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1. A 45 year old man consulted  a doctor about a plaque-like formation on his neck. Histological   examination  of  a  skin  bioptate  revealed   clusters   of  round   and oval tumour cells with a narrow  border of basophilic  cytoplasm  resembling of cells of basal epidermal layer. What  tumour is it?

Explanation

Skin cancer (epithelial tumors) is divided into 4 groups:

·        Intraepidermal cancer (cancer in situ): Bowen’s disease, erythroplasia of Queyrat.

·        Basal cell carcinoma (BCC, basalioma)

·        Epidermoid cancer

·        Skin appendage cell carcinoma: Paget’s disease

Basal cell carcinoma (basalioma) is malignant; the tumor is characterized by slow growth (sometimes for years), locally destructive invasive growth without metastases and frequent recurrences. The tumor is of polymorphous structure derived from the epidermis and skin appendages. The most prevalent location is the face, neck and scalp. Gradually increasing in size, they can form a large plaque or node with ulcerative depression in the center and elevated borders. It has the appearance of a flat well-defined reddish, round or oval-shaped spot or plaque.

2.

Preventive  examination  of  a  patient  revealed  an enlarged lymph  node  of metastatic origin on the medial wall of the left axillary crease Specify the most likely localization  of the primary tumour:

Explanation

Metastases of breast cancer is either local or distant. Local metastases is usually to the lymphatic nodes of breast base, axilla, subclavicular, parasternal nodes. Distant metastases are hematogenic ones, 40-50% to the bones, lungs, and liver.

Cancer of any of the following will metastasize locally through:

            Submandibular salivary gland – submandibular nodes

            Thyroid gland – deep anterior cervical nodes

            Stomach – celiac nodes

            Lungs – visceral thoracic lymph nodes

3. Examination of a 55 year old woman revealed   under   the   skin  of  submandibular area a movable slowly growing pasty formation with distinct borders 1,0x0,7 cm large.  Histological  examination revealed lipocytes that form segments of different forms and sizes separated from each other by  thin  layers  of  connective tissue  with vessels. What is the most probable diagnosis?

Explanation

Lipoma is a benign tumor of fatty tissue. It is the most frequent soft tissue tumor, arising in subcutaneous regions at any site but most commonly on the back, shoulder and neck. It may develop in every site where there is fat tissue. Lipomas are encapsulated, usually small yellow node with distinct (clear) borders.

Liposarcoma and fibrosarcoma are malignant with no distinct borders. Angioma is tumor of vessels; Fibroma and Fibrosarcoma are tumors of connective tissue.

4.

A  39 year  old  man  who  had  been operated for the stomach ulcer died 7 days after  the  surgery.  Autopsy revealed  that peritoneal leaves were dull, plephoric, covered  with  massive  yellow-greenish films,  the  peritoneal cavity  contained for about  300 ml of thick yellow-greenish liquid.  What  pathologic process  was revealed  in the peritoneal cavity?

Explanation

Fibrinopurulent peritonitis: Supurative or purulent inflammation is characterized by the production of large amounts of pus. The cellular inflammatory response in peritoneal cavity is composed primarily of dense collections of neutrophils and fibrinopurulent debris that coat the visceral and abdominal wall. Serous peritonitis – thin fluid (not pus); Hemorrhagic peritonitis  - hemorrhage.

5.

Autopsy of  a  17 year  old  girl  who died   from   pulmonary  failure   revealed a small area of caseous necrosis in the inferior  lobe of the right lung, and occurrences of caseous necrosis in the bronchopulmonary, bronchial  and bifurcational lymph nodes. What is the most probable postmortem diagnosis?

Explanation

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Types of tuberculosis:

o   Primary tuberculosis

o   Post primary tuberculosis: - secondary tuberculosis

                                                   - Hematogenous tuberculosis

            Primary tuberculosis is the infection of an individual who has not been previously infected or immunized. Also called Ghon’s complex or childhood tuberculosis. The primary complex in lungs is usually located in the lower part of the right upper lobes or the upper part of the lower lobes in segments 3,8,9,10. (NB: 8,9,10 segments are in the inferior lobe of the lungs). Primary complex or Ghon’s complex consists of 3 components: pulmonary component; lymphatic vessel component and lymph node component.

            Secondary tuberculosis mainly affects the upper lobes of the lungs.

6. A 10 year old child had the mantoux tuberculin  test   administered.  48  hours later  a  papule  up  to  8 mm  in  diameter appeared  on  the   site  of  the   injection. What type of hypersensitivity reaction developed after the tuberculin injection?

Explanation

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The Mantoux skin test should be read between 48 and 72hrs after administration. The basis of reading  is the presence or absence of induration, which may be determined by inspection and by palpation. A record should also be made of formation of vesicles, bullae, lymphangitis, ulceration and necrosis at the test site. The formation of vesicles, bullae or necrosis at the test site indicates positive result. A negative mantoux result usually signifies that the individual has never been exposed to Mycobacterium tuberculosis i.e. absence of cell mediated immunity to tuberculin.

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Mantoux test is a type IV Hypersensitivity reaction (HSR), which involves macrophages,T-lymphocytes and lymphokines(cytokines). Mononuclear cells (lymphocytes,monocytes,macrophages).

7.

A 38 year old man died all of a sudden. Autopsy  revealed   myocardial   infarction in  the  posterior wall  of  the  left  ventricle. What  are  the  most  likely alterations in  myocardiocyte structure  that   can  be revealed   microscopically   in  the  infarction focus?

Explanation

     In myocardial infarction there is necrosis. Nuclear changes in necrosis observed microscopically (light microscope) includes:

·        Karyopicnosis: at first nucleus shrinks and becomes dense.

·        Karyorrhexis: characterized by rupture of nuclear membrane and fragmentation of nucleus. Nucleus is decomposed into small granules.

·        Karyolysis: develops when nucleus dissolves

At electron microscope level, in addition to the above nuclear changes, disorganization and disintegration of the cytoplasmic organelles and severe damage of the plasma membrane are seen.

8.

Histologic  analysis  of uterus  mucous membrane  revealed   twisting  glands, serrated and spinned,  they were extended by stroma  growth with proliferation of its cells. Formulate a diagnosis:

Explanation

     Hyperplasia of endometrium is classified into 3 types:

·        Simple hyperplasia (cystic glandular hyperplasia)

·        Adenomatous hyperplasia (complex hyperplasia without atypia)

·        Atypical hyperplasia (complex hyperplasia with atypia)

Simple hyperplasia (cystic glandular hyperplasia) is characterized by the presence of large and cystically dilated varying-sized glands, which are lined by atrophic epithelium.

9.

Bacterioscopy of  nasopharyngeal mucus  taken   from  a  2,5  year  old  child with nasopharyngitis revealed  gram- positive   diplococci   looking   like   coffee grains. What  organs  of the child are most likely to be affected  if these  microorganisms penetrate the blood?

 

Explanation

     Neisseria diplococcic are gram negative cocci that resemble paired kidney beans/coffee grains. The genus Neisseria contains two important human pathogens: Neisseria meningitides and Neisseria gonorrhoeae. Portal of entry is respiratory and genital tracts respectively. Meningococcal infection is an acute infectious process which has 3 main forms: nasopharyngitis; purulent meningitis and meningococcemia.

Meningitis is an acute or chronic inflammatory process chiefly affecting the pia and arachnoid mater (brain tunics) and cerebrospinal fluid. Meningococcal meningitis is characterized by the hyperemia of the pia mater, saturated with dull serous exudates during the first days of the disease.

10.

Autopsy of a man who died from ethylene glycol  poisoning   revealed   that his   kidneys   are   a   little   bit   enlarged, edematic; their capsule can be easily removed.  Cortical  substance  is broad  and light-grey.  Medullary substance   is  dark- red. What pathology had this man?

 

Explanation

     Acute tubular necrosis/Necrotic nephrosis/Necronephrosis involves the death of tubular epithelial cells that form the renal tubules of the kidneys. Most common cause of acute renal failure. It can be ischemic or nephrotoxic.

·        Ischemic acute tubular necrosis occurs due to hypoperfusion of the kidneys.

·        Nephrotoxic acute tubular necrosis occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents. Toxic agents causing nephrotoxic acute tubular necrosis includes mercuric chloride, ethylene glycol, carbon tetrachloride etc.

Macroscopically, the kidneys are enlarged and swollen (edematous). On cut section, the cortex is pale, while the medulla is slightly darker than normal. The capsule can be easily removed.

11.

Autopsy   of    a    man    who    had tuberculosis revealed  a 3x2 cm large cavity in the  superior lobe  of the  right  lung. The cavity was interconnected with a bronchus,   its  wall  was  dense  and  consisted  of  three   layers:  the  internal  layer was pyogenic, the middle layer was made by tuberculous granulation tissue and the external one  was made  by connective tissue. What is the most likely diagnosis?

Explanation

Secondary tuberculosis usually results from reactivation of dormant, endogenous tubercle bacilli in a sensitized patient who has had previous contact with the tubercle bacillus. Reactivation typically begins in the apical or posterior segments (often 1st and 2nd segments) of one or both upper lobes (“simon’s foci”), where the organisms were seeded during the primary infection. There are 8 forms or stages of the secondary tuberculosis: Acute local tuberculosis; Fibrous local tuberculosis; Infiltrative tuberculosis; Tuberculoma; Caseous pneumonia; Acute cavernous tuberculosis; Fibrous cavernous tuberculosis; Cirrhotic tuberculosis.

Fibrous cavernous tuberculosis is the most frequent form. Macroscopically, the lesions are spherical and cavitary (cavity can contain blood and blood clots); the so-called coin lesions. Microscopically, the outer wall of cavity shows fibrosis or sclerosis. Internal surface may be connected with bronchus. The wall of cavern has 3 membranes:

·        Internal membrane occurs by necrotic tissue

·        Middle membrane occurs by special granular tissue

·        External membrane occurs by connective fibrous tissue

12.

During    examination  of   a   6-year-old    child    a    doctor     revealed     greyish    films    on    the    pharyngeal    tonsils. Their removal  provoked moderate haemorrhage. Bacterioscopy revealed gram-positive clublike bacteria. What symptoms will develop in this child within the next few days if no specific treatment is provided?

Explanation

There are two types of fibrinous inflammation: croupous and diphtheric fibrinous inflammation. Usually croupous inflammation develops on the columnar epithelium. In this case the fibrinous membranes unfix easily, without any effort. Diphtheric fibrinous inflammation develops on the squamous or intermediate epithelium and the fibrinous membranes unfix with difficulties and may even bleed when trying to unfix it.

“their removal provoked moderate hemorrhage” – Diphtheric inflammation. General changes in diphtheria are accompanied by toxinemia and appear as toxic lesions to myocardium, nerves (peripheral nervous system) adrenal glands, kidney (interstitial nephritis) and liver.

13.

Autopsy of  a  woman  with  cerebral atherosclerosis  revealed   in  the  left cerebral hemisphere a certain  focus that is  presented by  flabby,  anhistic,  greyish and yellowish tissue with indistinct  edges. What pathological process is the case?

Explanation

     Stroke is sudden loss of blood circulation to an area of the brain resulting in a corresponding loss of neurologic function. Types:

·        Ischemic (70-80% of cases):

- Atherosclerotic (thrombotic): most common type

- Embolic

·        Intracerebral hemorrhage

·        Subarachnoid hemorrhage

·        Lacunar stroke

Atherosclerotic (thrombotic) stroke: Ischemic type of stroke is commonly caused by platelet thrombosis that develops over a disrupted atherosclerotic plaque. Characteristics: it usually develops at the periphery of the cerebral cortex, swelling of brain, loss of dermacation between gray and white matter, breakdown of myelin, pale infarct; Cystic area develops after 10days to 3weeks due to liquefactive necrosis.

14.

A 38-year-old man died in the attempt of lifting weight. He had collaptoid state. Autopsy revealled  an  extensive  aneurism rupture  of  thoracic   aorta.   He   suffered from   visceral  syphilis  during   his  lifetime. What pathological process caused weakness  of aortic  wall, its dilatation and rupture?

Explanation

image     

The main forms of syphilis are Gumma; syphilitic aortitis; neurological syphilis. In syphilitic aortitis, the aorta is affected by an infiltration of lymphocytes and plasma cells beginning around the vasa vasorum and extending into the media, causing weakening due to focal destruction (windowing) of the specialized elastic tissues. There is compensatory irregular thickening of the intima (tree-bark appearance), but the important effect is expanding aneurysm formation because the elastic fibers are destroyed.

15.

Microscopical  examination of an enlarged cervical lymph node revealed blurring  of its structure, absence  of lymphoid  follicles; all the  microscopic  fields showed cells with roundish nuclei and thin limbus of basophil cytoplasm. It is known from the clinical data that other groups  of lymph  nodes  are  also enlarged as well as spleen  and  liver. What  disease might be suspected?

 

Explanation

     Lymphoid leukosis is a type of malignant neoplasm characterized by the proliferation of cells native to the lymphoid tissues; that is - lymphocytes, histiocytes and their precursors and derivatives. It is characterized by an enlarged liver due to infiltration of cancerous lymphoid cells. In addition, other abdominal organs are also affected.

16.

A worker  of a cattle  farm fell acutely ill and then died from the progressing intoxication. Autopsy revealed  enlarged, hyposthenic spleen  of dark-cherry colour when  dissected;  excessive  pulp  scraping. At the base and fornix of brain pia maters are edematous, soaked  with blood,  dark-red  (\"scarlet hat\").   Microscopic   examination revealed serous haemorrhagic inflammation  of  brain  tissues  and  tunics along  with destruction of small vessel walls. What is the most likely diagnosis?

Explanation

There are two medically important Bacillus species: Bacillus anthracis and Bacillus cereus. Bacillus anthracis causes anthrax.

