MCQs in Objective Pathology

MCQs MCQs in in

Obje bj ective ct ive Pa Pathol th olog ogy y with Explanations

MCQ MCQs i n

Objective Pathology w ith Exp Expla lana nati tions ons Second Second Edition

Sumant Sharma MD Laboratory Director/ Director of Infection Control Prince Sultan Kidney and Heart Center  Najran, Kingdom of Saudi Arabia

Yogesh Chhabra

MD

Director of Blood Bank and Transfusion Services King Khalid Hospital Najran, Kingdom of Saudi Arabia

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JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London • Dhaka • Kathmandu

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Jaypee Brothers Medical Publishers (P) Ltd. Headquarter Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi–110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd. 83 Victoria Street London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: [email protected]

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Website: www.jaypeebrothers.com Website: www.jaypeedigital.com  © 2012, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at:  jaypee@jaypeebr others.com This book has been published in good faith that the contents provided by the authors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the authors specifically disclaim any damage, liability, or loss incurr ed, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the authors. MCQs in Objective Pathology with Explanations  First Edition: 2000 Second Edition: 2012 ISBN: 978-93-5025-904-7 Printed at 

Dedicated to Dr Swarn Kanta Sharma and Dr Smita

Bade Jatan se Beeni Chadariya Jyon ki Tyon Rakh Deeni Chadariya  After living with great care, I will give back this life uncorrupted.  – Sant Kab ir 

 Preface to the Second Edition Pathology is an oceanvast and without shores. The second edition of this book (the first edition was entitled MCQs in Objective  Pathology  authored by Dr Sumant Sharma), is an attempt to condense this ocean in a drop. As Gautama Buddha described (and later Immanuel Kant proved it to be correct) man is in the middle of  creation (Madhyam Sthith ), i.e. as far is man from the beginning of creation, so is God from man. Man’s knowledge of Pathology also has reached this middle point and it just makes the challenge of knowing it all more daunting. Buddha also described the characteristics of a good horse (Shrestha Ashwa ). An excellent horse is one that gets up from slumber with the sight of rider’s cane. A slightly lower standard is given to a horse which gets up on hearing the stroke of the cane on his friend. The worst is one that requires the stroke of the rider’s cane to awaken. Hurry up, flip the pages. The journey may be longer than expected. Let’s draw blood!

Sumant Sharma Yogesh Chhabra

 Preface to the First Edition Most Pathology books are written with one examination or another in mind. The one in your hands now, is an all encompassing workbook. You can use it to enhance your skills in the subject or use it as a workbook to test your learning. The format of true/false  is used in many national and international licensure examinations. Study the chapter from any comprehensive textbook and then check your learning using this book. Give 1 mark for any correct answer and 0 for unanswered one, Give 1 mark for any incorrect response. In this way, a score of up to 70% should be deemed appropriate. For somebody, who has regular responsibilities, it is difficult to compile such a Question Bank without the outside help from fellow professionals. I wish to thank everyone who has been directly or indirectly involved with the project.

Sumant Sharma

 Acknowledgments I am extremely thankful to Shri Jitendar P Vij (Chairman and Managing Director) for his patient support to the project. I must also mention the support given by the publishing team of M/s Jaypee Brothers Medical Publishers, New Delhi, India, especially Ms Samina Khan and Mr Gurnam Singh. Lastly, I thank the past and future students of this great sub ject who have served as lamp-posts all throughout.

Contents 1. Introdu ctio n to Patholog y ............................................. 1 2. Genetic and Environ mental Causes o f Diseases ...................................................... 37 3. Miscellaneous Topics in General Pathology ..............42 4. Disord ers of Growth and Diff erentiation .................... 45 5. Disord ers of Metabol ism and Homeost asis ................ 48 6. Cardio vascular System ................................................. 52 7. Blood and Bone Marro w ............................................. 56 8. Respiratory Syst em ...................................................... 61 9. Liver, Bili ary Tract and Exocrine Pancreas ...............65 10. Alimentary Tract ........................................................... 67 11. Male and Female Genital Tract and Endocrin e Syst em ......................................................... 73 12. Breast ............................................................................ 76 13. Male Genital Tract ........................................................ 78 14. Kidn ey and Uri nary Tract ............................................ 81 15. Skin, Soft Tissue and Skeletal System ......................84 16. Nervo us System ............................................................ 87

Chapter 1  Introduction to Pathology 

 Including Cell Pathology and Immunopathology (Including Special Diagnostic Techniques) PRETEST 1. Which of the following are correctly matched? (R-1) A. Virchow—Invention of microscope. B. Celsius—Work on naked eye appearance of diseased organs. C. Pasteur—Showed the way to active immunization. D. Jenner—Laid foundation of bacteriology. E. Mendel—Discovered principles of inheritence. 2. Which of the following are pathology subspecialities!? A. Histopathology—The diagnosis of disease by examining altered histology of tissue sections. B. Exfoliate cytology—Diagnosis of disease by studying body fluids secretion and excretions. C. Toxicology—Study of defence processes in the body D. Hematology—Study of infectious processes. E. Forensic pathology—Use of pathology for legal purposes. 3. Which of the following definitions are correct? A.  Allophenic mouse—A mouse in which two types of cells form clones of varying number in different organs.

