Pathology

Question 0

Transmural inflammation of arteries with fibrinoid necrosis?

Answer 0

Polyarteritis nodosa

Question 1

Findings on arteriole biopsy in pt with malignant HTN?

Answer 1

onion-like concentric thickening

due to laminated smooth muscle cells and reduplicated BMs

Question 2

Is polyarteritis nodosa (PAN) segmental or nonsegmental? What infection is PAN associated with?

Answer 2

Segmental: bead-like aneurysm formation

associated with Hepatitis B infection in 30% of pts!!

Question 3

What disease results from abnormally low lipoprotein lipase activity? What is the most common presentation?

Answer 3

Hyperchylomicronemia
(Type I familial dyslipidemia)

Most common presentation is abdominal pain due to acute pancreatitis.
Skin xanthomas may be present, but tendon xanthomas and xanthelasmas (medial eyelids) are NOT (seen in familial hypercholesterolemia)

Question 4

Are patients with familial hyperchylomicronemia at risk for premature coronary artery disease?

Answer 4

NO increased risk for atherosclerosis

Question 5

Small bluish lesion under nailbed of finger that is painful to touch? Origin and function?

Answer 5

Glomus tumor/glomangioma
(could also be a melanoma)

Arises from the modified smooth muscle cells of a glomus body, which have a thermoregulatory function.

Question 6

Bright red slightly elevated lesion on buttocks of an infant? Will it grow or regress?

Answer 6

Strawberry hemangioma
unencapsulated aggregates of closely packed, thin-walled capillaries

will initially grow in proportion to the child, but then regresses spontaneously at 5-8 years old

Question 7

Heaviness in legs with cashier job and dilated, tortuous superficial veins in lower legs? Mechanism? Complications?

Answer 7

varicose veins
due to prolonged increases in intraluminal pressure or loss of vessel-wall tensile strength – leads to venous dilation which stretches venous valves and causes them to fail

Complications: painful thromboses, skin ulcerations, poor wound healing, superficial infections

Question 8

Homogenously thickened arteriolar walls that stain pink on H&E? Mechanism?

Answer 8

Hyaline arteriolosclerosis
from long-standing nonmalignant HTN and/or diabetes

hyaline material derived from leakage of plasma constituents across the vascular endothelium and from excessive ECM production by smooth muscle cells

Question 9

Myxomatous changes in arteries? Predisposes to? Associations?

Answer 9

pathological weakening of connective tissue
found in cystic medial degeneration

medial degeneration:

• fragmentation of elastic tissue (“basket weave” pattern of separated elastic fibers)
• separation of elastic and fibromuscular components of the tunica media by small cleft-like spaces that become filled with amorphous ECM

Predisoposes to the development of aortic dissections and aortic aneurysms.
Seen in younger individuals with Marfan syndrome (fibrillin-1 defect) and can also be induced by a chemical found in certain kinds of sweet peas.

Question 10

40yo man with red skin lesions near axilla - small bright-red, papular lesions? Composed of? Do they regress?

Answer 10

Cherry angioma
proliferation of capillaries and post-capillary venules in papillary dermis

do not regress, increased frequency with age
appears in 30s/40s

Question 11

Bright red central papule surrounded by outwardly radiating vessels that blanch when pressed and refill? Dependent on?

Answer 11

Spider angioma
dilation of central arteriole and its superficial capillary network

estrogen-dependent

Question 12

What is a cystic hygroma? Found where? Associations?

Answer 12

cavernous lymphangioma
lymphatic cyst lined by endothelium

found on neck and lateral chest wall

associated with Turner syndrome (and Down syndrome)

Question 13

Child with vascular lesions of IgA and C3 deposition on skin biopsy? Associated with? Presentation?

Answer 13

Henoch-Schonlein purpura (HSP)
vasculitis due to IgA deposition
often follows a URI (due to excess IgA production)

Classic triad:

• skin: palpable purpura on buttocks/legs
• arthralgias
• GI: abdominal pain, melena

Question 14

A significant mismatched defect on ventilation-perfusion scan indicates? Ventilation defect anatomically matched by a perfusion defect (matched defect)?

Answer 14

indicates blood flow has been occluded to that segment of lung
is a specific finding for a pulmonary embolism

matched defect usually indicates lung collapse or consolidation

Question 15

Pt with decrescendo-type diastolic murmur over left sternal border? Positive FTA-ABS antibodies – how does this pathological process start?

Answer 15

aortic regurgitation murmur: decrescendo blowing diastolic

Tertiary syphilis leading to aneurysmal dilatation of thoracic aorta (dilated aortic valve ring = aortic regurg. murmur)

Begins with vasa vasorum endarteritis and obliteration, resulting in inflammation, ischemia, and weakening of adventitia – leads to dilatation of the thoracic aorta.

Question 16

Radial mastectomy pt ten years later comes in with persistent right arm swelling – increased risk of?

Answer 16

Lymphangiosarcoma
malignancy of endothelial lining of lymphatic channels

persistent lymphedema with chronic dilatation of lymphatic channels predisposes to lymphangiosarcoma
(classic presentation: post-radial mastectomy)

Question 17

40yo pt with oliguria and intranasal ulcer? Marker?