Human disease occurs in 3 main forms: cutaneous, pulmonary (inhalation) and gastrointestinal. Humans are most often infected cutaneously at the time of trauma to the skin, which allows the spores on animal products such as hides, bristles and wool to enter. Spores can also be inhaled or when contaminated meat is ingested. After being inhaled, the organism moves rapidly to the mediastinal lymph nodes and causes hemorrhagic mediastinitis. Pathogenesis is based on the production of two exotoxins  (Anthrax toxin) – edema factor and lethal factor. Hemorrhagic mediastinitis, septic shock hemorrhagic meningitis and death are severe life-threatening complications. In fatal cases, the organism may affect the spleen, liver, intestines, kidneys, adrenal glands and meninges.

Live spore vaccine (STI) is used for vaccination against anthrax. STI live vaccine
17.

A man with a wound  of his limb that had been  suppurating for a long time died  from  intoxication. Autopsy  revealed extreme emaciation, dehydration, brown atrophy of liver, myocardium, spleen  and cross-striated muscles as well as renal amyloidosis. What diagnosis corresponds with the described  presentations?

 

Explanation

     Chronic sepsis (chroniosepsis): this form of sepsis is characterized by durably availability, not healing of primary septic focus that progress into a chronic one. In organs and tissues, there is atrophy and dehydration are expressed. Brown atrophy is found in the liver, myocardium and striated muscles. The spleen is decreased.

18. Chronic inflammation and transformation   of   the   one-layer  ciliated   epithelium  into   multiple-layers  flat  epithelium was  revealed   in  the  thickened  mucous membrane  of  the  bronchus bioptate  of the  patient with smoke  abuse.  Which  of the processes is the most likely?

Explanation

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Metaplasia is a reversible change of one type to another type of adult epithelial or mesenchymal cells, usually in response to abnormal stimuli and often reverts back to normal on removal of stimulus. Types (2):

·        Epithelial: *Squamous metaplasia: in bronchus (chronic smokers), cervix

  *Columnar metaplasia: there is transformation to columnar epithelium.

·        Mesenchymal metaplasia: osseous and cartilaginous.

Hyperplasia: ↑number of cells; Hypertrophy: ↑in size.

19.

Microscopic examination of the enlarged  neck   gland   of  a  14  year   old girl   revealed    destruction   of    the    tissue  structure  of  the  node,   absence   of the lymph follicles, sclerotic areas and necrosis foci, cell constitution of the node is polymorphous, lymphocytes,  eosinophils, big atypical cells with multilobular nuclei (Beresovsky-Sternberg cells) and mononuclear cells  of  the  large  size  are present. What is the most likely diagnosis?

Explanation

     Hodgkin’s disease or lymphogranulomatosis is a disorder involving primarily the lymphoid tissue. It is separated from non-hodgkin lymphoma because:

First, it is characterized morphologically by the presence of distinctive neoplastic giant cells called Reed-sternberg’s (RS) cells, admixed with a variable inflammatory infiltrate.

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Secondly, it is often associated with distinctive clinical features, including systemic manifestations such as fever.

Reed-sternberg cell: classically, it is a large cell, most often binucleate or bilobed, with two halves often appearing as mirror images of each other. Its identification is essential for the histologic diagnosis. The origin of Hodgkin’s lymphoma is unknown.

20. Pulmonary  examination  of  a  patient  who  has  worked  as  a  stone  grinder for 9 years  revealed  small dense  roundish  nodules   consisting   of  connective  tissue. The nodules were found to have peripheral macrophages. Such pulmonary  alterations are indicative  of the following disease:

Explanation

image     

Silicosis is a lung disease that is caused by inhaling tiny bits of silica. Silica is a common mineral that is part of sand, rock and mineral ores like quartz. People who work in jobs where they could breathe in these tiny silica bits like sandblasting, mining, construction etc; are at risk for silicosis. The silica dust can cause fluid buildup and scar tissue in the lungs that cuts down the ability to breathe. Silicosis cannot be cured, but you can prevent it if you take specific steps to protect yourself.

21. Autopsy of a 75-year-old  man  with a long history  of atherosclerosis revealed  a grey irregular-shaped focus of loose consistency in the right parietotemporal region of brain.  What  is the most likely cause of this process?

Explanation

image

The middle (medial) cerebral artery arises from the internal carotid artery and enters the lateral sulcus. There, it gives branches that supply the greater portion of the superolateral surface of the cerebral hemisphere; including the frontal, parietal, temporal lobes and the insula.

Anterior cerebral artery supplies the medial surface of hemisphere.

Posterior cerebral artery supplies the inferior surface of temporal lobe and the inferior and medial surfaces of the occipital lobe

Basilar artery gives the following branches: posterior cerebral arteries, anterior inferior cerebellar artery, superior cerebellar artery, pontine arteries.

            Only the middle (medial) cerebral artery supplies the right and left parietotemporal region of brain.

22.

Autopsy  of   a   man   with   a   malignant    stomach    tumour   who   had   died   from   cancer    intoxication  revealed in the posteroinferior lung fields some dense, grayish-red  irregular foci protruding above the section surface. Microscopic examination  revealed   exudate  containing a large  amount of neutrophils in the lumen and walls of small bronchi and alveoles. Such pulmonary alterations indicate the following disease:

Explanation

     Bronchopneumonia (focal pneumonia) is marked by patchy exudative consolidation of lung parenchyma. Bronchopneumonia often is a complication of other disease (complication of stomach cancer). Initially bronchi are affected. Then, inflammation spreads to parenchyma of lungs with accumulation of exudates in the alveoli. Grossly, the lungs show dispersed, elevated, focal areas of palpable consolidation and suppuration. Histological features consist of acute (neutrophilic) suppurative (purulent) or mixed exudates filling airspaces and airways, usually around bronchi and bronchioles.

23.

Autopsy   of    a    1,5-year-old    child revealed  haemorrhagic skin rash, moderate hyperaemia and edema  of nasopharyngeal mucous membrane, small haemorrhages in the mucous  membranes and  internal organs;  dramatic  dystrophic alterations in liver and myocardium; acute necrotic nephrosis; massive haemorrhages in the  adrenal glands.  What  disease  are these alterations the most typical for?

Explanation

Morphologically, meningitis can be: meningococcal nasopharyngitis, meningococcal meningitis, meningococcemia. In meningococcemia, changes on the organs are characterized by generalized damage of microcirculation, skin rash, changes in the joints, vascular membrane of the eyes, adrenal glands and kidneys. Changes in the serous layers of the pericardium are observed. The rash is hemorrhagic, star-like, located mainly on the buttocks, lower extremities, eyelids and scleras. Focal necrosis and hemorrhages or bilateral massive hemorrhages with the development of acute adrenal insufficiency (waterhouse-friderichsen syndrome) are noted in the adrenals. Necrosis of nephrothelium of the tubules (necrotic nephrosis) is observed in the kidneys.

 

24.

A  46-year-old   man   had   a  bulging dark macula on skin that caused no discomfort.  With  time  it began  to increase in size and became  painful. It turned dark brown and there  was a nodule  on palpation. Histological  examination of tissues revealed spindle and polymorphous cells with multiple mitoses. Their cytoplasm contained brown  pigment.  What  tumour is it?

 

Explanation

Melanoma is strongly linked to acquired mutations caused by exposure to ultraviolet (UV) radiation in sunlight. Melanomas show striking variations in colour, appearing in shades of black, brown, red, dark blue and gray. The borders of melanomas are irregular and often notched, unlike the smooth, round and uniform borders of melanocytic nevi. The positive DOPA reaction indicates the presence of melanocytes. Melanoma arises in the skin, meninges, uvea of the eye.

25.

Autopsy of a 58 year old man revealed that bicuspid valve was deformed, thickened   and   unclosed.    Microscopically: foci  of  collagen   fibrilla  are   eosinophilic, react positively to fibrin. The most probably  it is:

Explanation

     Due to the positive fibrin reaction and eosinophilia of the collagen fibers, it is better to choose fibrinoid swelling since there is no record of any inflammatory reaction or cells. Fibrinoid swelling changes is a stromal vascular proteinous degeneration. The main signs are revealed microscopically: the bands of collagen fibers are homogenous, impregnated with plasma proteins.

26.

Histological  examination of  the  biopsy  material obtained  from  the  lower third  of  the  esophagus of  a  57-year-old male  with  the  symptoms   of  continuous reflux  revealed  the  change  of the  stratified  squamous epithelium to  the  single-layer  columnar glandular epithelium with  signs  of  mucus   production.  Specify the  pathological process  in  the  mucous membrane:

Explanation

Metaplasia is a reversible change of one type to another type of adult epithelial or mesenchymal cells, usually in response to abnormal stimuli and often reverts back to normal on removal of stimulus. Types (2):

·        Epithelial: *Squamous metaplasia: in bronchus (chronic smokers), cervix

                            *Columnar metaplasia: there is transformation to columnar epithelium.

·        Mesenchymal metaplasia: osseous and cartilaginous.

Hyperplasia: ↑number of cells; Hypertrophy: ↑in size.

27.

Microscopy  of   the   bronchial wall revealed atrophy  of the mucosa, metaplastic change from columnar  to squamous  epithelium, an   increase    in the number of goblet cells, diffuse infiltration    of   the   bronchial  wall with lymphoplasmacytic elements with a large number of neutrophilic granulocytes, pronounced sclerosis. Specify the morphological form of bronchitis:

 

Explanation

Pronounced sclerosis indicates a chronic condition. The diffuse infiltration of bronchial wall with lymphoplasmocytic elements with a large number of neutrophils indicates a purulent inflammation. Bronchial wall – bronchitis

28.

Microscopy   of  the  myocardium  of a  patient who  had  died  from  heart  failure revealed foci of fibrinoid necrosis located  diffusely in the interstitial stroma, and often around the vessels. Such foci were surrounded by lymphocytes, macrophages, histiocytes.  Pericardium was found  to have signs of sero-fibrinous pericarditis. What  is the  most  likely  diagnosis?

 

Explanation

Rheumatic fever has 4 stages:

·        Mucoid swelling: edema of connective tissue; they undergo swelling, fraying, fragmentation and disintegration.

·        Fibrinoid changes: the affected areas take on a deeply eosinophilic appearance resembling fibrin – fibrinoid degeneration or necrosis.

·        Cellular reactions: infiltration by lymphocytes, plasma cells, histiocytes and fibroblasts. Pathognomonic focal inflammatory nodules called Aschoff bodies are the most characteristic in the heart. In its early phase, they constitute a foci of fibrinoid necrosis, initially surrounded by lymphocytes, macrophages and a few plasma cells.

·        Sclerosis: Aschoff bodies or diffuse inflammatory cellular infiltration are slowly replaced by fibrous scar mainly around the vessels.

The microscopic findings are basically describing the Aschoff bodies and the 3rd and 4th stages of rheumatic fever.

29.

A  65-year-old   male   suddenly   lost the  vision  in  one  eye  due  to  the  retinal  detachment. The  patient underwent enucleation.    Histological     examination of  the  removed eye  retina   and  choroid revealed   clusters   of   atypical   cells  with marked polymorphism of cells and nuclei,  with  a  moderate number   of  mitoses including the pathological ones. The cell  cytoplasm   and   intercellular  medium contained brown pigment giving a positive  DOPA  reaction. Perls’ reaction was negative.  What  is the  most  likely diagnosis?

 

Explanation

Melanoma is strongly linked to acquired mutations caused by exposure to ultraviolet (UV) radiation in sunlight. Melanomas show striking variations in colour, appearing in shades of black, brown, red, dark blue and gray. The borders of melanomas are irregular and often notched, unlike the smooth, round and uniform borders of melanocytic nevi. The positive DOPA reaction indicates the presence of melanocytes. Melanoma arises in the skin, meninges, uvea of the eye.

30.

At the post-mortem examination the stomach of a patient with renal failure was found  to have a yellow-brown  coating  on the  thickened mucosa.The  coating  was firmly adhering to its surface  and  had  significant thickness. Microscopy revealed congestion  and  necrosis  of mucosal  and submucosal  layers,  fibrin presence. What is the most likely diagnosis?

 

Explanation

Fibrinous inflammation is an inflammatory response of mucous surface (oral, respiratory, bowel) to toxins of diphtheria or irritant gases. As a result of denudation of epithelium, plasma exudes on the surface where it coagulates and together with necrotized epithelium, forms false membrane that gives this type of inflammation its name. Histologically, fibrin appears as an eosinophilic network of threads or sometimes as an amorphous coagulum.

31. Histological  examination of the removed skin neoplasm  revealed  clusters and cords of atypical cells of stratified squamous epithelium, growing into the underlying tissue. What  diagnosis  can be assumed?

Explanation

The epidermis of skin is composed of stratified squamous epithelium. It is nonkeratinizing because it is growing into the underlying tissue. It probably would have being keratinized if it is growing out of the tissue.

32.

Autopsy  of  a  man  who  died  from chronic  cardiovascular collapse  revealed \"tiger  heart\". Sidewards  of endocardium a yellowish-white banding can be seen; myocardium is dull, dark-yellow.  What process caused this pathology?

Explanation

     Intracellular accumulations (parenchymal degeneration or dystrophies). Intracellular fatty degenerations are the abnormal accumulations of triglycerides within parenchymal cells. The liver, heart, kidneys are damaged the most frequently. Fatty degeneration of the heart – Tiger’s heart; fatty degeneration of the liver – Goose liver; fatty degeneration of the kidney – large white kidney.

33. Autopsy  of  a  62-year-old   woman revealed  a dense well-circumscribed node of 6 cm in diameter in the  cranial  cavity. The node  was attached to the dura  mater and histologically consisted of clusters and micro-concentric structures of endothelial cells, psammoma bodies.  What  kind of tumor  was found at autopsy?