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B. In paraffin wax technique, tissue is fixed usually in 10 percent formalin, dehydrated graded alcohols, cleared in xylol, chloroform or other solvent which is mixable with both alcohol and wax. C. Pathogenesis—The cause of disease. D. Etiology—The mechanism by which disease is caused E. Recombinant DNA—Artificial joining of DNA of one species (e.g. humans) to that of others (e.g. bacteria). 4. Which of the following are true about electron microhyplum scopy? A. Can differentiate between lymphoma and carcinoma as well as between adenocarcinoma and mesothelioma. B. Can be used to classify lymphomas. C. Can employ osmium tetraoxide as a fixative as well as special stain for lipids. D. Can differentiate between prostate cancer and gastric cancer. E. Can locate the primary site of a squamous cell carcinoma (SCC). 5. Which of the following are true about cytology? A. FNAC preserves cellular and tissue architecture. B. Urinary cytology detects transitional cell carcinoma C. Diagnosis is not very accurate. D. Exfoliate cytology is performed on cells aspirated by fine needle. 6. Which of the following are true? A.  A biopsy should be sent to pathology ideally fresh in saline, but is sent in 10 percent formalin 10 to 20 times the volume of specimen. B. For immunohistochemical (IHC) analysis using immunoflouresence of immunoperoxide method, the latter (IP) method is less advantageous. C.  A biopsy can be sent to laboratory without any information. D. Cloning involves isolation of a particular fragments of  DNA (usually a gene) and obtaining multiple copies. E. Vectors used for cloning can be plasmid vectors or  artificial yeast chromosomes (YACS).

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7. Which of the following prefixes and suffixes are correctly defined? A. Hypo—deficient B. It’is—Inflammation C. Plasia—Growth abnormality D. Hetero—Dissimilar in composition E. Meta—In excess

ANSWERS 1. A. B. C. D. E. 2. A. B. C. D. E. 3. A.

B. C. D. E. 4. A. B. C. D. E. 5. A. B. C.

False: Inventor of microscope was Leeuwenhoek. True False: Pasteur laid the foundation of bacteriology. False: Jenner showed the way to active immunization. True True True False: Toxicology is study of effect of poisons. False: Hematology is study of blood disorders. True True: Alophenic mice are produced by implantation into a psuedopregnant female a combined embryo developed in vitro by fusing two developing eggs from two pregnant mice. True False: Pathogenesis is the mechanism by which disease is caused. False: Etiology is the cause of disease. True True False: Immunohistochemistry (IHC) or gene rearrangement studies are required. True False: Immunohistochemical studies for prostate specific antigen are required. False False: Cellular morphology is preserved but not the tissue architecture. True False: FNAC can be used to diagnose tumors in some situations and may eliminate the need for surgery.

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MCQs in Objective Pathology with Explanations

D. False: In exfoliate cytology cells shed or scraped from a epithelium surface are examined. 6. A. True B. False: The immunoperoxide method provides a permanent slide–a major advantage over immunofluorescene. C. False: The request form should tell the site of biopsy and patient’s age and sex besides other operative details. D. True E. True 7. A. True B. True C. True D. True E. False: Meta denotes a change from one form to another. Excess is denoted as hyper.

CONCEPTS Q.1. Which of the following are true about cell-cell interactions? A. Occluding junctions and zona adherence are the same. B. Macula densa are also called nexus. C. Integrins and selectins share a common role of leukocyte—endothelial cell interaction. D. Cadherins prevent cancers from becoming invasive. E. Immunoglobulin superfamily molecules have a role in recognizing and binding immunological molecules. F. Cytokines are secreted by hemopoietic cells only. G. Tyrosine kinase associated receptors cause synthesis and secretion of various hormones. H. G-proteins are also called guanosine nucleotide binding regulatory proteins. Ans. A. False: Occluding junctions are called zonula occludens and adhering junctions are called zonula adherence. B. False: Macula densa is another name for desmosomes and gap junctions are called nexus. C. True: Besides the selectins also cause movement of  leukocytes and platelets. D. True: Cadherins are calcium dependent adhesion mole-

Introduction to Pathology  5

E. F.

G. H.

cules which bind adjacent cells and prevent invasion of  ECM by cancer cells. True: These act through other adhesion molecules and cytokines. False: Cytokines can be secreted by nonhemopoietic cells too. So far about 50 cytokines have been recognized. True: This is an example of enzyme-linked receptors which are involved in cell growth. True

Q.2. Which of the following are true? A. Cyclin E controls synthesis of mRNA and proteins required for DNA synthesis; cyclin A controls DNA replication, and cyclin B controls correct daughter DNA synthesis. B.  After mitosis cyclins and cyclin dependent kinases are degraded in peroxisomes. Ans. A. True B. Caretaker proteins—Ubiquitins are responsible for this. Q.3. Which of the following are true? A. Hypoxia and Ischemia result in same type of reversible injury. B. Inability to reverse mitochondrial function after removal of causative agent and membrane damage are two defining differences between reversible and irreversible injury. C. Intracellular accumulation of lactic acidosis is a cause of chromatin clumping. D. Intracellular accumulation of potassium causes hydropic swelling of cell. E. Myelin figures are found only intracellularly in reversible injury. . Ans. A. False: Reversible injury due to ischemia blocks the nutrient supply to cells too and thus both aerobic and anaerobic respiration in the cell is compromised, resulting in more severe cell injury. Furthermore, highly specialized cells like myocardium, proximal tubular cells of kidney and neurons are specially dependent on aerobic respiration and are thus more severely and rapidly affected by ischemia than hypoxia alone.

