free wall. He
develops congestive heart failure (CHF) with decreased cardiac output. Now, a year later, his CHF is
worsening. By echocardiography there is a large, bulging akinetic area typical for a left ventricular
aneurysm. Which of the following laboratory tests on serum would best indicate poor peripheral tissue
perfusion in this patient?
A

Elevated troponin I

Increased sodium

Elevated lactate

Increased hematocrit

E
Increased sedimentation rate

(C) CORRECT. Under conditions of poor tissue perfusion, there will be more anaerobic glycolysis and
more acidosis in cells throughout the body. The blood lactate rises in this condition.

Question 20
A 22-year-old woman has a congenital anemia. She has required multiple transfusions of red blood cells
for many years. She now has no significant findings on physical examination. Which of the following
microscopic findings would most likely present in her liver?

Steatosis in hepatocytes

Bilirubin in canaliculi

Hemosiderin in hepatocytes

Glycogen in hepatocytes

E
Amyloid in portal triads

(C) CORRECT. There is 250 mg of iron in each unit of blood. The body has no mechanism for getting rid
of excess iron. A small amount of iron is lost with normal desquamation of epithelia, and menstruating
women will lose a bit more. The excess iron becomes storage iron, or hemosiderin. Over time,
hemosiderosis involves more and more tissues of the body, particularly the liver.

Question 21
A 20-year-old man is involved in a motor vehicle accident which results in multiple blunt trauma and
lacerations to his lower extremities. The left femoral artery is lacerated, and he incurs extensive blood
loss and remains hypotensive for hours during transport to the emergency department. On admission,
his hematocrit is 12%. Which of the following tissues is most likely to withstand the impact of these
events with the least damage?
A

Skeletal muscle

Intestinal epithelium

Retina

Cerebral cortex

E
Renal tubules

(A) CORRECT. The skeletal muscle tissue is the least metabolically active of the ones listed, and is also
able to function with anaerobic glycolysis.

Question 22
A 40-year-old woman has the sudden onset of severe abdominal pain. On physical examination she has
diffuse tenderness in all abdominal quadrants, with marked guarding and muscular rigidity. She has
laboratory findings that include serum AST of 43 U/L, ALT of 30 U/L, LDH 630 U/L, and lipase 415 U/L.
An abdominal CT scan reveals peritoneal fluid collections and decreased attenuation along with
enlargement of the pancreas. Which of the following cellular changes is most likely to accompany these
findings?
A

Coagulative necrosis

Dry gangrene

Fat necrosis

Apoptosis

E
Liquefactive necrosis

(C) CORRECT. The enzymes released from the pancreas with acute pancreatitis damage the
surrounding fat and form soaps -- localized soft tan to yellow areas of fat necrosis. The damaged
pancreatic exocrine cells release lipase and amylase as markers for their injury.

Question 23
A 26-year-old man has had a high fever for the past 2 days. On exam he has a heart murmur.
Echocardiography shows destruction of the aortic valve by large, irregular vegetations. Staphylococcus
aureus is cultured from his blood. He develops left upper quadrant pain. Abdominal CT shows a wedge-
shaped 1.5 x 3 cm splenic lesion with base on the capsule. The splenic lesion is most likely to result from
which of the following cellular abnormalities?
A

Coagulative necrosis

Abscess formation

Metaplasia

Caseous necrosis

E
Liquefactive necrosis

(A) CORRECT. The description is that of a typical infarct with vascular occlusion following embolization
from vegetations of infective endocarditis.

Question 24
A 35-year-old woman has developed increasing icterus over the last week. On exam her liver span is
increased. Laboratory studies show hyperammonemia. Abdominal CT scan shows a liver twice normal
size with markedly reduced attenuation. These changes in her liver most likely resulted from which of
the following conditions?
A

Galactosemia

Hemochromatosis

Tuberculosis

Alcoholism

E
Hypoxemia

(D) CORRECT. The marked fatty change (steatosis) of the liver with hepatomegaly is a typical sequel of
chronic alcohol abuse. With x-rays, fat density approaches that of air density (dark). Grossly, the liver
would appear yellowish. Microscopically, the hepatocyte cytoplasm would contain a large lipid droplet.