Explanation

Psammoma bodies are laminated concentric spherules with dystrophic calcification. PSaMMoma bodies are seen in:

·        Papillary carcinoma of thyroid

·        Serous papillary cystadenocarcinoma of ovary

·        Meningioma

·        Malignant mesothelioma

Meningioma is the only one in the options given.

34.

Autopsy  of  a  patient  who  suffered from croupous  pneumonia and died from pneumococcal sepsis  revealed  900 ml of turbid   greenish-yellow  liquid  in  the  right pleural  cavity. Pleural  leaves are dull, plephoric. Name the clinicopathological form of inflammation in the pleural cavity:

Explanation

     Complications of croupous or lobar pneumonia includes empyema, gangrene, carnification, abscess formation, bacteremic spread which leads to purulent meningitis, bacterial endocarditis, arthritis, pericarditis and other organs. Empyema is a purulent inflammation of serous membranes (empyema of pleura, empyema of gall bladder and urinary bladder etc). Purulent or suppurative inflammation is characterized by the production of large amounts of pus or purulent exudates (liquids) consisting of a lot of neutrophils, necrotic cells and edema fluid.

35.

A patient died from progressive  heart failure.  Autopsy revealed  that  the  heart was enlarged in diameter, flabby. The muscle  section  exhibited  irregular blood supply. Histological  study of myocardium revealed hyperemia, the stroma was found to  have  lymphohistiocytic  infiltrates  with  degeneration of  cardiomyocytes.  The revealed  morphological changes  are indicative of:

Explanation

Hyperemia and lymphohistiocytic infiltrates indicates inflammation. It is not myocardial infarction nor cardiosclerosis because no necrosis is involved. No fatty infiltration, therefore it is not cardiomyoliposis. Therefore, the best answer is Non-purulent interstitial myocarditis.

36.

A  patient  underwent biopsy  of  the soft palate  arches  for  a suspected tumor (macroscopy  revealed   an  ulcer   with  a dense  floor).Study  of the  biopsy material revealed mucosal necrosis with infiltration of lymphocytes,  epithelioid cells, plasma cells, single neutrophils in the submucosa.  There  were  also apparent signs  of  endovasculitis  and  perivasculitis. The described  changes are typical for:

Explanation

Primary syphilis: the chancre develops at the site of inoculation in 10-90days (average 21 days) and has a characteristic “luetic vasculitis” (endovasculitis and perivasculitis). The chancre is a slightly elevated, firm, reddened papule that erodes to create a clean-based, shallow ulcer. Histologically, the chancre contains an intense infiltrate of plasma cells, with scattered macrophages and lymphocytes and an obliterative endarteritis. The regional lymph nodes are usually enlarged and may show nonspecific acute or chronic lymphadenitis, plasma cell-rich infiltrates or focal epitheloid granulomas. The combination of chancre, lymphangitis and lymphadenitis is called – primary syphilitic complex.

37. Examination of the removed stomach revealed   a  deep   roundish  defect   with regular edges at the lesser curvature of the antrum.  The defect  reached the muscular tunic and was 1,5 cm in diameter. Within the  defect  floor  there  was  a  translucent dense  area  resembling of a hyaline  cartilage. What  process  had  developed in the floor of the stomach defect?

Explanation

Hyalinosis (hyaline changes): transparent, glass-like, usually refers to an alteration within cells or in the extracellular matrix which gives a homogenous, glassy, pink appearance. It can be classified according to its localization (vascular and connective tissue hyalinosis) and propagation (generalized and localized). It is localized because it has a diameter of 1.5cm; it did not affect a large portion or the whole stomach wall.

38.

A diseased  child has a high fever, sore throat, swelling of submandibular lymph nodes. Objectively:   pharyngeal  mucosa is edematous, moderately hyperemic, the tonsils are enlarged, covered  with grayish membrane tightly adhering  to the  tissues above. Attempts to remove the membrane produce the  bleeding   defects.  What  disease are these presentations typical for?

 

Explanation

Diphtheria is an acute infectious disease characterized by fibrinous inflammation in the focus of primary fixation of the causative agent and general intoxication due to exotoxin absorption. Causative agent – Corynebacterium diphtheria. Local changes in Diphtheria in the pharynx: gray or white patches of exudates appear on the pharyngeal mucosa, usually over the tonsils. These enlarge and coalesce and with the accumulation of blood, become gray or black. The lymphoid tissues both in regional lymph nodes and systematically (as in the spleen) undergo hyperplasia with the development of prominent germinal centers that are often centrally necrotic. The epithelial surface becomes necrotic and easily adherent to the overlying membrane; this adherence explains why raw bleeding points are exposed when the membrane is forcibly removed. The soft tissue of the neck is swollen. In severe toxic forms, the edema is considerable and can involve the anterior surface of the chest.

39.

14 days after quinsy a 15-year-old  child presented with morning  facial swelling, high  blood  pressure, \"meat   slops\"urine. Immunohistological   study    of   a   renal biopsy sample revealed  deposition of immune complexes on the basement membranes of the  capillaries  and  in the glomerular mesangium.  What disease developed in the patient?

Explanation

Peritonsillar abscess also known as quinsy ( a complication of tonsillitis) caused by both aerobic and anaerobic bacteria (streptococcus, staphylococcus and haemophilus).

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Acute poststreptococcal glomerulonephritis: most frequently seen in children. Occurs approximately 2 weeks after group A streptococcal infection of pharynx or skin. Resolves spontaneously. Type III hypersensitivity reaction (Immune complex). Presents with peripheral and periorbital edema, cola-coloured urine, hypertension. On immunofluorescent microscopy: granular appearance due to IgG, IgM and C3 deposition along glomerular basement membrane and mesangium. On electron microscopy: subepithelial immune complex humps. On light microscopy: glomeruli enlarged and hypercellular.
40. Autopsy of a 78-year-old  patient revealed   that  retroperitoneal tissue  was soaked  with  blood,  the  abdominal aorta had a sacciform protrusion including a defect  with  irregular edges.  The  wall of the aorta  was here and there  of stone-like density.  This  is the  complication of  the following disease:

Explanation

Atherosclerosis of aorta is the most common form of atherosclerosis in which the aorta aneurysm usually develop. Most common aneurysm associated with atherosclerosis is the saccular aneurysm (sacciform protrusion). Wall of aorta – stone-like density as a result of scarring from Atherosclerosis.

41.

Study of the biopsy material revealed a  granuloma consisting of lymphocytes, plasma cells, macrophages with foamy cytoplasm  (Mikulicz  cells), many  hyaline globules. What disease can you think of?

 

Explanation

Microscopic examination of specific granulomas:

* In Rhinoscleroma of nose, the granuloma (scleroma) consists of plasma cells, epitheloid cells, lymphocytes and hyaline sphere. Large macrophages with light cytoplasm containing klebsiella rhinoscleromatis (Mikulicz’s cells), sclerosis and hyalinosis takes place.

* In TB, the granuloma is reffered to as a tubercle and is classically characterized by the presence of central necrosis surrounded by epitheloid cells, lymphocytes, plasma cells and giant langhance cells. In contrast, caseous necrosis is rare in other granulomatous diseases.

* The syphilis granuloma is calle Gumma. Gumma consist of a central area of fibrinoid or caseous necrosis surrounded by mononuclear inflammatory cells, mostly plasma cells, lymphocytes, epitheloid cells and seldom-giant langhance cells. Around gumma forms the granulation tissue and endovasculitis.

* In Tuberculoid Leprosy, the epidermis contains confluent granulomas composed of macrophages, plasma cells and leprous Virchow’s cells – Leprous Virchow’s cells (or Leprous cells) refer to large foamy macrophages within fatty vacuoles containing leprous mycobacterium.

* Actinomycosis caused by Actinomyces. It occurs rarely in human but rather frequently in cattle. Characterized by the formation of painful abscess. Infected man often have poor oral hygiene or recent dental work. Does not form granulomas.

42. A child entering the school for the first time  was given Mantoux  test  in order  to determine if there  was a need for revaccination.  The  reaction was negative.  What is the meaning of this test result?

Explanation

Tuberculin (Mantoux) skin test: this test is done by intradermal injection of tuberculoprotein (tuberculin), purified protein derivative (PPD). Type IV hypersensitivity reaction.

Immunization against tuberculosis is induced by injection of attenuated strains of bovine type of tubercle bacilli, Bacilli Calmette Guerin (BCG).

The Mantoux skin test should be read between 48 and 72hrs after administration. The basis of reading  is the presence or absence of induration, which may be determined by inspection and by palpation. A record should also be made of formation of vesicles, bullae, lymphangitis, ulceration and necrosis at the test site. The formation of vesicles, bullae or necrosis at the test site indicates positive result. A negative mantoux result usually signifies that the individual has never been exposed to Mycobacterium tuberculosis i.e. absence of cell mediated immunity to tuberculin.

43.

At autopsy  the occipital  lobe of brain was  found  to  have  a  cavity  2,5x1,5 cm large filled with a transparent liquid. The cavity had  smooth  brownish  walls. What process had developed in the brain?

Explanation

Cyst cavity contains transparent fluid, blood, tissue or tumor cells; Abscess cavity contains pus. Both are with a distinguishable wall.

44.

A  male  patient is 28 years  old.  Histological  study of a cervical lymph node revealed  a change of its pattern due to the proliferation of epithelioid, lymphoid cells and macrophages having nuclei in form of a  horseshoe. In  the  center  of  some  cell clusters  there  were  non-structured light-pink areas with fragments of nuclei. What disease are these changes typical for?

Explanation

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When tubercle bacilli are introduced into the tissue, they are ingested by the alveolar macrophage. Macrophages undergo changes resembling epithelial cells – EPITHELOID cells. Some of the macrophages form MULTINUCLEATED GIANT cells by fusion of adjacent cells (langerhan’s or foreign body type). The giant cells may have 20 or more nuclei. These nuclei may be arranged at the periphery like HORSE-SHOE, RING or clustered at the poles or they may be present centrally (foreign body giant cells). Lymphocytes, plasma cells and fibroblasts surround the epitheloid cells and giant cells (hard tubercle- no central necrosis). Within 10-14 days, the centre of the cellular mass begins to undergo caseation necrosis – soft tubercle. This is the hallmark of tuberculous lesions.

During the hematogenous spreading, the most serious immediate complication is MILIARY tuberculosis. The name miliary derives from its resemblance to millet seeds. Lesions of miliary tuberculosis consist of small granulomas, with a central necrotic portion. Organs often affected are lung, spleen, liver, kidney, meninges and bone marrow.

45. Bacteriological  examination  of purulent discharges from the urethra revealed  some  gram-negative bean- shaped  bacteria located  in the leukocytes. They  can  be  identified  as  the  causative agent of the following disease:

Explanation

Gonorrhea is caused by Neisseria gonorrhoeae. Its often intracellular (within neutrophils), gram-negative diplococci.  It is sexually or perinatally transmitted.

Syphillis is caused by Treponema pallidum(spirochetes),  Chancroid is caused by Haemophilus ducreyi. Trichonomoniasis is caused by trichomonas vaginalis. Veneral lymphogrnaulomatosis is caused by Chlamydia trachomatis (L1-L3). They are all sexually transmitted.  Specific identification of the gonococcus can be made either by its fermentation of glucose (but not maltose) or by fluorescent-antibody staining.

46. A  60-year-old   patient  with  a  long history   of  atherosclerosis  and   a  previous  myocardial   infarction   developed an attack  of  retrosternal pain.  3 days  later the  patient was hospitalized and then  died of progressive  cardiovascular insufficiency. At autopsy a white fibrous depressed area  about  3 cm in  diameter with  clear boundaries  was  found   in  the  posterior wall of the  left ventricle  and  interventricular   septum.   The   dissector   evaluated these changes as:

Explanation

Focal cardiosclerosis. Focal –white fibrous depressed area 3cm in diameter.    Cardiosclerosis-Atherosclerosis.     

Diffuse cardiosclerosis

Diffuse – multiple whitish layers of connective tissue

Cardiosclerosis – Atherosclerotic calcified plaques

47.

A 7-year-old boy got ill with diphtheria. On the third day he died of asphyxiation. At autopsy the mucosa of the larynx, trachea and bronchi had thickened, edematous, lustreless appearance and was covered with gray films which could be easily removed. Specify the type of laryngeal inflammation:

Explanation

There are two types of fibrinous inflammation: croupous and diphtheric fibrinous inflammation. Usually croupous inflammation develops on the columnar epithelium. In this case the fibrinous membranes unfix easily, without any effort. Diphtheric fibrinous inflammation develops on the squamous or intermediate epithelium and the fibrinous membranes unfix with difficulties and may even bleed when trying to unfix it.

48.

A child with suspected  tuberculosis was given Mantoux test. After 24 hours  the site of the  allergen injection  got swollen, hyperemic and painful. What are the main components that determine such response of the body?

Explanation

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Mantoux test is a type IV Hypersensitivity reaction (HSR), which involves macrophages,T-lymphocytes and lymphokines (cytokines). Mononuclear cells (lymphocytes, monocytes, macrophages).

Remember,it is antibody independent (i.e does not involve antibodies).

B-lymphocytes - Plasma cells - Ig(Antibodies)------- none is involved in Type IV HSR.

The Mantoux skin test should be read between 48 and 72hrs after administration. The basis of reading  is the presence or absence of induration, which may be determined by inspection and by palpation. A record should also be made of formation of vesicles, bullae, lymphangitis, ulceration and necrosis at the test site. The formation of vesicles, bullae or necrosis at the test site indicates positive result. A negative mantoux result usually signifies that the individual has never been exposed to Mycobacterium tuberculosis i.e. absence of cell mediated immunity to tuberculin.

49. Histological examination of biopsy samples taken from the thickened edges of a gastric ulcer revealed small clusters of small, markedly atypical hyperchromatic epithelial cells that were localized in the overdeveloped stroma. Specify the tumor:

Explanation

Undifferentiated carcinoma: tumor is composed exclusively of undifferentiated cells with deeply stained pleomorphic nuclei and scanty cytoplasm, with no evidence of differentiation toward squamous carcinoma or adenocarcinoma. Pure undifferentiated carcinoma of the gastric cardia is rarely seen.