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B. True C. True D. False: Failure of energy dependent sodium potassium pump causes intracellular accumulation of Sodium. E. False: Myelin figures seen in cell injury are disintegrated membrane blebs containing water and dissociated lipoproteins between lamellae of membranes.They can be found both intracellularly and extracellularly. Q.4. Which of the following are true? A. Phospholipid rich amorphous densities are seen in mitochondria in irreversible cell injury. B. Ischemia-reperfusion injury is mainly because of oxidative damage to cell. C. Generation of oxygen free radicals occurs in cytoplasm. D. Superoxide oxygen is the most reactive of the oxygen free radicals. E. Cyanide kills by poisoning mitochondrial cytochrome oxidase. F. Ionising radiation can injure the DNA and the cell by radiolysis of water and production of oxygen free radicals. Ans. A. False: These are characteristic of reversible injury. In irreversible injury, calcium rich densities are seen. B. True C. False: It begins within mitochondrial inner membrane. D. False: Hydroxyl radical is the most reactive. E. True F. True Q.5. Which of the following are true? A. Cloudy swelling and hydropic swelling are the same. B. Russell’s bodies representing excessive immunoglobin in plasma cells’ rough endoplasmic reticulum represent a form of hyalin change. C. Hyalin degeneration occurs in rectus abdomin’s muscle in typhoid fever. D. Mallory’s hyalin is seen in hepatocytes in cholestasis. E. Corpora amylacea represent a form of intracellular hyaline. Ans. A. False: Cloudy swelling involves excessive accumulation of sodium and water whereas in hydropic swelling mainly only water accumulates (vacuolar degeneration).

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B. C. D. E.

True True: This is called Zenker’s degeneration. False: It is seen in alcoholic hepatitis. False: It is an example of extracellular hyaline.

Q.6. Which of the following are true? A. In hepatic Steatosis, granulomas may be found in the liver. B. In hepatic steatosis, neutral fat accumulates both inside the hepatocytes and outside. C. Mallory’s hyaline bodies are basically proteins. D.  Albinos are more prone to skin cancers. E. Ochronosis and alkaptonuria are synonymous. Ans. A. True: Lipogranulomas may appear consisting of collections of lymphocytes, macrophages and some multinucleated giant cells. B. False: There is only intracellular accumulation. Stromal infiltration by mature adipose cells is sometimes seen in obesity; most common organs affected being the heart and pancreas. C. True: These are intermediate filaments of cytokeratin D. True: Albinos are deficient in tyrosinase activity in skin and have generalized hypopigmentation. This makes them more prone to develop basal cell and squamous cell cancers on excessive exposure to sun. E. False: Ochronosis is a rare condition marked by dark pigmentation of ligaments, cartilage,fibrous tissue skin and urine. It may be caused by an inborn error of metabolism, alkaptonuria. This allows formation of Homogentisic acid, part of which is excreted in the urine and part of which is stored in tissues. But ochronosis may also be caused by chronic phenol poisoning. Q.7. In which cases are the number of cisterns of rough endoplasmic reticulum increased and in which conditions are they decreased? Ans. 1. Increased number of cisterns: In all cells with high protein production and secretion, e.g. plasma cells. 2. Decreased number of cisterns: Inactive cells with decreased protein synthesis, e.g. in liver of undernourished patients.

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Q. 8. What is oncosis? Ans. Irreversibly impaired metabolism (generally oxidative metabolism) brings about the death of cells with subsequent vacuolar swelling of cell and reactive inflammation in the absence of programmed cell death. The morphologic result is necrosis Note : Cell death and necrosis are not identical. A once-living cell submerged and fixed in formaldehyde is chemically dead although from a structural standpoint it remains intact and “animate”.

SYNONYM OF ONCOSIS IS ACCIDENTAL CELL DEATH Q.1. What are oncofetal lesions of rough endoplasmic reticulum (RER)? Ans. Deranged cisterns of RER, which occur in this form only in fetal and tumor tissue.

Types 1. Ribosome-layer complexes: These are layered aggregates of RER cisterns with interposed rows of ribosomes. 2. Annulated lamellae complexes: These are layered aggregates of perinuclear RER cisterns with nuclear pores. 3. Mitochondrial-lamellar-layer complexes: These are layered aggregates of longitudinally compressed mitochondria and RER cisterns. Q.2. What are cytoplasmic nuclei? Ans. This is the histological correlate of onion-layered aggregation of smooth endoplasmic reticulum (“fingerprint degeneration”). Cytoplasmic nuclei are a sign of blocked enzyme synthesis, such as is occasionally seen in blocked or degenerative protein synthesis. Q.3. Why is golgi apparatus atrophied in erythroblasts? Ans. Atrophy of golgi apparatus is the ultrastructural correlate of  disturbed protein synthesis with or without impaired posttranslational protein modification. So it is typical in cells that

Introduction to Pathology  9

lose their nuclei, e.g. erythroblasts and undifferentiated malignant tumors. Q. 4. Give examples in which various substances accumulate in the golgi apparatus. Ans. Several disorders are attributed to disturbed secretion and therefore to dysfunctioning of golgi apparatus. Examples are: 1. Cholestasis: Gall drainage disorders in which gall is blocked up into cisterns of the golgi apparatus. 2. Fatty liver: Hereditary or acquired disorders of lipoprotein metabolism, lipoprotein component accumulates in cisterns of golgi of hepatocytes. 3. Achondroplasia:  (Chondrodystrophica fetalis, dwarfism) Impaired proteoglycan synthesis causes proteoglycan accumulation in golgi cisterns of chondrocytes. 4. Alveolar proteinosis: Surfactant proteins accumulate in golgi cisterns of type II alveolar surface cells. Q.5. What are oncocytes? Ans. These are swollen cells with grainy eosinophilic cytoplasm. Pathogenesis: Mitochondrial DNA mutation disturbs ATP synthesis. This in turn causes compensatory mitochondrial proliferation. So oncocyte is a descripitive term for a cell rich in mitochondria. This is not a tumor cell. Carcinomas of salivary and thyroid glands, though, may exhibit total or  partial oncocytic transformation (Oncocytic thyroid ca., Oncocytic salivary gland ca.) These tumors have mahogany brown color because of high cytochrome content. Q.6. What are megamitochondria? Ans. These occur in severe deficiencies (Vitamin B complex deficiency or alcoholism) as a result of defective mitochondrial division or fusion. They are not caused by toxic swelling. Q.7. What is “turbid swelling of parenchymal organs”? Ans. First described by R Virchow in 1852, this implies swelling of internal organs with enlarged, doughy, turbid cut surface. Microscopically, cells are swollen with granular light cytoplasm. Ultrastructurally, swelling begins in response to the change in osmotic pressure with condensation of matrix and swelling of space between the cristae (crista type). This is followed by distribution of mitochondrial matrix and mito-