Answer 17

granulomatosis with polyangiitis (Wegener’s)

c-ANCA positive
pathognomic for Wegener’s

Question 18

Abdominal pain with rare vascular tumor associated with past arsenic, radiation, thorotrast (formerly used contrast), or polyvinyl chloride (plastics) exposure? What marker exists on tumor cells?

Answer 18

Hepatic angiosarcoma

Tumor cells express CD31

Question 19

What is angiosarcoma? Associations?

Answer 19

rare blood vessel malignancy typically in head, neck, breast
usually in elderly on sun-exposed areas

associated with radiation therapy and arsenic (pesticides)

Question 20

60yo pt with episodes of thrombophlebitis in various sites in arms and legs? May indicate? Mechanism?

Answer 20

migratory thrombophlebitis / Trousseau’s syndrome
should always make you think CANCER
(could also be a small vessel hypersensitivity type vasculitis)

Hypercoagulability is a common paraneoplastic syndrome
often seen in adenocarcinomas of pancreas (also lung, colon)
leads to chronic intravascular coagulations that are both disseminated and tend to migrate

Question 21

What is aortic dissection? What is the most important risk factor?

Answer 21

intimal tear through the tunica intima of the aorta leading to formation of a false lumen

Hypertension is the most important risk factor for intimal tear development leading to aortic dissection. Other risk factors:

• bicuspid aortic valve
• connective tissue disorders (Marfan’s)

Question 22

Does atherosclerosis and related factors (diabetes, smoking, etc.) predispose to aortic dissection?

Answer 22

NO.

Atherosclerosis predisposes more to aortic aneurysm than aortic dissection.

Question 23

Foot ulcers and hypersensitivity to intradermally injected tobacco extract? What is the pathologic process?

Answer 23

Buerger disease (thromboangiitis obliterans)

segmental thrombosing vasculitis extending into contiguous veins and nerves

Acute and chronic inflammation of arterial walls, often with thrombosis of lumen (which can undergo organization and recanalization)
Can extend into contiguous veins and nerves to encase all structures in fibrous tissue

Question 24

Which vasculitis presents with transmural inflammation with fibrinoid necrosis? With segmental thrombosing vasculitis?

Answer 24

Polyarteritis nodosa = transmural inflammation of arterial wall with fibrinoid necrosis

Buerger disease = segmental thrombosing vasculitis

Question 25

Asthmatic with wrist drop and neutrophil myeloperoxidase antibodies? Granulomas?

Answer 25

Churg-Strauss
neutrophil myeloperoxidase antibodies = p-ANCA

Granulomatous, necrotizing vasculitis with eosinophilia!

Question 26

Chewing difficulty and persistent headaches? Type of inflammation? Treatment?

Answer 26

Giant cell arteritis
granulomatous inflammation of the media, also seen in Takayasu

Treat with corticosteroids (even before getting results of biopsy, to prevent irreversible blindness due to opthalmic artery occlusion)

Question 27

12yo with flat yellow spots on inner surface of aorta? Composed of? Do they predict atherosclerosis?

Answer 27

Fatty streaks
earliest lesions in progression to atherosclerosis, seen in all individuals after age 10

composed of intimal, lipid-filled foam cells (macrophages that have engulfed LDL)
stage BEFORE smooth muscle cell migration, proliferation, and ECM deposition in response to PDGF

do NOT predict the occurrence or location of atheromatous plaques later in life (atheromas form after SMC activity and fibrous plaque formation)

Question 28

Severe nosebleeds and pink spider-like lesions on oral and nasal mucosa, face, and arms? Mechanism?

Answer 28

hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
autosomal dominant

Telangiectasias in skin and mucus membranes of the lips, oronasopharynx, respiratory tract, GI, and urinary tract.
Rupture may cause epistaxis, GI bleeding, or hematuria as a result.

Question 29

50yo with difficulty walking – cramps in thigh that resolve quickly with rest and decreased sexual performance; history positive for MI? Cause? Mechanism?

Answer 29

Intermittent claudication (exercise-induced lower extremity pain that remits with rest)

Claudication almost always the result of ATHEROSCLEROSIS of arteries. Obstruction due to fixed stenotic atheromatous lesions (bulge into lumen) and prevent sufficient INCREASE in blood flow to muscles during exercise = ischemic muscle pain.
Diminished blood flow to internal iliac and internal pudendal branches = difficulty maintaining erection.

Question 30

How is coarctation of the aorta associated with intracranial hemorrhage?

Answer 30

coarctation of the aorta

• may occur solitary, but may also be associated with other congenital cardiac anomalies and berry aneurysms (in the Circle of Willis)
• leads to hypertension in branches of the aortic arch proximal to the coarctation, increasing risk of rupture (leading to subarachnoid hemorrhage)

Question 31

What is the cause of an abdominal aortic aneurysm? What is the cause of thoracic aortic aneurysm?

Answer 31

Abdominal aortic aneurysm – associated with ATHEROSCLEROSIS (atheromas can sufficiently progress enough to weaken the underlying media of the aortic wall)

Thoracic aortic aneurysm – associated with CYSTIC MEDIAL DEGENERATION (MYXOMATOUS) due to HTN, Marfan, or tertiary syphilis