Scirrhous carcinoma: in this pattern, the stomach wall is thickened due to extensive desmoplasia. Therefore, we have scirrhous undifferentiated carcinoma.

50.

A 10-year-old child was found to have a congenital hypoplasia of the left kidney. Ultrasound examination revealed that the right kidney was markedly enlarged and had regular shape. No functional disorders were revealed. Specify the process that developed in the right kidney:

Explanation

Pathological hypertrophy (hyperplasia) types: neurohumoral; working; compensatory reparative; vicarious (substitutional); hypertrophic vegetations

* Vicarious (substitutional) hypertrophy: following nephrectomy (or congenital hypoplasia) on one side in a young patient, there is compensatory hypertrophy as well as hyperplasia of the nephrons of the other kidney.

* Working hypertrophy: cardiac muscle develop hypertrophy at some cardiac diseases such as systemic hypertension, aortic stenosis or insufficiency; skeletal muscles (e.g. biceps) in athletes. ↑ work load → hypertrophy

51.

A 35-year-old female patient has undergone biopsy of the breast nodules. Histological examination has revealed enhanced proliferation of the small duct and acini epithelial cells, accompanied by the formation of glandular structures of various shapes and sizes, which were located in the fibrous stroma. What is the most likely diagnosis?

Explanation

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Adenoma: benign epithelial tumor from the epithelium of the glands and glandular organs. More often they can be found in the breast, thyroid gland, liver, ovaries, prostate gland, GIT. In the question, it is located in the fibrous stroma – FIBROADENOMA.

52.

A 54-year-old female was brought to the casualty department after a car accident. A traumatologist diagnosed her with multiple fractures of the lower extremities. What kind of embolism is most likely to develop in this case?

Explanation

Embolism is occlusion of a vessel by material travelling in the circulation.

* Fat/Adipose embolism: obstruction of arterioles and capillaries by fat globules constitutes fat embolism. It may occur following severe fracture trauma to bones, inflammation of bones and soft tissues, fatty liver

* Thromboembolism: a detached thrombus or part of thrombus which may arise in the arterial or venous circulation.

* Gas embolism: two main forms of gas embolism are air embolism and decompression sickness. Air embolism is usually due to accidental pumping of air into the venous circulation during intravenous (IV) injection or transfusion ( bubble – air escaped).

Tissue embolism: fragments of tissue.

53.

There are cortical and medullary substances separated by connective tissue layer in the endocrine gland specimen. Parenchyma cells make up three zones in cortical substance, with rounded masses in the superficial zone, parallel chords in the middle one, reticular structure of cell chords in the deep one. What gland is it?

Explanation

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The adrenal gland (suprarenal gland) has a secretory parenchymal tissue organized into cortical and medullary regions. Adrenal cortex (derived from mesoderm; steroid-secreting portion) and medulla (derived from neural crest; catecholamine-secreting portion). The adrenal cortex is divided into 3 zones on the basis of arrangement of its cells:

* Zona glomerulosa (15%): arranged in closely packed ovoid clusters; secretes aldosterone.

* Zona fasciculata (80%): large and polyhedral; arranged in long straight cords; secretes cortisol.

* Zona reticularis (5-7%): cells are arranged in anastomosing cords separated by fenestrated capillaries; secretes androgens.

54. A patient underwent surgical removal of a cavitary liver lesion 2 cm in diameter. It was revealed that the cavity wall was formed by dense fibrous connective tissue; the cavity contained muddy, thick, yellowish-greenish fluid with an unpleasant odor. Microscopically, the fluid consisted mainly of polymorphonuclear leukocytes. What pathological process are these morphological changes typical for?

Explanation

Chronic abscess has internal pyogenic membrane; middle – granulation tissue; external – fibrous tissue membrane. Acute abscess basically has only a pyogenic membrane no fibrous tissue membrane. Phlegmon: diffuse purulent inflammation which occurs along muscular fibers, tendons, fascias etc. Empyema is a purulent inflammation of serous membranes (e.g. empyema of pleura). Both phlegmon and empyema does not involve the formation of cavity (“cavitary lesion”).

55.

Autopsy has revealed shrunken kidneys weighing 50 mg, with fine-grained surface and uniformly thinned substance. Microscopic investigation has shown the thickening of arteriole walls due to accumulation of homogeneous anhistic pink-coloured masses in them. Glomerules were undersized, sclerotic, with atrophied tubules. What disease are these changes characteristic of?

 

Explanation

Primary shrunken kidney is a renal form of essential hypertension. It is characterized by chronic arteriolosclerotic nephrosclerosis. Macroscopically, both kidneys are affected equally and are reduced in size and weight. The surface of the kidney is finely granular. The cut surface shows firm kidney and narrowed cortex. Microscopically, there is variable degree of atrophy of parenchyma; these include glomerular shrinkage, deposition of collagen in Bowman’s space, periglomerular fibrosis.

Secondary shrinkage of kidneys is found in chronic glomerulonephritis.

56.

On the 24th day since the onset of disease, a male patient diagnosed with typhoid fever and undergoing treatment in an infectious diseases hospital has suddenly developed clinical presentations of acute abdomen leading to the death of the patient. During autopsy peritonitis has been revealed, with numerous ulcers covering the colon mucosa and reaching as deep as muscular and, in places, serous tunic. The ulcers have smooth edges and even floor. The intestinal wall is perforated. What stage of typhoid fever has the lethal complication arisen at?

Explanation

The changes in typhoid fever can be local and generalized. Local changes: has 5 stages. Each stage takes approximately one week.

* medullar swelling

* necrosis (7-10 days)

* ulcer formation (unclear, dirty ulcers)

* clean ulcer

* healing (recovery)

Clean ulcers has regular shape without necrotic tissue. In this stage the perforation can develop.

57.

 An HIV-positive patient’s cause of death is acute pulmonary insufficiency resulting from pneumonia. Pathohistological investigation of lungs has revealed interstitial pneumonia, alveolocyte desquamation and their methamorphoses: alveolocyte enlargement, large intranuclear inclusions surrounded by lightly-colored areas. Transformed cells resemble owl’s eye. Name the pneumonia causative agent:

Explanation

Cytomegalovirus (CMV) causes congenital infection, mononucleosis, pneumonia, retinitis. Infected cells have characteristic “owl-eye” inclusions. Transmitted congenitally and by transfusion, sexual contact, saliva, urine, transplant. Interstitial pneumonia is mainly caused by viruses or mycoplasma. CMV is responsible for the most common viral opportunistic infection in persons with HIV infection.

58.

A 37-year-old male patient developed pseudoarthrosis after a closed fracture of the femur. Specify the type of regeneration in the patient:

Explanation

59.

A patient with suspected tumor of lung had been admitted to the oncological department. Examination revealed localised pathology in the inferior lobe of the left lung. How many bronchopulmonary segments does this lobe have?

Explanation

krushkrok No100 (2014)

The inferior lobe of left lung has 5 segments: superior, medial basal, anterior basal, lateral basal, posterior basal segments.

60. Tissue sampling of a 37-year-old male patient with chronic renal disease has revealed the following: sclerosis, lymphocytic and plasmocytic infiltration of renal pelvis and calices walls, dystrophy and atrophy of tubules. Remaining tubules are enlarged and stretched with colloid masses, epithelium is flattened out (\"scutiform\" or \"shield-shaped\" kidney). What is the most likely diagnosis?

Explanation

Chronic pyelonephritis: microscopic changes involve predominantly tubules and interstitium. Tubules show atrophy and hypertrophy diffusely or dilatation. Dilated tubules may be filled with colloid crystals producing thyroidisation of tubules (thyroid-like). There is chronic interstitial inflammatory reaction, chiefly composed of lymphocytes, plasma cells, and macrophages with pronounced interstitial fibrosis. Renal pelvis and calyces are dilated and show marked chronic inflammation and fibrosis.

61.

Autopsy of a 50-year-old male who had tuberculosis revealed a dense gray-white nidus in form of a nodule 2 cm in diameter in the subpleural portion of the upper right lobe. The pleura in this region was thickened, in the pleural cavity there was a small amount of serous hemorrhagic fluid. Histological study of the region revealed some glandular structures with signs of cellular atypia and abnormal mitoses, which were found within the fibrous connective tissue. What other pathology had developed in the lungs?

Explanation

Glandular structures – ‘adeno’.  Adenocarcinoma is an invasive malignant epithelial tumor with glandular differentiation or mucin production by the tumor cells. The lesions are usually peripherally located. Tumors (≤3cm) with a small invasive component (≤5mm) associated with scarring and a peripheral lepidic growth pattern are called microinvasive adenocarcinoma. Adenocarcinoma is one of the most common malignancies associated with tuberculosis.

62.

A 10-year-old child has painful swallowing, neck edema, temperature rise up to 39, 0oC, the whole body is covered with bright-red petechial rash. Back of the throat and tonsils are hyperemic, the tongue is crimson-colored. Tonsillar surface is covered with isolated grayish-colored necrosis nidi. What disease is it?

 

Explanation

Scarlet fever is an acute infectious disease accompanied by local inflammatory changes mainly in the pharynx and typical generalized rash.

* Local changes: primary scarlatnic affect/complex – catarrhal or necrotic tonsillitis. Catarrhal tonsillitis: hyperemia of pharynx (flaring pharynx or burning faucet). Necrotic tonsillitis: coagulative necrosis and ulceration.

* General changes are first of all RASH. The face is also involved, but usually a small area about the mouth (nasolabial triangle) remains relatively unaffected to produce a circumoral pallor. Tongue is beefy red/crimson red and glistening, strawberry tongue.

63. A 3-year-old child with meningeal symptoms died. Postmortem macroscopy of the pia matter revealed miliary nodules which were microscopically represented by a focus of caseous necrosis with masses of epithelioid and lymphoid cells with some crescent-shaped large cells inbetween having peripheral nuclei. Specify the type of meningitis in the child:

Explanation

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When tubercle bacilli are introduced into the tissue, they are ingested by the alveolar macrophage. Macrophages undergo changes resembling epithelial cells – EPITHELOID cells. Some of the macrophages form MULTINUCLEATED GIANT cells by fusion of adjacent cells (langerhan’s or foreign body type). The giant cells may have 20 or more nuclei. These nuclei may be arranged at the periphery like HORSE-SHOE, RING or clustered at the poles or they may be present centrally (foreign body giant cells). Lymphocytes, plasma cells and fibroblasts surround the epitheloid cells and giant cells (hard tubercle- no central necrosis). Within 10-14 days, the centre of the cellular mass begins to undergo caseation necrosis – soft tubercle. This is the hallmark of tuberculous lesions.

During the hematogenous spreading, the most serious immediate complication is MILIARY tuberculosis. The name miliary derives from its resemblance to millet seeds. Lesions of miliary tuberculosis consist of small granulomas, with a central necrotic portion. Organs often affected are lung, spleen, liver, kidney, meninges and bone marrow.

64. X-ray examination of a patient allowed to diagnose a tumor in the superior lobe of the right lung. There is a probability of metastases spread to the following lymph nodes:

Explanation

The dominant lymphatic drainage from the right upper lobe flowed into the superior mediastinal nodes. The sternal or parasternal nodes is one of the superior mediastinal nodes.

65.

A young woman suddenly developed fever up to 39oC accompanied by a strong headache. Examination revealed marked nuchal rigidity. Spinal puncture was performed. Gram-stained smear of cerebrospinal fluid contained many neutrophils and Gram-positive diplococci. What bacteria could be the cause of this disease?

Explanation

Gram negative diplococcic are Neisseria meningitides and N. gonorrhoeae.

N. meningitidis cause meningitis, meningococcemia (nuchal rigidity is a sign of meningitis).

N. gonorrhoeae causes gonorrhea, septic arthritis. Sexually transmitted or perinatally.

66. A patient has hoarseness of voice. During laryngoscopy a gray-white larynx tumor with papillary surface has been detected. Microscopic investigation has shown the following: growth of connective tissue covered with multilayer, strongly keratinized pavement epithelium, no cellular atypia. What is the most likely diagnosis?

Explanation

Papillomas are benign epithelial neoplasms producing microscopically or macroscopically visible fingerlike or warty projections from epithelial surfaces. Polyp: when a neoplasm – benign or malignant produces a macroscopically visible projection above a mucosal surface and projects, for example, into the gastric or colonic lumen. Fibroma: benign, node of differentiated connective tissue. Angioma and angiofibroma are related to vessels.

67.

During autopsy approximately 2,0 liters of pus have been found in the abdominal cavity of the corpse. Peritoneum is lustreless and has grayish shade, serous tunic of intestines has grayish-colored coating that is easily removable. Specify the most likely type of peritonitis in the patient:

Explanation

Fibrinopurulent peritonitis: Supurative or purulent inflammation is characterized by the production of large amounts of pus. The cellular inflammatory response in peritoneal cavity is composed primarily of dense collections of neutrophils and fibrinopurulent debris that coat the visceral and abdominal wall. Serous peritonitis – thin fluid (not pus); Hemorrhagic peritonitis  - hemorrhage; Tuberculous peritonitis – the patient must have TB, before there can be an extrapulmonary TB.

68.

Autopsy of the dead patient who died from pulmonary edema revealed a large yellow-grey nidus in the myocardium, and a fresh thrombus in the coronary artery. What is the most likely diagnosis?

Explanation

The macro- and microscopic changes in the Myocardial Infarction (M.I.) correspond to the age of the infarct.

   * first 24hrs: No gross changes; coagulative necrosis

               * 1-3days: pallor of infracted tissue

               * 3-7days: red granulation tissue surrounds area of infarction

               * 7-10days: necrotic area is bright YELLOW

               * first 2 months: infarct is replaced by white, patchy, noncontractile scar

                  tissue.