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MCQs in Objective Pathology with Explanations

chondrial cristae (matrix type). There is usually generalized cytoplasmic degeneration with formation of vacuoles. Q.8. Which of the following are true about dysplasia? A. It rarely occurs in epithelial tissue. B.  It can be called atypical hyperplasia. C. Loss of polarity in dysplasia means disorderly arrangement of cells from basal layer to surface layer. D. Dysplasia always progresses to carcinoma. E.  Anaplasia is a hallmark of dysplasia. Ans. A. False: Dysplasia means disordered cellular development and often is accompanied with metaplasia and hyperplasia. It occurs most commonly in epithelial tissue. B. True: Epithelial dysplasia is a characterized by cellular  proliferation and cytological changes. C. False: Loss of basal polarity means nuclei lying away from basement membrane. Of course in dysplasia, disorderly arrangement of cells in different layers is also seen but it is not termed ‘loss of basal polarity’. D. False: On removal of inciting stimulus which is usually chronic irritation or prolonged inflammation, changes may disappear. E.  False: Anaplasia is loss of cellular differentiation and functions is a feature of frank cancer.

SUPPLEMENTARY TOPICS—GENERAL PATHOLOGY Q.1. Which of the following are true/false? A. General pathology is related to basic reactions of cells and tissues to abnormal stimuli that underlie all diseases. B. Specific responses to all stimuli of specialized organs and tissues are examined under special or systemic pathology. C. Etiology and pathogenesis are synonymous. D. In modern terms, intrinsic or genetic and environmental are the two groups of etiological agents of diseases. E. Understanding pathogenesis of cystic fibrosis involves knowing the gene responsible for its causation. F. Morphological changes in a diseased organ have nothing to do with diagnosis of etiological process.

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G. Molecular techniques like DNA microassays and immunological approaches for analysis diseases are no more helpful in studying diseases than traditional morphological methods. H. Rudolf Virchow has no contribution to modern pathology. I. Study of origins, molecular mechanisms and structural changes of cell injury alone are enough to understand morphological and clinical patterns of tissue and organ injury. Ans. A. True. B. False: Special or systemic pathology is concerned with specific responses of specialized organs or tissues to more or less well-defined stimuli. C. False: Etiology is the cause of a disease. Pathogenesis refers to sequences of events in the response of cells or tissues to the etiological agent. It is the mechanism of disease. So even if the genes and their mutant forms underlying a great number of diseases and the entire human gename have been mapped, functions of encoded proteins and how mutations induce disease are often still obscure. The latter part forms pathogenesis of a disease. D. True: Though there are two major classes of etiological agents, concept of one cause for one disease is obsolete. Almost all diseases known today have both genetic and environmental etiologies combined. E. False: To know full mechanism (pathogenesis) and manifestations (Morphology) of cystic fibrosis, besides the knowledge of defective gene and gene product, the biochemical immunological and thus the morphological events leading to formation of cysts and fibrosis in lungs, pancreas and organs are required. F. False: Molecular changes in a disease refer to structural alterations in cells or tissues that are either characteristic of the disease or diagnostic of etiologic process. Diagnostic pathology is devoted to identify nature and progression of disease by studying morphological changes in tissues and chemical alterations in patients. G. False: Molecular analyses have begun to reveal genetic differences that bear on behavior of tumors. Examples

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MCQs in Objective Pathology with Explanations

are breast cancers and tumors of lymphocytes that look morphologically identical but may have widely different courses, therapeutic responses and widely different courses, therapeutic responses and prognosis. Increasingly, such techniques extend and even supplant traditional morphological methods. H. False: Rudolf Virchow, known as the father of modern pathology first put forth a concept in nineteenth century that virtually all forms of organ injury start with molecular  or structural alterations in cells. I. False: Different cells in tissue constantly interact with each other and an elaborate system of extracellularmatrix is necessary for integrity of organs. Cell-cell and cell-matrix interactions contribute significantly to response to injury which are as important as cell injury in defining the morphologic and clinical patterns of disease.

KEY WORDS Etiology, pathogenesis, morphological changes, clinical significance, molecular biology, tissue, cell and organ injury, Father of modern pathology. Q.2. Which of the following are true? A.  Atrophy involves decrease in number of cells of an organ. B.  Adaptation, reversible injury and cell death are separate events not interlinked and can occur independently or  each other. C. Cell death can be normal. D. Necrosis can be physiological as apoptosis can be pathological (abnormal). E. Calcification is always pathological. F. Cells exposed to even sublethal or chronic stimuli are always damaged. G. Cellular aging occurs with cumulative sublethal injury with increasing life span. Ans. A. False: Atrophy involves decrease in function and size of  cells. B. False: Adaptation, reversible injury and cell death can be considered stages of progressive impairment of cell’s normal function and structure. For instance in response