Question 25
A clinical study is performed in which the conditions leading to the appearance of calcification on CT
scans are analyzed in patients from 60 to 90 years of age. One set of patients has the finding of
incidental calcification, with no serious health problems. In which of the following tissue locations is
this incidental calcification most likely to be noted?
A

Coronary artery

Renal cortex

Tricuspid valve

Pulmonary parenchyma

E
Pineal gland

(E) CORRECT. Such calcification is commonly seen in adults, and has no consequence. The pineal gland
does not have any important function. The bright calcifications provide a good midline marker.

Question 26
A 55-year-old man has a 30-year history of poorly controlled diabetes mellitus. He has had extensive
black discoloration of skin and soft tissue of his right foot, with areas of yellowish exudate, for the past 2
months. Staphylococcus aureus is cultured from this exudate. A below-the-knee amputation is
performed. The amputation specimen received in the surgical pathology laboratory is most likely to
demonstrate which of the following pathologic abnormalities?
A

Neoplasia

Gangrene

Vasculitis

Hemosiderosis

Caseation


(B) CORRECT. Gangrenous necrosis is a typical complication of diabetes mellitus with marked
peripheral vascular disease from atherosclerosis. Gangrene is a form of coagulative necrosis that
involves a body part, including several tissues. The infection adds an element of liquefactive necrosis,
best described as 'wet gangrene.'

Question 27
The lifestyle patterns of healthy persons from 20 to 30 years of age are studied. A subset of these
persons have a lifestyle characterized by consumption of a lot of pizza and very little physical exercise.
Which of the following tissue changes is most likely to develop in this subset of persons as a
consequence of this lifestyle?
A

Fatty metamorphosis of liver

Pancreatic fat necrosis

Fatty degeneration of myocardium

Hypertrophy of steatocytes

E
Metaplasia of muscle to adipose tissue

(D) CORRECT. The fat cells (adipocytes) increase in size (hypertrophy) with obesity in adults, and this is
the predominant effect of weight gain.

Question 28
In an experiment, a tissue preparation is subjected to oxidant stress. There are increased numbers of
free radicals generated within the cells. Generation of which of the following enzymes within these cells
is the most likely protective mechanism to reduce the number of free radicals?
A

Glutathione peroxidase

Catalase

Hydrogen peroxide

NADPH oxidase

E
Myeloperoxidase

(A) CORRECT. The glutathione peroxidase system is designed to help break down free radicals
generated from various forms of cell injury. This system works in the background with small numbers
of free radicals. Disease processes generating greater amounts of free radicals and cell injury can
overwhelm this system.




Question 29
A 38-year-old man incurs a traumatic blow to his upper left arm. He continues to have pain and
tenderness even after 3 months have passed. A plain film radiograph reveals a 4 cm circumscribed mass
in the soft tissue adjacent to the humerus. The mass contains peripheral areas of brightness on the x-
ray. Over the next year this mass gradually resolves. Which of the following terms best describes the
changes described?
A

Dysplasia

Hyperplasia

Hypertrophy

Metaplasia

Neoplasia

(D) CORRECT. The brightness on x-ray suggests calcification from osseous metaplasia of connective
tissues that developed in the healing process. This condition is known as myositis ossificans, because
there is bone formation in the injured muscle.

Question 30
A 31-year-old primigravida has a difficult delivery of a term infant, with loss of 1500 cc of blood. She
has hypotension for 6 hours. Over the next month, her ACTH level decreases. Within the next 3 months,
her adrenal glands become decreased in size. This alteration of the adrenals is primarily due to which of
the following cellular processes?
A

Metaplasia

Gene mutation

Apoptosis

Autophagocytosis

Coagulative necrosis

(E) Incorrect. Loss of ACTH does not lead to infarction of the adrenal. With three arterial blood supplies,
the adrenal is very hard to infarct.




Question 31
A 48-year-old man has a history of chronic alcohol abuse. He is still able to perform work at his job. He
has had no major illnesses. On physical examination, there are no significant findings. Laboratory
studies show a serum albumin of 4.1 g/dL, ALT 30 U/L, AST 33 U/L, and total bilirubin 1.1 mg/dL.
Which of the following microscopic findings in his liver is most likely to be present?
A

Cholestasis

Fatty change

Hemochromatosis

Hypertrophy of smooth endoplasmic reticulum

Coagulative necrosis

(B) CORRECT. The toxic effects of the alcohol culminate in large lipid droplet accumulation within
hepatocytes. Over time, more hepatocytes are affected and the liver is less able to compensate. At this
point, the man retains sufficient hepatocyte function.