69. A male patient is 28 years old. Histological study of a cervical lymph node revealed a change of its pattern due to the proliferation of epithelioid, lymphoid cells and macrophages having nuclei in form of a horseshoe. In the center of some cell clusters there were non-structured light-pink areas with fragments of nuclei. What disease are these changes typical for?

Explanation

FullSizeRender (7)

When tubercle bacilli are introduced into the tissue, they are ingested by the alveolar macrophage. Macrophages undergo changes resembling epithelial cells – EPITHELOID cells. Some of the macrophages form MULTINUCLEATED GIANT cells by fusion of adjacent cells (langerhan’s or foreign body type). The giant cells may have 20 or more nuclei. These nuclei may be arranged at the periphery like HORSE-SHOE, RING or clustered at the poles or they may be present centrally (foreign body giant cells). Lymphocytes, plasma cells and fibroblasts surround the epitheloid cells and giant cells (hard tubercle- no central necrosis). Within 10-14 days, the centre of the cellular mass begins to undergo caseation necrosis – soft tubercle. This is the hallmark of tuberculous lesions.

70.

During autopsy the following has been revealed: the meninges of the upper cerebral hemispheres are extremely plethoric, of yellow-green color and are soaked with purulent effluent. What kind of meningitis is characterised by such clinical presentations?

Explanation

Gram negative diplococcic are Neisseria meningitides and N. gonorrhoeae.

N. meningitidis cause meningitis, meningococcemia (nuchal rigidity is a sign of meningitis).

Meningococcal meningitis is characterized by hyperemia of pia mater (extremely plethoric), by the end of the 2nd – 3rd day the exudate becomes thicker, green-yellow, purulent (yellow-green cap). Dull-serous exudates during the first days of the disease.

71. A 40-year-old patient with the progressing staphylococcal purulent periodontitis developed purulent inflammation of bone marrow spaces of the alveolar process, and then of the body of mandible. Microscopy revealed thinning of bone trabeculae, foci of necrosis, bone sequesters surrounded by the connective tissue capsule. What is the most likely diagnosis?

Explanation

Chronic osteomyelitis: most common causative agent is staphylococcus aureus. Characterized by bone necrosis (sequestrum formation), low-grade inflammation, persistent and progressing infection.  Also characterized by low-grade clinical presentations.

72.

A 40-year-old female patient has undergone thyroidectomy. Histological study of thyroid gland found the follicles to be of different size and contain foamy colloid, follicle epithelium is high and forms papillae, there is focal lymphocytic infiltration in stroma. Diagnose the thyroid gland disease:

Explanation

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Basedow’s disease (Grave’s disease, diffuse toxic goiter, primary hyperplasia): prismatic epithelium turns into cylindrical, epithelium proliferation with formation of papillae, colloid vacuolization (foamy colloid), formation of lymphoid follicles with germ centers are observed.

Hashimoto’s thyroiditis is devoid of colloid.

73.

Extensive    thromboembolic   infarction   of   the   left   cerebral  hemispheres, large septic spleen, immunocomplex glomerulonephritis, ulcers on the edges of the  aortic  valves, covered  with polypous thrombus with colonies of staphylococcus were  revealed   on  autopsy  of  the  young man  who  died  in  coma.  What   disease caused cerebral thromboemboly?

 

Explanation

     Septic (bacterial) endocarditis is the form of sepsis, for which septic lesion of valves of the heart is characteristic. The most often causative agents are staphylococcus albus, staphylococcus aureus, streptococcus viridian and enterococcus. Polypous-ulcerative endocarditis develops on both sclerotic and intact valves. Large thromboembolic polyp-shaped plaques appear on sclerotic valves. The spleen is enlarged due to prolonged pulp hyperplasia (“septic spleen”). Immune-complex diffuse glomerulonephritis develops in the kidneys, foci of softening and hemorrhages are observed in the brain due to vascular changes (vasculitis, aneurysm) and thromboembolism.

74.

A  45 year  old  male  died  from  disseminated tuberculosis. On  autopsy  the symptoms  of tuberculosis were confirmed by both microscopical and histological analyses. All the affected organs had epithelioid cell granulomas with caseous necrosis in the centre. What kind of hypersensitivity reaction underlies the process of granuloma development?

Explanation

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Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal)

Type II (cytotoxic): antibody dependent reactions e.g. Goodpasture syndrome, Myasthenia gravis, Graves disease, ABO hemolytic disease of newborn etc.

Type III (immune-complex): deposition of antigen-antibody complexes e.g. systemic lupus erythromatous (SLE), Arthus reaction, serum sickness, poststreptococcal glomerulonephritis etc.

Type IV (cell mediated, delayed): antibody-independent T-cell mediated reactions e.g. positive mantoux reaction (tuberculin test), hashimoto’s thyroiditis or transplant rejection etc.

75.

A patient with high-titer antinuclear antibodies died from progressing  renal impairment. Autopsy  revealed   mesangioproliferative glomerulonephritis and abacterial polypous  endocarditis. There was periarterial bulbar  sclerosis in spleen and  productive proliferative vasculitis  in skin. What is the most likely diagnosis?

Explanation

Systemic lupus erythematous (SLE, Libman-sacks disease) is the classic prototype of the multisystem disease of autoimmune origin, characterized by a bewildering array of autoantibodies, particularly antinuclear antibodies. It is characterized principally by injury to the skin, joints, kidney, and serosal membranes. Antinuclear antibody is directed against several nuclear antigens and can be grouped into 4 categories:

·        Antibodies to DNA

·        Antibodies to histones

·        Antibodies to nonhistone proteins bound to RNA

·        Antibodies to nuclear antigens.

SLE is a type III hypersensitivity reaction with formation of immune complexes. It can cause diffuse proliferative glomerulonephritis seen under the light microscope as “wire loop” of capillaries and granular under the immunofluorescence microscopy.

76.

A 50 year old patient underwent resection  of  tumour  of  large   intestine wall. Microscopically  it presents itself as fascicles of divergent collagen fibers of different thickness  and form and some monomorphous fusiform cells that are irregularly  distributed among  the  fibers. Cellular    atypia   is   not   evident.    What tumour is it?

Explanation

Fibroma is a benign connective (fibrous) tissue tumors. It can be hard (dense) or soft fibroma. Hard fibroma has fibrous connective tissue (e.g. collagen fibers) prevail over the cellular elements. Soft/loose fibroma has more cells than the connective tissue component.

In the question; fascicles of divergent collagen fibers with SOME fusiform cells irregularly distributed among the fibers i.e. fibers > cells (fibers dominate). Fibers are greater than cells.

77. A  patient who  abuses  smoking  has chronic  bronchitis.  Biopsy of his primary bronchus  revealed  multilayer pavement epithelium.  What   pathological  process was revealed  in the bronchus?

Explanation

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Metaplasia is a reversible change of one type to another type of adult epithelial or mesenchymal cells, usually in response to abnormal stimuli and often reverts back to normal on removal of stimulus. Types (2):

·        Epithelial: *Squamous metaplasia: in bronchus (chronic smokers), cervix

  *Columnar metaplasia: there is transformation to columnar epithelium.

·        Mesenchymal metaplasia: osseous and cartilaginous.

Hyperplasia: ↑number of cells; Hypertrophy: ↑in size.

78. 2   days   after    labour    a   woman developed  shock  along  with  DIC syndrome  that caused her death.  Autopsy revealed  purulent endomyometritis, regional  purulent lymphangitis,  lymphadenitis and  purulent thrombophlebitis. There were also dystrophic alterations and interstitial inflammation of  parenchymal organs. What is the most likely diagnosis?

Explanation

Septicemia is a form of sepsis. Hemorrhagic syndrome is well pronounced (petechial rash, hemorrhages to the serous and mucus membranes and internal organs, DIC). Hyperplasia of lymphoid and hemopoietic system is typical. Proliferation of lymphoid and reticular cells as well as accumulation of mature and immature blood cells are found in the spleen and lymph nodes. Interstitial inflammation develops  in the parenchymal organs (heart, liver, kidneys). Septicemia can lead to septic shock. DIC – disseminated intravascular coagulation

79.

Acute    renal    impairment   caused death  of a bleeding patient. Autopsy revealed  enlarged kidneys  with  a  broad pale pink cortical layer expressively demarcated from  dark  red  renal  pyramids.   Macroscopic    examination  revealed lack of epithelial nuclei of convoluted tubules,  tubulorrhexis,  phlebostasis. The cell nuclei of choroid  glomus and straight tubules  were  present. What  pathology is it?

Explanation

     Acute tubular necrosis/Necrotic nephrosis/Necronephrosis involves the death of tubular epithelial cells that form the renal tubules of the kidneys. Most common cause of acute renal failure. It can be ischemic or nephrotoxic.

·        Ischemic acute tubular necrosis occurs due to hypoperfusion of the kidneys.

·        Nephrotoxic acute tubular necrosis occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents. Toxic agents causing nephrotoxic acute tubular necrosis includes mercuric chloride, ethylene glycol, carbon tetrachloride etc.

Macroscopically, the kidneys are enlarged and swollen (edematous). On cut section, the cortex is pale, while the medulla is slightly darker than normal. The capsule can be easily removed.

80.

Examination of a bronchial  tissue sample revealed atrophy  of mucous membrane, cystic degeneration of glands, focal  metaplastic changes  of  lining  prismatic epithelial cells into multilayer squamous cells; increase in goblet cell number;  in some  parts  of bronchial wall and  especially  in the  mucous  membrane there  was marked cellular  inflammatory infiltration  and  growth  of granulation tissue bulging  into  the  bronchial lumen  in form  of a polyp.  What  is the  most  likely diagnosis?

 

Explanation

The hallmark and earliest feature of chronic bronchitis is hypersecretion of mucus in large airways and is associated with hypertrophy of the submucosal glands in the trachea and bronchi. As chronic bronchitis persists, there is also a marked increase in goblet cells of small airways leading to excessive mucus production that contributes to airway obstruction. Histological features of the small airways:

·        Goblet cell metaplasia with mucus plugging of the lumen.

·        Inflammatory infiltration

·        Fibrosis of bronchiolar wall (granulation tissue)

·        Atypical metaplasia and dysplasia of the respiratory epithelium, providing a possible soil for cancerous transformation.

81.

Autopsy  of  a  75  year  old  patient who  had   been   suffering   from   disseminated  atherosclerosis and died under chronic cardiac failure revealed  constriction and deformation of coronary  arteries, tuberous intima  whose  section  appeared to be white and petrosal. Specify the stage of atherosclerosis morphogenesis:

Explanation

Stages of atherosclerosis.

* Pre-lipid stage: mucoid swelling  of intima, destruction of endothelium, elastic & collagen fibres of intima’s basal membrane.

* Stage of fatty stripes (lipidosis):  Fatty stripes appear on intima. Macrophages that have accumulated lipid in their cytoplasm appear as csantomic or foam cells.

* Stage of liposclerosis: Lipid accumulates  not only in macrophages but also in smooth muscle cells. In areas of lipidosis (lipid core), a young CT grows & forms a fibrous cap/plaque.

* Stage of atheromatosis: Necrosis of central part of fibrous cap, with formation of atheromas. Atheromas consist of  amorphous lipid-rich material & are soft.

* Stage of ulceration: Break of fibrous cap cover & ulceration with small hemorrhage into plaque.

* Stage of atherocalcinosis: Deposition of calcium in ulcerative plaque. Calcification of vessels leads to hardening of arteries, which appears white & petrosal.

82. A 71 year old man had been presenting  with  diarrhea for  10 days.  The  feces had  admixtures of blood  and  mucus.  He was delivered to a hospital in grave condition and died 2 days later. Autopsy of the body  revealed   the  following:  diphtheritic colitis with multiple  irregularly-shaped ulcers  of different depth  in both  sigmoid colon and rectus.  Bacteriological analysis revealed  Shigella. What  was the main disease?

Explanation

Dysentery refers to bloody diarrhea with mucus. It refers to diarrhea with abdominal cramping and tenesmus in which loose stools contain blood, pus and mucus. Bacillary dysentery is caused by shigella dysenteriae, Shigella flexneri, Shigella boydii and Shigella sonnei. Morphology: it has 4 stages namely: catarrhal colitis; fibrinous colitis; ulcer formation (ulcerative colitis); healing of the wound. Complications of dysentery include perforation, intraintestinal hemorrhage and eventually death may result from intestinal or extraintestinal complications.

83.

A 46-year-old man complains of difficulties with nasal breathing. Mikulicz’s cells, accumulation of epithelioid cells, plasmocytes, lymphocytes, hyaline balls were discovered in the biopsy material of the thickened nasal mucosa. What is the most likely diagnosis?

Explanation

Microscopic examination of specific granulomas:

* In Rhinoscleroma of nose, the granuloma (scleroma) consists of plasma cells, epitheloid cells, lymphocytes and hyaline sphere. Large macrophages with light cytoplasm containing klebsiella rhinoscleromatis (Mikulicz’s cells), sclerosis and hyalinosis takes place.

* In TB, the granuloma is reffered to as a tubercle and is classically characterized by the presence of central necrosis surrounded by epitheloid cells, lymphocytes, plasma cells and giant langhance cells. In contrast, caseous necrosis is rare in other granulomatous diseases.

* The syphilis granuloma is calle Gumma. Gumma consist of a central area of fibrinoid or caseous necrosis surrounded by mononuclear inflammatory cells, mostly plasma cells, lymphocytes, epitheloid cells and seldom-giant langhance cells. Around gumma forms the granulation tissue and endovasculitis.

* In Tuberculoid Leprosy, the epidermis contains confluent granulomas composed of macrophages, plasma cells and leprous Virchow’s cells – Leprous Virchow’s cells (or Leprous cells) refer to large foamy macrophages within fatty vacuoles containing leprous mycobacterium.