Introduction to Pathology  13

to increased hemodynamic loads, heart muscle first becomes enlarged—an adaptation. If blood supply to myocardium is insufficient to meet with demand, muscle becomes reversibly injured and finally cell death occurs. C. True: Cell death is a normal and essential part of embryogenesis, the development of organs, maintenance of homeostasis and is aim of cancer therapy. D. False: Necrosis is a cell death that is always pathologic.  Apoptosis can be pathological too when cells are damaged beyond repair and especially, if cell’s nuclear  DNA is damaged. E. False: Metabolic derangements can cause some intracellular accumulations of which calcium is one. However  calcification also occurs normally during skeletal mineralization. F. False: Damage might not occur in sublethal, chronic stimuli but cells may show subcellular alterations. G. True. Q.3. A. Give an example of cellular adaptation involving alterations in protein synthesis. B. What are the major molecular mechanisms of cellular  adaptations? C. Do estrogens have any effect on (1) DNA synthesis of  uterine epithelial cells (2) Structural components of  myometrial cells? D. In hormonal hyperplasia of physiological type, some hormones may themselves act as growth factors—True or false. E. Compensatory hyperplasia of physiological type in liver  occurs only by proliferation of remaining cells—True or  false. F. Some bone marrow cells can give rise to liver cells— True or false. Ans. A. Example 1: induction of new protein synthesis by target cells as in response of muscle cells to increased physical exercise. Example 2: Switch from one type of  protein synthesis to another—Or, markedly overproducing on type of protein—cells producing various collagen types and extracellular matrix proteins in chronic inflammation and fibrosis.

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MCQs in Objective Pathology with Explanations

B. 1. Direct: Stimulation of cells by factors produced by responding cells or other cells in environment. 2. Activation of various cell surface receptors and downstream signalling pathways. C. 1. Yes: Hormone induced growth of uterus involves increase in both number (hyperplasia)(→↑ DNA synth.) and size (hypertrophy) ( ↑  Str Comp.) of smooth muscle cells and epithelial cells. Abnormal endometrial hyperplasia is an example of pathological hyperplasia and the consequence is mainly hyperplasia of endometrial glands though both hypertrophy and hyperplasia of epithelial and endomyometrial cells takes place to some extent. This is a common cause of abnormal menstrual bleeding. 2. After normal menstruation, there is a rapid burst of  proliferative activity that is stimulated by pituitary hormones and ovarian estrogen. It is brought to a halt by rising level of progesterone usually about 10 to 14 days before anticipated menstrual period. If by any cause the balance between estrogen and progesterone is tripped, there is absolute or relative increase in estrogen with consequent hyperplasia of endometrial glands. D. True: Hyperplasia is caused by increased local production of growth factors, increased levels of growth factor  receptors on responding cells, or activation of particular  intracellular signalling pathways. These changes cause production of transcription factors that turn an may cellular genes including those envolving growth factors, growth factor receptors and cell cycle regulators-net result being cellular proliferation. Hormones themselves can act as growth factors and trigger source of growth factors in compensatory hyperplasia is not clear transcription of cellular genes. E. False: Not only remaining cells but some new cells are also formed from stem cells. In liver, intrahepatic stem cells don not play a role in hyperplasia after hepatectomy but contribute to regeneration after some forms of liver  injury like chronic hepatitis in which proliferative capacity of hepatocytes is compromised.

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F. True: Recent clinical and experimental data suggests that some bone marrow stem cells may be able to give rise to many types of differentiated, specialized cell types including hepatocytes. Then these bone marrow stem cells have a potential to repopulate damaged tissues. Q.4. A. What is the difference between cell proliferation that occurs pathological benign hyperplasia and cancer? B. What role does tissue hyperplasia play in wound healing? C. Skin and mucosal tissue can be stimulated by growth factors. True or false. Ans. A. Pathological hyperplasia (alone) regresses, if the stimulus for growth is taken off. Whereas growth in number  of cells in cancer is because of loss of normal growth control mechanisms and goes on occurring after  particular phase of initiation. Most forms of pathological hyperplasias are caused by excessive hormonal or  growth factor stimulation of target organs. Benign prostatic hyperplasia, e.g. occurs because of stimulation by androgens. Pathological hyperplasia however, provides a fertile soil on which cancer can arise. Thus patients of  endometrial hyperplasia are more prone to endometrial cancer. B. Hyperplasia is an important connection tissue response in wound healing in which proliferation of fibroblasts and blood vessels and in repair growth factors are responsible for this hyperplasia. C. True: Stimulation of skin epithelium can occur by growth factors in papilloma viral infections leading to skin warts. Same viruses and other viruses can also cause similar  mucosal lesions. Q.5. A. In nondividing cells like myocardial cells, both hyperplasia and hypertrophy can occur. True or false? B. Why is nuclear DNA content of hypertrophied cells higher than the rest of cells? C. There’s a similarity in mechanisms of production of bulging muscles of men engaged in ‘pumping iron’ and cardiac hypertrophy in hypertension. True or false.

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MCQs in Objective Pathology with Explanations

D. When do uterus and breast physiologically grow in size? Ans. A. False: Cells capable of division can respond to stress by both hyperplasia and hypertrophy but in nondividing cells only hypertrophy occurs. Hypertrophy refers to increase in individual cell size leading to increase in size of whole organ. B. Because of arrest at some stage of cell cycle in these cells without undergoing metosis. C. True: Most common stimulus for hypertrophy of muscles is increased workload. In both the examples given, the increase workload is shared by greater mass of cellular  components and each muscle false is spared of excess work and so escapes injury. The enlarged muscle cell achieves a new equilibrium, permitting it to function at a higher activity level. The striated skeletal and heart muscle are able to respond to increased workload (and thus ! metabolic demands) by tremendous hypertrophy as there is no mitotic response. In chronic hemodynamic load like faulty values or HT, an imbalance occurs between demand and response of cell’s functional capacity. Greater number of myofilaments per cell permits an increase workload with a level of metabolic activity per unit volume of cell not different from that borne by normal cell. D. Uterus: During pregnancy, uterus grows massively because of hypertrophy and hyperplasia both caused by hormonal influence of estrogens on smooth muscles. Oestrogens act on hormone receptors on individual myometrial cells leading to hypertrophy—increase in smooth muscle protein synthesis and increase in cell size. Breast: During lactation again the stimulus is hormonal. This time it is estrogen and prolactin. Q.6. A. Is these a conclusive and substantial evidence that during stress, hypertrophy and hyperplasia occur together? B. For a patient in cardiac failure decompensation because of previous MI, coronary and peripheral vascular atherosclerosis is a common setting. Previous to decompensation, peripheral vascular atherosclerosis might have caused gene induction of which genes in heart muscle?