Question 32
A 44-year-old woman has had episodes of right upper quadrant pain during the past 2 weeks. Her
stools have become pale in colour over the past 3 days. Laboratory studies show a serum total bilirubin
of 9.7 mg/dL. A cholangiogram shows that a gallstone has passed into the common bile duct, resulting
in obstruction of the biliary tract. Which of the following tissue accumulations is most likely to be
visualized on her skin surfaces?
A

Hemosiderosis

Calcification

Lipofuscin deposition

Icterus

Steatosis

(D) CORRECT. She has a 'jaundiced' appearance to her sclerae and skin due to the increased amount of
bilirubin. The bile pigments impart a yellow colour to the tissues. She has biliary tract obstruction from
cholelithiasis and choledocholithiasis.




Question 33
A 45-year-old man has a traumatic injury to his forearm and incurs extensive blood loss. On physical
examination in the emergency department his blood pressure is 70/30 mm Hg. Which of the following
cellular changes is most likely to represent irreversible cellular injury as a result of this injury?
A

Epithelial dysplasia

Cytoplasmic fatty metamorphosis

Nuclear pyknosis

Atrophy

Anaerobic glycolysis

Autophagocytosis

(C) CORRECT. The hypotension leads to diminished tissue perfusion with ischemic injury. Nuclear
chromatin clumping is reversible, but nuclear pyknosis is not.

Question 34
A 73-year-old man suffers a 'stroke.' On physical examination he cannot move his right arm. A cerebral
angiogram demonstrates occlusion of the left middle cerebral artery. An echocardiogram reveals a
thrombus within a dilated left atrium. Which of the following is the most likely pathologic alteration
from this event that has occurred in his brain?
A

Cerebral softening from liquefactive necrosis

Pale infarction with coagulative necrosis

Predominantly the loss of glial cells

Recovery of damaged neurons if the vascular supply is reestablished

Wet gangrene with secondary bacterial infection

(A) CORRECT. Liquefactive necrosis typifies brain infarction. The brain tissue contains abundant lipid.
After the initial softening, tissue macrophages will increase in number and clear the necrotic debris,
leaving a cystic space. Since neurons cannot regenerate, the size of the infarct determines the amount of
functional loss. The brain has some capacity for rewiring, but this capacity diminishes with age.




Question 35
A 30-year-old woman is claiming in a civil lawsuit that her husband has abused her for the past year. A
workup by her physician reveals a 2 cm left breast mass. There is no lymphadenopathy. No skin lesions
are seen, other than a bruise to her upper arm. A needle biopsy of the breast mass is performed. On
microscopic examination, the biopsy shows fat necrosis. This biopsy result is most consistent with
which of the following etiologies?
A

Physiologic atrophy

Breast trauma

Lactation

Radiation injury

Hypoxic injury

(B) CORRECT. Fat necrosis is seen with trauma to the breast, and her lawyer will make good use of that
documentation. The pattern of multiple injuries of differing ages at different sites suggests abuse.

Question 36
A 46-year-old man has smoked 2 packs of cigarettes per day for the past 30 years. He has had a chronic
cough for the past 3 years, worsening over the last 2 weeks. A suspicious left pulmonary parenchymal
lesion is seen on a chest x-ray. He has a bronchoscopy performed. A biopsy of a segmental bronchus
shows squamous metaplasia. Which of the following is the most appropriate interpretation of this
finding?
A

Ischemic tissue damage

Irritant effect

Early stage of cancer

Viral infection

Congenital anomaly

(B) CORRECT. The irritant effect, such as the various chemicals in cigarette smoke, leads to replacement
of the normal epithelium with another (such as squamous epithelium replacing respiratory epithelium).
This metaplastic process is the first step that could lead to dysplasia and then to neoplasia. Note that

histologists call any flattened epithelium a 'squamous' epithelium, but pathologists refer to specific cell
types, and consider a true squamous epithelium to be a stratified squamous epithelium.