 

84.

A young man has a painless formation without marked borders in the soft tissues of his thigh. On the tissue bioptate the formation looks like flesh of fish and consists of immature fibroblast-like cells with multiple mitosis growing through the muscles. What is the most likely diagnosis?

Explanation

Macroscopically, sarcoma looks like “fish flesh”. Fibrosarcoma occurs in deep soft tissue sites, showing increased fibroblastic cells, anaplasia and abundant mitotic figures. It looks like node or encapsulated formation.

85.

Autopsy of a man ill with severe hypothyroidism  revealed   that   connective tissue, organ stroma, adipose and cartilaginous tissues  were  swollen,  semi- transparent, mucus-like.  Microscopic examination of  tissues  revealed   stellate cells  having  processes  with  mucus between them.  What  type  of  dystrophy is it?

 

Explanation

Stromal vascular carbohydrate degenerations develop due to disturbance of glycosaminoglycans and glycoproteids metabolism. When glycoproteid metabolism is disturbed, chromotropic substances are released from the protein bonds. They accumulate in the main substance of the connective tissue. Collagen fibers change into mucus-like mass. Connective tissue mucin is associated with:

·        Mucoid or myxoid degeneration in some tumors (myxomas)

·        Neurofibromas, soft tissue sarcomas etc

·        Myxomatous change in the dermis in myxedema

·        Myxoid change in the synovium in ganglion on the wrist.

The condition results in colliquative necrosis with formation of cavities filled with mucus.

86. A   28  year   old   patient  had   high arterial   pressure,  hematuria   and   facial  edemata. In  spite  of  treatment renal insufficiency  was  progressing.   6  months later  the  patient died  from  uremia.  Microscopic examination of his kidneys  and their glomerules  revealed  proliferation of capsule  nephrothelium and  of podocytes with  \"demilune\" formation, sclerosis  and hyalinosis of glomerules. What disease corresponds with the described  picture?

Explanation

We have acute, subacute and chronic glomerulonephritis. Subacute glomerulonephritis does not necessarily follow acute attacks. It is usually characterized by the general symptoms of glomerulonephritis like proteinuria, hematuria, edema and azotemia persisting for many days and even weeks. Renal changes include those of rapidly progressive and membranoproliferative glomerulonephritis.    DEMILUNE”

87.

A 6 year old child was delivered to a hospital.  Examination revealed   that  the child  couldn’t  fix  his  eyes,  didn’t  keep his  eyes  on  toys,  eye  ground   had   the cherry-red spot sign. Laboratory analyses showed that brain, liver and spleen had high rate  of ganglioside  glycometide.  What congenital  disease is the child ill with?

Explanation

Tay- sachs disease is a progressive neurodegeneration, developmental delay, “cherry-red” spot on macula, lysosomes with onion skin, no hepatosplenomegaly. It is an autosomal recessive disease, caused by the deficiency of hexosaminidase A resulting in the accumulation of GM2 ganglioside in organs of the body (e.g. brain, liver, spleen).

88. Autopsy  of  a  49-year-old   woman who died from chronic renal insufficiency, revealed: kidneys were dense, reduced, multicoloured, with  haemorrhagic areas. Microscopic  examination revealed   some hematoxylin   bodies    in   the   nuclei   of the renal tubule  epithelium; \"wire-loop\" thickening of  the  glomerular capillary basement membrane; here and there in  the  capillaries  some  hyaline  thrombi and foci of fibrinoid necrosis were present. What is the most likely diagnosis?

Explanation

Systemic lupus erythematous (SLE, Libman-sacks disease) is the classic prototype of the multisystem disease of autoimmune origin, characterized by a bewildering array of autoantibodies, particularly antinuclear antibodies. It is characterized principally by injury to the skin, joints, kidney, and serosal membranes. Antinuclear antibody is directed against several nuclear antigens and can be grouped into 4 categories:

·        Antibodies to DNA

·        Antibodies to histones

·        Antibodies to nonhistone proteins bound to RNA

·        Antibodies to nuclear antigens.

SLE is a type III hypersensitivity reaction with formation of immune complexes. It can cause diffuse proliferative glomerulonephritis seen under the light microscope as “wire loop” of capillaries and granular under the immunofluorescence microscopy.

89.

A 20 year old patient died from intoxication 8 days  after  artificial  illegal abortion    performed    in    her    14-15th week    of   pregnancy.    Autopsy    of   the corpse revealed yellowish colour of eye sclera   and   of  skin,  necrotic   suppurative endometritis, multiple pulmonary abscesses,  spleen  hyperplasia with  a  big number    of   neutrophils  in   its   sinuses. What complication after abortion was developed?

 

Explanation

Septicopyemia is a form of sepsis, main attributes of which are purulent processes in the entrance of infection and bacterial embolism with formation of abscesses in many organs and tissues. At the dissection, there is primary septic focus, it is usually in the entrance of infection with purulent lymphangitis and lymphadenitis. At first metastatic abscesses appear in the lungs, then in the liver, kidneys (apostematous nephritis), spleen is septic, hyperplastic processes in blood – creating lymphatic tissues.

90. Histological   examination  of  a  skin tissue sampling revealed granulomas consisting of macrophagal nodules with lymphocytes   and  plasmatic   cells.  There are also some big macrophages with fatty vacuoles  containing   causative   agents  of a disease packed up in form of spheres (Virchow\'s cells). Granulation tissue is well vascularized. What disease is this granuloma typical for?

Explanation

     Leprosy (Hansen’s disease) is a chronic generalized infectious disease, which involves mainly the ectoderm components (the skin, mucous membranes and the peripheral nervous system), lymphatic nodes, liver, spleen, bones and endocrine glands. The causative agent is acid proof and alcohol-resistant Mycobacteria leprae. Three types of leprosy are distinguished: lepromatous; tuberculoid; undifferentiated (the first 2 are the main forms). In tuberculoid leprosy, the epidermis contains confluent granulomas composed of macrophages, plasma cells and leprous Virchow’s cells. Leprous Virchow’s cells (or leprosy/hansen’s cells) refer to large foamy macrophages within fatty vacuoles containing leprous mycobacterium.

91.

Examination of a young woman revealed   a  tumour  up  to  3  cm  in  diameter  in   form   of   a   knot    localized along  the  acoustic  nerve.  The  tumour is homogenous,  soft  and  elastic,  of  pink-and-white colour. Microscopically  the tumour contains  clusters of cells with oval nuclei.  Fibrous  cell clusters  form  regular structures made  up  by  parallel  rows  of regularly  oriented cells arranged in form of  a  palisade.  Zones   between the  rows of cells are acellular and homogenous (Verocai bodies).  What tumour is it?

Explanation

image

Neurinoma or Schwannoma is a benign tumor of peripheral nervous system. It is formed of spinder-like cells with rod-shaped nuclei. The cells and fibers form rhythmical structures. An acoustic neurinoma is a benign tumor that may develop on the hearing and balance nerves (CNVIII vestibulocochlear nerve) near the inner ear. The tumor results from an overproduction of Schwann cells – small sheet-like cells that normally wrap around nerve fibers like onion skin and help support the nerves.

92.

A section  of the  left lung was found to have  an area  of dense  red  tissue.  The area was cone-shaped, stood out distinctly from  the  healthy  tissue,  with its base  directed  to the pleura.  The dissected  tissue was granular, dark-red. What  is the  most likely diagnosis?

Explanation

Infarction is an area of ischemic necrosis within a tissue or an organ, produced by occlusion of either its arterial supply or its venous drainage. Infarction of the lungs: embolism of the pulmonary arteries may produce pulmonary infarction, though not always. The pulmonary infarcts are classically wedge-shaped or cone shaped with base on the pleura (periphery) hemorrhagic, variable in size and most often in the lower lobes. Cut surface is dark purple or red and it may show the blocked vessel near the apex of the infracted area. Old organized and healed pulmonary infarcts appear as retracted fibrous scars. The characteristic feature is coagulative hemorrhagic necrosis of the alveolar walls.

93. A patient with severe course of respiratory  viral infection  presented with clinical signs of progressing  heart  failure  that led to his death in the 2nd week of disease. Autopsy revealed   that  the  heart   cavities  were  significantly  dilated,   the   heart was  flabby.  Histological   examination  of the myocardium revealed  microvascular plethora  and  diffuse  stroma   infiltration with  lymphocytes   and  histiocytes.  What is the most likely diagnosis?

Explanation

Myocarditis is inflammation of the heart myocardium. Microvascular plethora and diffuse stroma infiltration with lymphocytes and histiocytes are indicative of an inflammatory process taking place in the heart. Heart failure, dilated heart cavities are complications of myocarditis.

94. A pathology-histology laboratory received  a vermiform  appendix  up to 2,0 cm thick.  Its serous  membrane was pale, thick and covered with yellowish-green films. The  wall was flaccid, of grayish-red colour.  The  appendix lumen  was dilated and filled with yellowish-green substance. Histological   examination  revealed   that the appendix wall was infiltrated with neutrophils. Specify the appendix disease:

Explanation

Acute appendicitis is the most common acute abdominal condition requiring surgery. Clinico-morphological classification of acute appendicitis includes:

·        Simple appendicitis

·        Superficial appendicitis

·        Destructive forms: phlegmonous appendicitis; phlegmonous-ulcerative appendicitis; apostematous appendicitis and gangrenous appendicitis.

Acute phlegmonous appendicitis occurs with diffuse infiltration of leukocytes (especially neutrophils) in the wall of appendix. Gross appearance: appendix is increased, swollen, tense and markedly congested and covered by fibrinous exudates (yellowish-green films).

95. Gynecological examination of the uterine cervix in a 30-year-old  woman revealed   some  bright-red lustrous   spots that  easily  bleed  when  touched. Biopsy showed  that  a part  of the  uterine cervix was  covered  with  cylindrical  epithelium with papillary  outgrowths; in the depth  of tissue  the  growth  of glands  was present. What pathology of the uterine cervix was revealed?

Explanation

Erosion of the cervix is a defect in the epithetlium covering the vaginal portion of the cervix. It is usually caused by inflammation of the mucous membrane of the cervical canal or less frequently, of the vagina. Irritation by cervical leucorrhea results in maceration and scaling of the epithelium with the formation of small superficial ulcers, bright red in colour that bleed when touched – True erosion. 7 – 10days later, columnar (cylindrical) epithelium growing out of the cervical canal gradually covers the ulcerous surface; the resulting “pseudoerosion” may persist with recurrences for many years.

96. Autopsy   of   a   man    who    died from  influenza   revealed   that   the  heart was slightly enlarged and pastose.  The surface of the incision of myocardium appeared to be pale, with specks. Microscopic  examination revealed   signs  of parenchymatous  adipose   and   hydropic degeneration, edematic stroma with scant lymphocytic and macrophage infiltration; plethoric vessels; perivascular petechial hemorrhages. What type of myocarditis is it?

Explanation

97. Autopsy of a man, who had been suffering from the multiple bronchiectasis for  5 years  and  died  from  chronic  renal insufficiency, revealed that kidneys were dense  and enlarged, with thickened cortical layer of white colour with greasy lustre. What renal disease might be suspected?

Explanation

Amyloidosis is the term used for a group of diseases characterized by extracellular deposition of fibrillar proteinaceous substance called amyloid. Systemic amyloidosis contain amyloid associated (AA) protein. It occurs as a complication of chronic infectious or noninfectious inflammatory conditions associated with tissues destruction such as tuberculosis, bronchiectasis, chronic osteomyelitis, chronic pyelonephritis etc. It is typically distributed in solid abdominal organs like liver, spleen, kidneys and adrenals. Morphologically, the kidneys may be normal-sized, enlarged or terminally contracted due to ischemic effect of narrowing of vascular intima. Cut surface is pale waxy and translucent.

98.

Autopsy   of   a   50-year-old    man revealed  the  following  changes:  his right lung was moderately compact  in all parts, the  dissected  tissue  was found  to  be  airless, fine-grained,  dryish. Visceral pleura had  greyish-brown layers  of fibrin. What is the most likely diagnosis?

Explanation

99. A  man  had  worked   in  a  coal  mine  for  over   20  years.  After   his  death autopsy   revealed    that   his   lungs   were dense,  grayish-black  and  had  large  areas of neogenic  connective tissue  containing a lot of microphages with black  pigment in the cytoplasm.  What  is the most likely diagnosis?

Explanation

Anthracosis also known as Coal workers’ pneumoconiosis or black lung disease; it is caused by lung exposure to coal dust. It is common in coal miners and others who work with coal. Inhaled coal dust progressively builds up in the lungs and is unable to be removed by the body; this leads to inflammation, fibrosis and in worse cases necrosis.

100.

Colonoscopy   of   a   patient   with dysentery revealed  that the mucous membrane of the large intestine was hyperemic, edematic,  and  its surface  was covered  with grey-and-green layerings. What  morphological form  of  dysenteric colitis is it?

 

Explanation

Morphology of dysenteric colitis has 4 stages: catarrhal colitis; fibrinous colitis; ulcer formation (ulcerative colitis); healing of the wound. During the stage of fibrinous colitis, within the course of 24hours, a fibrinosuppurative exudate first patchily, then diffusely covers the mucosa and produces a dirty grayish pseudomembrane, consisting of necrotic mucosa, neutrophils, fibrin and erythrocytes. Sloughed pseudomembrane, together with blood-tinged mucus, comprises the characteristic dysenteric stool.

101.

An   8-year-old   child   was  admitted to  the  infectious  department with  fever (up  to  38oC )  and  punctuate  bright-red skin  rash.  The  child  was  diagnosed  as having scarlet  fever. Objectively:  mucous membrane of pharynx  is apparently hyperaemic and edematic,  the  tonsils are enlarged and have dull yellowish-grey foci with some black areas.  What  inflammation is the  reason  for the  pharynx  alterations?