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C. When do the genes in heart muscle fibers switch to similar to fetal or meonatal forms from adult forms expression. Ans. A. Hyperplasia and hypertrophy often occur together. The conclusive evidence comes from the fact that cardiac and skeletal muscles, under stress, undergo an increase in their individual fiber size as well as (a recent discovery) repopulation from some existing and precursor cells. So neither hyperplasia nor hypertrophy is ever absolute. B. Blood pressure (arterial) increase is a common disease caused by atherosclerosis of peripheral and visceral vessels leading to increased risk of ischemic heart disease, if untreated for long. Hypertension causes hypertrophy (by definition only hypertrophy) of cardiac muscle fibers. During this increase in individed fiber  mass of cardiac muscles, three types of genes are induced: 1. Those coding transcription factors (C-fos, C-jun) 2. These coding growths factors (TGF-b, insulin like GF-1, IGF-1) fibrolast growth factor. 3. These coding vasoactive agents (alfa-adrenergic agonist, endothelin-1, angiotensin II) C. During muscle hypertrophy, e.g. 1.  In hypertrophied cardiac muscle fibers, b myosin chain production mostly replaces alpha-myosin heavy chain production. This leads to decreased myosin  ATP-ase activity. This leads to slow utilization of ATP by myosin and then slower contraction of individual fibers. So in a given time lesser ATP’s are used and heart rate decreases (efficiency of myosin is more). 2. Re-exprasion of early developmental gives like atrial natriuretic peptide in ventrides occur. (In embryo, ANP gene is expressed in both atrium and ventricle. After  birth, oly in atrium). ANP is a peptide hormone that causes increased slat and water loss by kidneys leading to decreased hemodynamic load on stressed heart.

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MCQs in Objective Pathology with Explanations

QUESTIONS AND ANSWERS Q.1. Why two classes of etiology’s theory is considered obsolete? Ans. Some single gene disorders on one hand and infections on the other gave rise two one disease—once cause concept. Two types of etiological types suggested were genetic and acquired; recent data supports role of genetic factors in acquired diseases like hypertension and DM similarly even infectious are prove to genetic susceptibility, e.g. lower  repiratory tract infections in cystic fibrosis. Q.2. Does pathogenesis involve knowing the earliest molecular event in a disease? Ans. Yes but not only this. Pathogenesis means the full course of immmunological, biochemical and morphological processes besides the initial infectious or molecular cause. It involves the whole process from the first stimulus to ultimate manifestation of a disease. Some of the processes in many diseases like the mechanism of manifestation of alteration in genes’structure are still a subject of research. Q.3. Why is morphological diagnosis of tumors not enough for management? Ans. Tumor behavior also depends on its genetic profile. So studies in molecular biology of tumors which may be morphologically similar but behave differently in therapeutic response are required, e.g. slymphomas. Q.4. What was the most pioneering concept put forth by Rudolph Virchow? Ans. Virchow, called the father of modern pathology, put forth the cell theory. All forms of organ injury starts with molecular  or structural cell injury. Though cells interact with each other  and extracellular matrix ECM. ECM also maintains cells in themselves. Q.5. What are the two types of pathogenesis identified? Ans. Casual and formal pathogenesis. Causal pathogenesis tells why a pathogen causes a disease. This considers the environmental factors, host’s bodily disposition (susceptibility without regard to adaptability) and the interplay of  nonspecific immune responses in producing resistance to

Introduction to Pathology  19

some diseases. Formal pathogenesis describes the structural changes observed during clinical course of a disease which culminate in the altered structural and functional state of diseased organ/body. Q.6. Define health and disease. Ans. WHO defines health as a condition of complete bodily, mental and social well-being. Disease is defined as a dysfunction in life-processing that alter the body or a part of body in a manner that the affected individual requires help for subjective, clinical or social reasons. Q.7. In what way is the type of clinical course of a disease defined as regards to its development. Ans. Peracute diseases are fulminant and usually lead to death in several days. Acute diseases are usually intense and last for a few days or weeks. Recuperation is possible. Subacute diseases are insidious in onset, clinical course lasting for  weeks with doubtful recuperation. Chronic diseases are mild and progress in stages over months. Primary chronic diseases begin without a manifest acute phase. Clinical course is episodic. Recuperation is not possible. Secondary chronic disorders occur subsequent to acute inflammation that fails to heal because of complications. Recuperation in secondary chronic diseases occurs with persisting structured damage and functional deficits after the disease and subsides. The social and functional adaptability is thus restricted. Recurrence is resurgence of what is basically a chronic disease after a gap. Remission is temporary disappearance of symptoms of a disease. Death (Exitus letalis = lethal end) Q.8. Will it be correct to say that homeostasis is a continuously changing state? Ans. Yes, but upto some extent only. The normal cell is confined to a fairly narrow range of function because of: 1. Genetic programming of metabolism, differentiation and specialization. 2. Constraints because of neighboring cells. 3.  Availability of metabolic substracts. The narrow range of functioning is the steady state or  homeostasis. Within this narrow range there is conti-