Question 37
A 44-year-old woman has had congestive heart failure for the past 4 years. She develops a fever that
persists for over a week. On physical examination, a heart murmur is present. Her temperature is
38.4C. Laboratory studies show a blood culture positive for Streptococcus, viridans group. An
echocardiogram reveals a 1 cm vegetation on the superior aspect of her mitral valve. Which of the
following pathologic changes is most likely present in her mitral valve?
A

Passive congestion

Necrosis

Extensive edema

Granulomatous inflammation

Dystrophic calcification

(B) CORRECT. Friable mitral valvular vegetations from infective endocarditis can damage the valve. The
inflammation is predominantly neutrophilic, and a collection of neutrophils release a variety of
enzymes that cause tissue damage.

Question 38
An 18-year old G2 P1 woman has an amniocentesis performed at 17 weeks gestation. Fibroblasts
recovered from amniocentesis are grown in culture to assess the karyotype of fetal cells. These cells are
subcultured for additional experimental work, but the culture is lost after 50 doublings of the cells has
occurred, and the fibroblasts no longer grow. Which of the following factors affecting these cells is most
likely demonstrated by this phenomenon?
A

Nutrition

Mutation

Apoptosis

Aging

Oxidation

(D) CORRECT. A number of factors play a role in aging, but the lack of immortality of individual cells is
one feature. The lack of telomerase activity in most somatic cells prevents repeated division. Stem cells
have greater replicative capacity.



Question 39
A 54-year-old man has sudden onset of severe, sharp chest pain with diaphoresis and dyspnea. On
physical examination he has tachycardia with an irregular heart rhythm. Electrocardiographic changes
suggest the possibility of focal myocardial damage involving the left lateral ventricular wall. Which of
the following laboratory tests on the patient's serum is most useful in this situation?
A

Total cholesterol

Creatine kinase

Triglyceride

Amylase

Sedimentation rate

(B) CORRECT. The CK will be elevated with myocardial ischemic injury. The CK-MB isoenzyme fraction
is most specific for cardiac muscle, while CK-MM is most specific for skeletal muscle. Another very
specific analyte for cardiac striated muscle injury is troponin. Myoglobin is a sensitive, but not specific
marker for myocardial injury, because it could also be released from skeletal muscle.

Question 40
A 42-year-old previously healthy woman notes that over the past week her eyes have developed a
yellowish appearance. She has had mild nausea and vomiting over the past week. On physical
examination she has scleral icterus. She has no other major physical examination findings except for
mild right upper quadrant tenderness. Which of the following underlying conditions is most likely to
contribute to development of her icterus?
A

Hypercholesterolemia

Thrombocytopenia

Metastatic carcinoma

Viral hepatitis

Diabetes mellitus

(D) CORRECT. Hepatitis, most often an infectious viral hepatitis, leads to liver cell dysfunction with
impaired uptake, conjugation, and excretion of bilirubin. As a result bilirubin is not cleared from the
blood and there is an increasing serum bilirubin that produces the yellowish appearance of jaundice
(icterus).


Question 41
A 56-year-old woman has smoked 2 packs of cigarettes per day for the past 35 years. She has had a
chronic cough for the past 8 years, but recently has noted increased sputum production. On physical
examination she has a few crackles auscultated best over the lung bases. Bronchoscopy with biopsy is
performed. The biopsy reveals bronchial epithelium with squamous metaplasia. Which of the following
statements represents the best interpretation of these findings?
A

Physiologic process of aging

Irreversible, even if she stops smoking

Metastases to the lung

Risk for infection

Thromboembolism with infarction

(D) CORRECT. The loss of normal functioning respiratory epithelium with loss of mucociliary protection
means that the normal innate barrier to infection has been weakened.

Question 42
At the end of a normal menstrual cycle, the endometrium sloughs. Examination of the endometrium
microscopically shows cellular fragmentation. Which of the following is most likely to trigger apoptosis
in these endometrial cells?
A

Acute inflammation

Hypoxia

p53 protein accumulation

Decreased estrogen

Anaerobic glycolysis

(D) CORRECT. This is one form of the intrnsic pathway for induced apoptosis. Falling hormone levels
late in the endometrial hormonal cycle induce menstruation.