Explanation

Scarlet fever is one of the forms of streptococcal infection. It is an acute infectious disease accompanied by local inflammatory changes mainly in the pharynx and typical generalized rash. A punctuate erythematous rash that is most abundant over the trunk and inner aspects of the arms and legs manifests exanthema. The face is also involved, but usually a small area about the mouth (nasolabial triangle) remains relatively unaffected to produce a circumoral pallor. Primary scarlatinic affect is characterized by catarrhal or necrotic tonsillitis:

·        Catarrhal tonsillitis is manifested by hyperemia of pharynx (flaring pharynx or burning faucet) with involvement of oral cavity and tongue. It presents a strawberry appearance because of the erythematous papillae that project from a gray-coated background. When peeling occurs, the tongue becomes beefy or crimson red and glistening.

·        Necrotic tonsillitis is characterized by coagulative necrosis and ulceration. Microscopically, there is a characteristic acute, edematous, neutrophilic (purulent) inflammatory reaction within the affected tissues, mostly affecting the soft palate, pharynx, auditory tube.

102.

While examining  a patient an otolaryngologist noticed  hyperaemia and significantly edematous tonsils with a grayish film upon them. Microscopical examination of  this  film  revealed   some gram-positive bacilli  placed  at  an  angle with each other. What disease might be suspected?

 

Explanation

Diphtheria bacteria (Corynebacterium diphtheria) is Gram positive, pleomorphic, often club-shaped rods and are arranged in palisades or in V (at an angle) or L-shaped formations. Media used for isolation are Tellurite agar & Lὄffler medium. Lὄffler nutrient medium consists of coagulated serum & nutrient broth. Selective indicator medium containing tellurite are used in selective culturing. K tellurite is used to inhibit the accompanying flora.

103.

Examination  of  a  patient revealed   a dense, movable skin tumour that is standing out distinctly  from the surrounding tissues. Its section is found to be white and composed  of fibrous tissue. Microscopic examination revealed  interlacing collagen fibers and few cells. What tumour is it?

Explanation

Fibroma is a benign connective (fibrous) tissue tumors. It can be hard (dense) or soft fibroma. Hard fibroma has fibrous connective tissue (e.g. collagen fibers) prevail over the cellular elements. Soft/loose fibroma has more cells than the connective tissue component.

In the question; fascicles of divergent collagen fibers with SOME fusiform cells irregularly distributed among the fibers i.e. fibers > cells (fibers dominate).

104. A   2   year   old   child   had   acute respiratory   viral    infection     and    died from     cardiopulmonary    decompensation.  Autopsy revealed  that  his right  lung was hyperemic;  in the  2nd, 6th and  10th segments  and  on the  incision  there  were airless  yellowish  foci  of  irregular form, from  several  mm  up  to  1 cm large.  Microscopical examination revealed exudate consisting mainly of neutrophils in the given areas of pulmonary tissue in the alveoles, bronchioles and bronchial tubes. What is the most probable diagnosis?

Explanation

     Bronchopneumonia (focal pneumonia) is marked by patchy exudative consolidation of lung parenchyma. Bronchopneumonia often is a complication of other disease (complication of stomach cancer). Initially bronchi are affected. Then, inflammation spreads to parenchyma of lungs with accumulation of exudates in the alveoli. Grossly, the lungs show dispersed, elevated, focal areas of palpable consolidation and suppuration. Histological features consist of acute (neutrophilic) suppurative (purulent) or mixed exudates filling airspaces and airways, usually around bronchi and bronchioles.

105. A 23 year old man has perforation of hard  palate.  In the  area  of this perforation there was a compact well-defined formation.  Microscopic   examination  of the  resected formation revealed   a  large focus   of   caseous   necrosis   surrounded by  granulation  tissue  with  endovasculitis, cellular infiltration composed  of lymphocytes,  epithelioid cells (mainly plasmocytes). What  is the  most probable diagnosis?

Explanation

Spirochetes are thin-walled, flexible, spiral rods. Three (3) genera of spirochetes cause human infection: Treponema (syphilis and the nonvenereal treponematoses); Borrelia (lyme disease and relapsing fever); Leptospira (leptospirosis). Treponema pallidum are thin, tight, spirals seen by darkfield illumination, silver impregnation or immunofluorescent stain.

Syphilis (lues) is a sexually transmitted disease of mankind caused by the spirochete – Treponema pallidum. Stages of syphilis are: primary (chancre); secondary (disseminated) and Tertiary (with lesions of deep organs following a latent period of 2 – 20 years or more).

The chancre develops at the site of inoculation in 10 – 90 days (average 21 days) and has a characteristic “luetic vasculitis” (endovasculitis, perivasculitis) in which endothelial cells proliferate and swell and the walls of the vessels become thickened by lymphocytes and fibrous tissue. Syphilis can also produce fibrinoid or caseous necrosis (gumma).

106.

A   patient  who   has   been   abusing tobacco  smoking  for a long time  has got cough  accompanied  by  excretion of  viscous mucus; weakness  after minor physical stress, pale  skin. The  patient has also lost  12,0 kg of body  weight.  Endoscopic examination of biopsy material his illness was diagnosed  as squamous cell carcinoma.  Name  a pathological process  that preceded formation of the tumour:

Explanation

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Metaplasia is a reversible change of one type to another type of adult epithelial or mesenchymal cells, usually in response to abnormal stimuli and often reverts back to normal on removal of stimulus. Types (2):

·        Epithelial: *Squamous metaplasia: in bronchus (chronic smokers), cervix

                          *Columnar metaplasia: there is transformation to columnar epithelium.

·        Mesenchymal metaplasia: osseous and cartilaginous.

Hyperplasia: ↑number of cells; Hypertrophy: ↑in size.

107.

A 33 year old man died from uraemia. Autopsy revealed  enlarged kidneys  weighing 500,0 each and consisting  of multiple cavities 0,5-2 cm in diameter. The cavities  were  full of light-yellow  transparent liquid.  Renal  pelvis  and  ureters had  no peculiarities. What renal disease caused uraemia?

 

Explanation

Adult polycystic disease is inherited as an autosomal dominant trait, generally becoming clinically manifest in adult life. Cysts develop and progressively enlarge over a number of years, but remain asymptomatic until the number and size of the cysts is so great that the patient becomes aware of abdominal masses. At about the same time, the replacement and compression of functioning renal parenchyma by the cysts leads to slowly progressive impairment of renal function and patients develop chronic renal failure (uremia) and hypertension.

Bilateral – both kidneys

Cyst – a cavity that may be filled with gas, liquid or solid

108.

A  patient died  from  acute  cardiac insufficiency, among clinical presentations there   was  gastrointestinal haemorrhage. Examination of mucous membrane of stomach   revealed   some  defects   reaching  myenteron;  their   edges  and  bottom were   mostly   even   and   loose,   some   of them contained dark-red blood. What pathological process was revealed?

Explanation

Ulcer is a local defect on the surface of an organ produced by inflammation. Morphogenesis and morphology of peptic ulcer disease includes: erosions, acute ulcer and chronic ulcer.

    Acute ulcer is characterized by loss of tissue penetrating into the submucosa. It is a single or multiple lesions through the stomach and duodenum. It is circular and small, less than 1cm in diameter. Inflammatory reaction is absent initially but develops secondarily. Massive hemorrhage may be fatal. This type of ulcer usually heals without a visible scar.

    Chronic ulcers are characterized by fibrinoid necrosis and granulation tissue with plasma cell and lymphocytic infiltration, also scarring. But there is no granulation tissue or fibrous tissue mentioned in the question.

109.

Examination   of   a   66   year   old patient  revealed   a  lytic  tumour  in  the locus of pathological rib fracture. Histologically  this tumour consists of atypical    plasmoblasts.   Further    examination  revealed   osteoporosis  in  the   bones of vertebral column and pelvis. These changes are typical for:

Explanation

Myeloma/Plasmocytoma/Multiple Myeloma

Multiple myeloma is a monoclonal plasma cell (“fried egg” appearance) cancer that arises in the marrow and produces large amounts of IgG (55%) or IgA (25%). It is the most common primary tumor arising within bone in people >40 – 50 years old. It is characterized by hypercalcemia; renal involvement; anemia; bone lytic lesions (osteoporosis); back pain. MM: monoclonal M protein spike.

110. A patient had been suffering from profuse  diarrhea and vomiting for 2 days. He died from acute dehydration. Autopsy revealed  that the intestinal wall was edematic and hyperemic, with multiple haemorrhages in the  mucous  membrane. Intestine lumen contains  whitish fluid resembling of rice water. What disease caused death?

Explanation

Cholera is an acute gastrointestinal infectious quarantinic disease and is characterized by diarrhea and exicosis. It has 3 clinical-morphological stages: choleric enteritis, choleric gastroenteritis and choleric exicosis (algid). Choleric gastroenteritis is characterized by the hard diarrhea, vomit and increase of dehydration. The loss of sodium and water causes severe diarrhea called “rice-water stool.” Fluid loss may exceed 1 liter per hour. Death occurs in algid period and is caused by dehydration, coma, uremia and intoxication.

111.

Autopsy of a 5 year old child revealed in  the  area   of  vermis  of  cerebellum a soft greyish-pink  node  2 cm in diameter with   areas   of  haemorrhage.  Histologically this tumour consisted  of atypical monomorphous small  roundish cells  with big polymorphous nuclei. What tumour is it?

Explanation

Medulloblastoma is a tumor made by immature cells, medulloblasts; therefore it is highly malignant. It is localized in the vermis of cerebellum. Macroscopically, it is pinkish-gray. Microscopically, medulloblastoma consists of homogenous small cells with dark round or oval nucleus and poorly seen rim of cytoplasm. The cells are located close to each other. Rosette is typical. Mitoses are numerous. Vessels are not numerous. Metastasis spread through the liquor routs.

112. A 46 year old patient who had been suffering from tuberculosis for 6 years died from massive pulmonary haemorrhage. Autopsy revealed   different-sixed foci  of sclerosis and caseous  necrosis  in lungs, in the upper  part of the right lung there  was a cavity 5 cm in diameter with dense grey walls,  the  cavity  contained liquid  blood and blood clots. What type of tuberculosis is it?

Explanation

Secondary tuberculosis usually results from reactivation of dormant, endogenous tubercle bacilli in a sensitized patient who has had previous contact with the tubercle bacillus. Reactivation typically begins in the apical or posterior segments (often 1st and 2nd segments) of one or both upper lobes (“simon’s foci”), where the organisms were seeded during the primary infection. There are 8 forms or stages of the secondary tuberculosis: Acute local tuberculosis; Fibrous local tuberculosis; Infiltrative tuberculosis; Tuberculoma; Caseous pneumonia; Acute cavernous tuberculosis; Fibrous cavernous tuberculosis; Cirrhotic tuberculosis.

Fibrous cavernous tuberculosis is the most frequent form. Macroscopically, the lesions are spherical and cavitary (cavity can contain blood and blood clots); the so-called coin lesions. Microscopically, the outer wall of cavity shows fibrosis or sclerosis. Internal surface may be connected with bronchus. The wall of cavern has 3 membranes:

·        Internal membrane occurs by necrotic tissue

·        Middle membrane occurs by special granular tissue

·        External membrane occurs by connective fibrous tissue

113. A patient ill with thrombophlebitis of his lower limbs had chest pain, blood spitting, progressing  respiratory insufficiency that  led to his death.  Autopsy diagnosed multiple lung infarctions. What is the most probable cause of their development?ow

Explanation

Pulmonary embolism is the most common and fatal form of venous thromboembolism in which there is occlusion of pulmonary arterial tree by thromboemboli. Pulmonary emboli are more common in hospitalized or bedridden patients. The majority of emboli arise from the deep veins of the lower extremities; most of the fatal ones arise from the ileofemoral veins. Consequences of thromboembolism include pulmonary infarction in which pyramidal segments (or ‘triangular’ segments) of hemorrhagic infarction are seen at the periphery of the lung. Detachment of thrombi from the thrombophlebitis site in the lower limbs produces a thromboembolus that flows through venous drainage into the large veins draining into the right side of the heart and then to the pulmonary circulation where they embolize.

114.

A  4  year  old  child  complained  of pain during deglutition, indisposition. Objectively:   palatine arches  and  tonsils are  moderately edematic and  hyperemic, there  are greyish-white films up to 1 mm thick closely adhering to the subjacent tissues. What pathological process are these changes typical for?

Explanation

Fibrinous inflammation or pseudomembranous inflammation is an inflammatory response of mucous surface (oral, respiratory, bowel) to toxins of diphtheria or irritant gases. There are 2 types of fibrinous inflammation: croupous and diphtheric fibrinous inflammation. Local changes of diphtheric inflammation in the pharynx is characterized by small gray or white patches of exudates which appear over the pharyngeal mucosa, usually over the tonsils. The epithelial surface becomes necrotic and easily adherent to the underlying membrane. Attempts to remove this necrotic membrane may expose raw bleeding points. The soft tissues of the neck are edematous.

115.

A patient has been suffering from diarrhea for 5 day. On the fifth day colonoscopy   revealed    that    membrane of rectum  was inflamed,  there  were greyish-green  films  closely  adhering to the  subjacent   tissue.  What   is  the  most probable diagnosis?

 

Explanation

Dysentery refers to bloody diarrhea with mucus. It refers to diarrhea with abdominal cramping and tenesmus in which loose stools contain blood, pus and mucus. Bacillary dysentery is caused by shigella dysenteriae, Shigella flexneri, Shigella boydii and Shigella sonnei. Morphology: it has 4 stages namely: catarrhal colitis; fibrinous colitis; ulcer formation (ulcerative colitis); healing of the wound. Complications of dysentery include perforation, intraintestinal hemorrhage and eventually death may result from intestinal or extraintestinal complications.