20

MCQs in Objective Pathology with Explanations

nuous change—in one of different metabolites and other  substances in the cell. Q.9. What are the triggers for muscle hypertrophy and for  changes in gene expression in cardiac muscle fibers in myocardial hypertrophy? Ans. Two groups: 1. Mechanical triggers (stretch). 2. Trophic triggers. The trophic triggers are chiefly growth factors (IGF- α) and vasoactive amines (angiotension II, DC-adrenergic organists). The latter are produced by nonmyocyte cells and myocytes themselves. Q.10. What ultimately regulates the size of myocardial cells? Ans. From the above discussion it is clear that environmental cues are important. Nutrients (blood supply to heart muscle) is also a limiting factor. Q.11. Why don not heart muscles enlarge unlimitedly in response to increase burden? Ans. There’s a limit upto which heart muscle fibers can resond to increase in their size. Any increase in burden after that leads to cardiac failure. Various factors are implicated but not confirmed. These are—limited blood supply, limited oxidative capacity adaptability of mitochondria, changes in number and type of proteins, degradation of proteins and changes in myofibril cytoskeleton. Various ultrastructural manifestations include the myocardial fibers degeneration. There may also be apoptosis or nucleosis of myocardial fibers. Q.12. Give two examples of physiological atrophy. Ans. Physiologic decrease in cell size that may ultimately culminate in cell death can lead to decrease in entire tissue or  even organ. Physiologically this is seen in (1) embryonic growth—thyroglossal of duct atrophy. (2) in uterus after  parturition. Q.13. When is atrophy accompanied by osteoporosis? Ans. Atrophy of disuse may be accompanied by osteoporosis of  disuse.

Introduction to Pathology  21

Q.14. In which conditions is cachexia seen? Ans. Marked muscle wasting or cachexia may be seen in protein energy malnutrition of (1) marasmus type or (2) chronic inflammatory states (because of secretion of TNF) or  (3) cancer. Q.15. What are the causes of widening of sulci and narrowing of gyri in above 50 years persons? Ans. Aging and compromised blood supply because of atherosclerosis. Aging typically causes cell loss in tissues containing permanent cells: particularly in brain and heart. Q.16. What are the other causes of atrophy? Ans. Besides disuse, malnutrition and aging, denervation, ischemia, loss of endocrine stimulation and pressure by expanding mass can cause atrophy. Q.17. What are the ultrastructural changes seen in atrophy? Ans. Ultrastructural changes in atrophy represent a new balance between compromised conditions and size of cell upto the limit of its viability. Atrophied muscle fibers have fewer  structural and functional components like myofibrils, mitochondria and endoplasmic reticulum. Q.18. Can atrophy lead to cell death? Ans. If the conditions are compromised limitlessly, cell death may result in atrophied tissue. Examples include ischemic necrosis and apoptosis in developing embryo. Q.19. What are the mechanisms involved in atrophy? Ans. 1. Proteolysis by lysosomal hydrolases and ubiquitin proteasome pathway. 2.  Autophagy by autophagic vacuoles. Lysosomes and proteasomes:  Cytosomal hydrolases like cathepsins degrade protein molecules from the intercellular environment, surface of cells, environment. Ubiquitin conjugates cytosolic and nuclear proteins and binds to large proteolytic organelles called proteasomes–leading to proteolysis. Ubiquitin proteasome pathway is involved in cancer cachexia and proteolysis by glucocorticoids and thyroxine. Insulin inhibits this. TNF also stimulates this.  Autophagy : Small membrane bound vacuoles within cell with fragments of organelles form and then fuse with

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MCQs in Objective Pathology with Explanations

lysosomes the latter throwing their proteolytic enzymes in the autophagic vacuoles. Some residual bodies— vascuoles with digested material may remain. Lipofuscin or aging pigment is a form of these residual bodies causing brown coloration of organs in which it accumulates brown atrophy. Q.20. What are the equivocal signs of death? Ans. These are cardiac arrest, lack of pulse, cessation of  breathing, areflexia and decreasing body temperature. This is referred to as clinical death. Q.21. What are the criteria for brain death? Ans. A patient is regarded as biologically dead where brain death has been diagnosed according to following criteria: 1.  An isoelectric or flat electroencephalogram for 24 hours. 2. Two angiographic studies performed ½ an hour apart demonstrating absent cerebral circulation. 3. Irreversible absence of spontaneous respiration. 4.  Aflexia (loss of corneal and papillary reflexes). Q.22. What are the unequivocal signs of death? Ans. Livores:  After cardiac arrest, gravity causes blood in venous system to collect in lowest part of body. This produces reddish violet skin spots that can be mobilized by applying local process. Regor mortis: Postmortem rigidity begins 3 to 6 hours after  death. Nystem’s law:  Rigor mortis begins at head and spreads towards feet. Later subsides in the same manner. Occurs due to lack of ATP and subsequent coagulation of active and myosin filaments.  Antolysis or decomposition:  Because of activiation of  lysosomal intrinsic protease and extrinsic protease from intestinal bacteria which digest the organic components of  body. Failure of tissue respiration causes lysosomal protease activation. Q.23. The above three types of signs of death can be simulated in which condition? Ans. In any condition causing reduced vital functions like barbiturate intoxication.(apparent death).

Introduction to Pathology  23

Q.24. Define average life expectancy, morbidity and mortality and lethality. Ans. Average life expectancy: Time period in which 50 percent of certain population group have died. The population group can be, e.g. women. Morbidity: Number of persons per year per 100,000 population who suffer from a disease. Mortality: Number of persons per year per 100,000 population who have died of a disease. Lethality:  Quotient obtained by dividing the number of  persons who have died of a certain disease by the number  of persons who have contracted that disease. Q.25. Define epidemic autopsy, clinical autopsy and insurance autopsy. Ans. Epidemic autopsy: Performed in equivocal cases involving chemical suspicious of infectious disease. Clinical autopsy: Performed on patients who died in hospital usually a part of hospital quality assurance program. Requires consent of next of kin. Insurance autopsy:  Done when required by insurance companies when: 1. Sudden death from uncertain or unnatural causes. 2. Occupational exposure to certain pathogens. The procedure is ordered by ensurer. This type of insurance autopsy to resolve insurance claim is almost never refused by next of kin. Q.26. What are the two main classes of nuclei seen in cell cycle? Ans. Interphase nucleus: Characterized by a nucleolus containing RNA, loosely structured, genetically active euchromatin and densely structured heterochromatin (genetically inactive) Mitotic nucleus: Characterised by visible chromosomes. Q.27. What is the structure of chromosomes in metaphase? Ans. Two strands of chromatids joined at centromere.  – short arm – p (for petit)  – long arm – q.