Question 43
An experiment is conducted to determine if cell membrane injury is lessened by the effects of vitamin E
ingestion. Which of the following cellular components is primarily involved in generation of lipid
peroxides, the formation of which is inhibited by the vitamin E?
A

Glutathione

Ionized calcium

Lactate

Ferric iron

Lipase

(D) CORRECT. Ferric ion is needed for reduced oxygen species to injure cells. Hydroxyl radicals initiate
lipid peroxidation.

Question 44
A 35-year-old woman has had headaches and abdominal pain worsening for 3 months. There are no
remarkable physical examination findings. On radionucleide scanning of the neck, she is found to have a
mass involving one of her parathyroid glands. An abdominal CT scan suggests extensive
nephrocalcinosis along with urinary tract calculi. Which of the following laboratory test findings is most
likely to accompany her disease?
A

CO2 of 30 mmol/L

Phosphorus of 2.2 mg/dL

Uric acid of 15.1 mg/dL

Sodium of 121 mmol/L

Calcium of 4.5 mg/dL

(B) CORRECT. Metastatic calcification occurs as a result of a high serum calcium, which in the case of
hyperparathyroidism is accompanied by a low serum phosphorus. The high calcium often induces a
fatal cardiac arrhythmia before metastatic calcification can occur.

Question 45
A 21-year-old woman has a routine Pap smear performed for a health screening examination. The
pathology report indicates that some cells are found cytologically to have larger, more irregular nuclei.
A follow-up cervical biopsy microscopically demonstrates disordered maturation of the squamous

epithelium, with hyperchromatic and pleomorphic nuclei extending nearly the full thickness of the
epithelial surface. No inflammatory cells are present. Which of the following descriptive terms is best
applied to these Pap smear and biopsy findings?
A

Dysplasia

Metaplasia

Anaplasia

Hyperplasia

Aplasia

(A) CORRECT. Disordered growth of an epithelium is seen in dysplasia, which can be a precursor to
neoplasia. When the term 'dysplasia' is used in pediatric conditions, it refers to disordered development
of a tissue, including cell types that ordinarily are not present. In adults, dysplasia refers to an abnormal
change in an epithelium, beyond physiologic alteration, that is starting down the road to cancer.

Question 46
A 38-year-old man has a health screening examination. He has a routine chest x-ray that shows a 2 cm
nodule in the right lower lobe. The nodule has focal calcifications. A wedge resection of the nodule is
done. On microscopic examination the nodule shows caseous necrosis and calcification. Which of the
following processes explains the appearance of the calcium deposition:
A

Dystrophic calcification

Apoptosis

Hypercalcemia

Metastatic calcification

Excessive ingestion of calcium

(A) CORRECT. Calcium is deposited in and around the granuloma as a reaction to injury with necrosis.
Most pulmonary granulomas are the result of infection, typically tuberculosis.

Question 47
A 3-year-old child has been diagnosed with ornithine transcarbamylase deficiency and has developed
hepatic failure. The left lobe of an adult donor liver is used as an orthotopic transplant. A year later, the
size of each liver in donor and recipient is greater than at the time of transplantation. Which of the
following cellular alterations is most likely to explain this phenomenon?

Metaplasia

Dysplasia

Hyperplasia

Anaplasia

Neoplasia

(C) CORRECT. After removal of part of the liver, remaining liver can undergo hyperplasia to
compensate. Hepatocytes are stable cells that are able to re-enter the cell cycle.

Question 48
A morbidly obese 51-year-old woman dies from complications of heart disease. At autopsy, her heart
weighs 600 gm (normal up to 300 gm) with all the chambers enlarged. Microscopically, there is
increased fibrous connective tissue seen in the interstitium between myocardial fibers. The fibers are
increased in size. Beneath the epicardium can be seen adipocytes interdigitating with the myocardial
fibers. Which of the following terms best describes the presence of the adipocytes in her myocardium?
A

Steatosis

Lipid degeneration

Fatty infiltration

Cholesterolosis

Xanthomatosis

(C) CORRECT. The adipocytes are normal fat cells. Obese persons just have more of them, and the
individual cells are larger, making them more obvious and prominent on examination. Their presence in
the superficial myocardium is more a marker of obesity than a risk for myocardial failure.