Fibrinous colitis stage produces a dirty grayish pseudomembrane (film). Catarrhal colitis stage produces edema (inflamed) and hyperemic mucosa.

116.

48 hours  after  tuberculine test (Mantoux test)  a child  had  a  papule  10 mm in diameter on the spot of tuberculine injection.  What hypersensitivity mechanism underlies these changes?

Explanation

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The Mantoux skin test should be read between 48 and 72hrs after administration. The basis of reading  is the presence or absence of induration, which may be determined by inspection and by palpation. A record should also be made of formation of vesicles, bullae, lymphangitis, ulceration and necrosis at the test site. The formation of vesicles, bullae or necrosis at the test site indicates positive result. A negative mantoux result usually signifies that the individual has never been exposed to Mycobacterium tuberculosis i.e. absence of cell mediated immunity to tuberculin.

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Mantoux test is a type IV Hypersensitivity reaction (HSR), which involves macrophages,T-lymphocytes and lymphokines(cytokines). Mononuclear cells (lymphocytes,monocytes,macrophages).
117.

6   months    after   labour    a   woman had   uterine  hemorrhage.  Gynaecological examination of uterine cavity revealed a  dark-red tissue  with  multiple   cavities resembling of a \"sponge\". Microscopic examination  of   a   tumour  revealed   in blood lacunas atypic light epithelial Langhans  cells and giant cells of syncytiotrophoblast. What tumour is it?

Explanation

Chorioepithelioma or choriocarcinoma or gestational choriocarcinoma is a malignant neoplasm of trophoblastic cells derived from a previously normal or abnormal pregnancy. NB: trophoblast differentiates into 2 layers (cytotrophoblast and syncytiotrophoblast) in the 2nd week of development of an embryo. Chorioepithelioma is a soft, fleshy, yellow-white tumor that usually has large pale areas of necrosis and extensive hemorrhages. Histologically, it does not produce chorionic villi and consists entirely of proliferating syncytiotrophoblasts and cytotrophoblasts.

118.

A 30 year old man had been suffering from  acute  respiratory disease  and  died from cardiopulmonary decompensation. Autopsy revealed  fibrinous-haemorrhagic inflammation  in  the  mucous  membrane of larynx and trachea, destructive panbronchitis, enlarged lungs that look black due to the multiple abcesses, haemorrhages, necrosis. What is the most probable postmortem diagnosis?

 

Explanation

Influenza is an acute respiratory viral infection. The clinical-morphological forms of influenza are slight influenza, mild influenza and severe influenza. The histopathologic features of mild influenza include a necrotizing tracheitis and bronchitis; diffuse hemorrhagic necrotizing pneumonitis with pulmonary edema. Pulmonary complications in severe influenza: lungs are dark and firm with interstitial emphysema (enlarged lungs); necrotic foci; abscesses; lungs appear as “large variegated (motley) influenza lung.” Obliterating bronchitis, bronchiolitis, bronchiectasis and other chronic lung diseases can develop.

119.

Autopsy  of  a  man  who  died  from burn   disease   revealed   brain   edema,   liver  enlargement as well as  enlargement of  kidneys  with  wide  light-grey  cortical layer and plethoric medullary area. Microscopic  examination revealed   necrosis of tubules  of main  segments  along  with destruction of basal  membranes, intersticium   edema   with   leukocytic   infiltration  and  haemorrhages. What  is the  most probable postmortem diagnosis?

Explanation

     Acute tubular necrosis/Necrotic nephrosis/Necronephrosis involves the death of tubular epithelial cells that form the renal tubules of the kidneys. Most common cause of acute renal failure. It can be ischemic or nephrotoxic.

·        Ischemic acute tubular necrosis occurs due to hypoperfusion of the kidneys.

·        Nephrotoxic acute tubular necrosis occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents. Toxic agents causing nephrotoxic acute tubular necrosis includes mercuric chloride, ethylene glycol, carbon tetrachloride etc.

Macroscopically, the kidneys are enlarged and swollen (edematous). On cut section, the cortex is pale, while the medulla is slightly darker than normal. The capsule can be easily removed.

120.

Examination of coronary arteries revealed  atherosclerotic calcified plaques closing  vessel  lumen  by 1/3. The  muscle has multiple  whitish layers  of connective tissue.  What  process  was revealed  in the myocardium?

 

Explanation

Diffuse cardiosclerosis

Diffuse – multiple whitish layers of connective tissue

Focal cardiosclerosis: Focal –white fibrous depressed area 3cm in diameter. Cardiosclerosis – Atherosclerotic calcified plaques         
121.

A   22  year   old   patient  from   the West   Ukraine  complains    of   laboured nasal breathing. Morphological examination  of biopsy material of nasal mucous membrane  revealed   lymphoid,   epitheliod, plasma cells as well as Mikulicz’s cells. What is the most probable diagnosis?

Explanation

Microscopic examination of specific granulomas:

* In Rhinoscleroma of nose, the granuloma (scleroma) consists of plasma cells, epitheloid cells, lymphocytes and hyaline sphere. Large macrophages with light cytoplasm containing klebsiella rhinoscleromatis (Mikulicz’s cells), sclerosis and hyalinosis takes place.

* In TB, the granuloma is reffered to as a tubercle and is classically characterized by the presence of central necrosis surrounded by epitheloid cells, lymphocytes, plasma cells and giant langhance cells. In contrast, caseous necrosis is rare in other granulomatous diseases.

* The syphilis granuloma is calle Gumma. Gumma consist of a central area of fibrinoid or caseous necrosis surrounded by mononuclear inflammatory cells, mostly plasma cells, lymphocytes, epitheloid cells and seldom-giant langhance cells. Around gumma forms the granulation tissue and endovasculitis.

* In Tuberculoid Leprosy, the epidermis contains confluent granulomas composed of macrophages, plasma cells and leprous Virchow’s cells – Leprous Virchow’s cells (or Leprous cells) refer to large foamy macrophages within fatty vacuoles containing leprous mycobacterium.

 

122. Examination of the anterior abdominal  wall  of  a  pregnant woman  revealed a  tumour-like  formation  that   arose   on the  spot  of a tumour that  was removed two years ago. The neoplasm  was well-defined,  dense, 2х1 cm large. Histological examination revealed that the tumour was composed  of differentiated connective tissue with prevailing  collagen fibres. What tumour might be suspected?

Explanation

     Desmoid fibroma is a benign connective tissue tumor. It a kind of dense fibroma and characterized by infiltrating growth and relapses. It is composed of banal, “tame-loking” fibroblasts that do not metastasize. More often it is located on the anterior abdominal wall.

123.

The liver puncture biopsy of a patient with hepatocellular insufficiency revealed hydropic  and  ballooning degenerationof hepatocytes, necrosis of certain  cells, presence of  Kaunsilmen’s bodies.  Portal and lobular stroma were infiltrated mostly with lymphocytes and macrophages as well as with a small number of polymorphonuclear lymphocytes.  What is the most likely diagnosis?

 

Explanation

     The morphologic changes in acute viral hepatitis are virtually the same regardless of the causative agent and can be mimicked by drug reactions. Grossly, the liver is slightly enlarged. Histologically, the major finding is hepatocellular injury characterized by necrosis of scattered hepatocytes; isolated liver cells or small cell clusters appear as eosinophilic rounded-up cells (apoptotic bodies, councilman’s bodies). Degenerated hepatocytes may also appear ballooned. Macrophages may phagocytize the necrotic hepatocytes and may accumulate clumps of lymphocytes and macrophages. Confluent necrosis may lead to bridging necrosis connecting portal-to-portal, central-to-central or portal-to-central regions of adjacent lobules, signifying a more severe form of acute hepatitis.

124.

A   patient   with   tuberculosis   died from progressing cardiopulmonary decompensation. Autopsy in the region of the right lung apex revealed  a cavity 5 cm in  diameter  communicating with  lumen of  a  segmental   bronchus.  On  the  inside cavity walls are  covered  with caseous masses   with   epithelioid  and   Langhans cells beneath them.  What  morphological form of tuberculosis is it?

 

Explanation

Secondary tuberculosis usually results from reactivation of dormant, endogenous tubercle bacilli in a sensitized patient who has had previous contact with the tubercle bacillus. Reactivation typically begins in the apical or posterior segments (often 1st and 2nd segments) of one or both upper lobes (“simon’s foci”), where the organisms were seeded during the primary infection. There are 8 forms or stages of the secondary tuberculosis: Acute local tuberculosis; Fibrous local tuberculosis; Infiltrative tuberculosis; Tuberculoma; Caseous pneumonia; Acute cavernous tuberculosis; Fibrous cavernous tuberculosis; Cirrhotic tuberculosis.

Acute cavernous tuberculosis develops due to lyses of caseous necrosis and characterized by formation of the round cavity.

      Tuberculoma consists of focus necrosis surrounded by fibrous capsule. Size of tuberculoma may be near 2-5cm.

Fibrous cavernous tuberculosis is the most frequent form. Macroscopically, the lesions are spherical and cavitary (cavity can contain blood and blood clots); the so-called coin lesions. Microscopically, the outer wall of cavity shows fibrosis or sclerosis. Internal surface may be connected with bronchus. The wall of cavern has 3 membranes:

·        Internal membrane occurs by necrotic tissue

·        Middle membrane occurs by special granular tissue

·        External membrane occurs by connective fibrous tissue

 

125.

A 70-year-old male patient died from acute coronary  insufficiency. He had knee joint  swelling, gonycampsis  and  gonalgia during his lifetime. Pathomorphologic examination of the deformed    joints and synovial membranes revealed membrane hyperemia with multiple perivascular inflammatory infiltrations made by lymphocytes, plasmocytes and macrophagocytes. There was an accumulation of organized  fibrin covering some  areas  of synovium  membrane and looking  like rice grains in the articular liquid. What is the most likely diagnosis?

Explanation

     Rheumatoid (atrophic) arthritis is a chronic progressive inflammatory arthritis of unknown origin involving multiple joints and characterized by disorganization of connective tissue of the synovial membrane and articular cartilage and development of their deformation. Disorganization of the connective tissue cause increase in proteoglycans and glycosaminoglycans (GAGs) concentration in blood. Proteoglycans and GAGs are responsible for the physical properties of ground substance. Main morphological appearance of rheumatoid arthritis is synovitis. It has 3 stages: in the first stage, it is characterized by an acute inflammatory reaction with development of edema, hyperemia and infiltration of lymphocytes, plasma cells and macrophages. Small areas of superficial necrosis or superficial erosions are covered by fibrinoid deposits. Not infrequently 2-3mm “rice bodies” (rice grains) composed of fibrin, fibronectin, collagen and immunoglobulin are present in joint cavities of seropositive patients.

126. A 49-year-old  patient with croupous pneumonia died from pneumococcal septicemia. Autopsy  revealed  up  to  700 ml of turbid greenish-yellow foul-smelling liquid in the left pleural cavity. The pleural leaflets   were   dull  and   plethoric.  What form of pleural inflammation is it?

Explanation

     Complications of croupous or lobar pneumonia includes empyema, gangrene, carnification, abscess formation, bacteremic spread which leads to purulent meningitis, bacterial endocarditis, arthritis, pericarditis and other organs. Empyema is a purulent inflammation of serous membranes (empyema of pleura, empyema of gall bladder and urinary bladder etc). Purulent or suppurative inflammation is characterized by the production of large amounts of pus or purulent exudates (liquids) consisting of a lot of neutrophils, necrotic cells and edema fluid.

127.

A patient died from cardiopulmonary decompensation. Histological  examination revealed  diffused pulmonary affection along  with interstitial edema,  infiltration of tissue by limphocytes,  macrophages, plasmocytes;  pulmonary fibrosis,  panacinar  emphysema. What  is the  most  likely diagnosis?

Explanation

     Fibrosing alveolitis is also known as interstitial pneumonia. It is characterized by progressive scarring of both lungs. The scarring (fibrosis) involves the supporting framework (interstitium) of the lung. There are patchy or lobar areas of congestion without the consolidation of bacterial pneumonias. A predominance of interstitial pneumonitis with widened, edematous alveolar walls containing a mononuclear inflammatory cell infiltrates. Interstitial pneumonia is the most common form of interstitial fibrosis.

128.

Acute    renal    impairment   caused death  of a bleeding patient. Autopsy revealed  enlarged kidneys  with  a  broad pale pink cortical layer expressively demarcated from  dark  red  renal  pyramids.   Macroscopic    examination  revealed lack of epithelial nuclei of convoluted tubules,  tubulorrhexis,  phlebostasis. The cell nuclei of choroid  glomus and straight tubules  were  present. What  pathology is it?

Explanation

     Acute tubular necrosis/Necrotic nephrosis/Necronephrosis involves the death of tubular epithelial cells that form the renal tubules of the kidneys. Most common cause of acute renal failure. It can be ischemic or nephrotoxic.

·        Ischemic acute tubular necrosis occurs due to hypoperfusion of the kidneys.

·        Nephrotoxic acute tubular necrosis occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents. Toxic agents causing nephrotoxic acute tubular necrosis includes mercuric chloride, ethylene glycol, carbon tetrachloride etc.

Macroscopically, the kidneys are enlarged and swollen (edematous). On cut section, the cortex is pale, while the medulla is slightly darker than normal. The capsule can be easily removed.

129.

Medical  examination of  a  20-year-old woman revealed  a dense incapsulated node  1 cm in diameter that  was palpated in the  mammary gland.  The  postoperative biopsy revealed  connective tissue overgrowth around  the  mammary ducts and glandular components of different  diameter that didn’t make lobules  and bore no signs of cellular  abnormality. What  diagnosis will be made?

Explanation

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Adenoma: benign epithelial tumor from the epithelium of the glands and glandular organs. More often they can be found in the breast, thyroid gland, liver, ovaries, prostate gland, GIT. In the question, it is located in the fibrous stroma – FIBROADENOMA.