Question 49
A cellular mutation results in transcription with translation of a protein that does not fold properly. The
misfolded protein remains within the cell and is not excreted. Activation of which of the following
cytoplasmic enzymes is most likely to occur?
A

Caspase

Glutathione peroxidase

NADPH oxidase

Ribonuclease

Telomerase

(A) CORRECT. Misfolded proteins can trigger apoptosis with release of caspases that lead to nuclear and
cytoplasmic fragmentation. Huntington disease is one example of a genetic disease with neuronal cell
loss from protein misfolding.

Question 50
A 53-year-old man suffers a cardiac arrest and his wife calls emergency services. The paramedics arrive
a few minutes later and begin life support measures. A regular heart rate is established after 40 minutes
of resuscitative efforts as he is being transported to the hospital. A thrombolytic agent (tPA) is
administered. Which of the following cellular processes is most likely to occur in his myocardium
following administration of the tPA?
A

Apoptosis

Free radical injury

Heterophagocytosis

Squamous metaplasia

Accumulation of cytokeratins

(B) CORRECT. The ischemia during the cardiac arrest followed by reperfusion established following
successful resuscitation will generate activated oxygen species to produce free radical injury. This is the
so-called 'reperfusion injury'.

Question 51
A 38-year-old woman has severe abdominal pain with hypotension and shock that has developed over
the past 36 hours. On physical examination, her abdominal muscles are rigid and her abdomen is
extremely tender. An abdominal CT scan reveals fluid density in the region of the pancreas, which
appears to be enlarged. Which of the following laboratory test findings in her serum is most likely to be
present?
A

Alanine aminotransferase of 1123 U/L

Total cholesterol of 324 mg/dL

Creatine kinase of 869 U/L

Urea nitrogen of 110 mg/dL

Lipase of 1134 U/L

(E) CORRECT. There is evidence for acute pancreatitis with edema and necrosis. The necrosis is
typically fat necrosis with grossly visible focal chalky-white deposits representing areas of
saponification as a consequence of release of pancreatic enzymes (lipase and amylase) with acute
inflammation.

Question 52
A 45-year-old man has noted scleral icterus for the past 4 days. He has been feeling tired and 'run down'
for about a month. On physical examination, other than mild tachycardia, his vital signs are normal. No
other physical examination findings are of noted other than scleral icterus. Laboratory studies show a
hematocrit of 25%. Which of the following conditions is most likely to account for these findings?
A

Systemic hypertension

Excessive iron absorption

Diabetes mellitus, type I

Intravascular hemolysis

Pulmonary squamous cell carcinoma

(D) CORRECT. The increased turnover of red blood cells leads to increased bilirubin production to
cause the icterus, as the amount of bilirubin generated exceeds the capacity of the liver to conjugate and
excrete it into the bile. This also explains his anemia.

Question 53
A 49-year-old man with a history of alcohol abuse has increasing abdominal girth. On examination his
liver edge is firm. A liver biopsy shows cirrhosis, and individual hepatocytes contain red, globular
inclusions positive for cytokeratin with immunohistochemical staining. Which of the following
structural elements are these intracellular globules most likely to contain?
A

Actin and myosin

Cholesterol esters

Fatty acids

Fibronectin

Intermediate filaments

Microtubules

(E) CORRECT. Intermediate filaments may collect in the damaged hepatocytes as the globular hyaline
known as Mallory hyaline. It is characteristic for alcoholic liver disease, but not pathognomic for it.

Question 54
A 31-year-old woman has been previously diagnosed with systemic lupus erythematosus. She has had
chest pain for the past 6 months. A chest radiograph shows bilateral pleural effusions. Thoracentesis on
the right yields 400 mL of clear yellow serous fluid, and a cell count shows only a few cells present.
What type of cell is most likely to be most numerous in this fluid?
A

Basophil

Ciliated columnar cell

Eosinophil

Fibroblast

Langhans giant cell

Lymphocyte

Neutrophil

(E) CORRECT. Small numbers of lymphocytes may be present with this serous effusion, typical for
autoimmune diseases that include serositis.