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MCQs in Objective Pathology with Explanations

Q.28. What is a karyogram? Ans. Chromosomes of a cell are shown to be arranged in a karyogram. This is a short formula or description of chromosomes using the following criteria:  – Total number of chromosomes.  – Sex chromosome status.  – Applicable aberrations. Q.29. Based on a computer model, which part of DNA corresponds to software and which one to hardware? Ans. The software is the program and base sequence containing and instructions for: 1. Copying the program—DNA replication. 2. Repairing program defect—DNA repair. 3. Using subprograms to create protein (Structure and functional). The replication process and machinery, transcription process and machinery and translation process and machinery can be compared to hardware—computer itself. Q.30. What is a nucleosome? Ans. Nucleosome consists of: 1. A histone molecule with 2, H2A, H2B, H3 and H4 polypeptides each. 2. One histolne H1 polypeptide 3. Limker DNA 4. DNA proper. Diameter of a nucleosome in a solenoid model is 11 cm.  A DNA double helix diameter is 2 mm. Q.31. What are the dimensions or diameter (average) of a chromatid? Ans. Each chromatid is a supercoil of around 700 mm diameter  with each coil of single DNA strand and histone molecules (polynucleosome) being of around 30 mm diameter. Q.32. Give an example of congenital DNA repair defect. Ans. Xeroderma pigmentosum. It is rare. It is hereditary (because of an endonuclease defect).

Introduction to Pathology  25

Pathogentic chain reaction: Ultraviolet radiation ↓ DNA damage in skin cells ↓ Increased DNA defects in skin cells Sequelae: 1. Skin atrophy (→Thinning of skin)→ an adaptive reaction of excessive cornification and hyperpigmentation is induced. Mitotic dysfunction in skin cells: Skin cancers. Clinically the→following lesions are seen: • Dry scaly skin (Xeroderma) with mottled hyperpigmentation. • It is a precusor of skin cancer. Later multiple skin tumors such as basal cell Ca, squamous cell Ca and malignant melanoma develop. Q.33. What are the types of UV radiation? Ans. Three wavelength ranges exist in UV portion of solar  spectrum: 1. UVA → 280 to 400 mm 2. UVB → 280 to 320 mm→ to cause cutaneous cancers. 3. UVC → 200 to 280 mm filtered by ozone layer. Q.34. Causation of skin cancers by UV radiation depends upon which factors? Ans. 1. Type of UV rays. 2. Intensity of exposure. 3. Quantity of light absorbing protective mantle of melanin in skin. Fair shinned Europeans who do not tan their  bodies and live near equator, e.g. Queensland Australia, have the highest incidence of cutaneous cancers. Q.35. What the subcellular level effects of UV rays? Ans. 1. Inhibition of cell division. 2. Induction of mutations → carcinogenicity of UV rays is attributed to formation of dipyrimidine dimmers in DNA. 3.  Cell death. 4. Inactivation of enzymes.

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MCQs in Objective Pathology with Explanations

Q.36. What is NER and discuss its role in UV radiation caused cutaneous tumors? Ans. NER or nucleotide excision repair is the mechanism of  repair of DNA damage such as formation of dispyrimidine dimmers by UV rays in chin cells. Steps of NER are: 1. Recognition of DNA lesion. 2. Incision of damaged portion on both sides of lesion. 3. Removal of damaged nucleotide. 4. Synthesis of normal nucleotide patch. 5. It is ligation to DNA. In mammalian cells upto 30 or more proteins are involved. It is postulated that in excessive sunlight UV ray damage, NER is overwhelmed leading to large transcriptional errors and thus cancer. Q.37. How does UVB radiation cause skin cancers in XP? Ans. There are basically two mechanisms: 1. Inherited inability to repair UVB damaged DNA. XP is a heterogenous disease with at least 7 variants each caused by a defect in one of several genes involved in NER. There is extreme photosensitivity and 2000 fold increased risk of skin cancers in sun exposed skin. 2. UVB also causes mutations in oncogenes and tumor  suppressor genes. Mutant forms of P53 and RAS are +. The mutations occur mainly at dipyrimidine sequences. In animal models, P53 mutations occur early than appearance of  tumors. In XP, there may also be neurological abnormalities. Q.38. What does the size of nucleus in a cell depend upon? Ans. 1. Size of cell. 2. DNA content of nucleus. 3. Functional state of nucleus. Q.39. In what conditions does nuclear polyploidy occur? Ans. Multiple complement chromosomes in a cells is called polyploidy. It occurs when: 1. Proliferating cells double their DNA in synthesis phase and just before mitosis become tetraploid. 2. Where mitosis fails to occur after the synthesis phase or is followed by several additional synthesis phases.

Introduction to Pathology  27

This occurs in some endocrine gland cells like thyroid. 3.  As a morphological sign of stress induced adaptative reactive as in. Barbiturate above: Increased liver metabolism results in liver cells polyploidy. Cardiac valvular defects:  Mycocardium works harder  and produces polyploidy. Haploid cells are normally seen only while spermiogenesis and oogenesis. Q.40. What is nuclear aneuploidy and what is its morphological sequela? Ans. Variation from normal euploid complement (Haploid or  Diploid) of chromosomes in which individual chromosomes do not exist in their normal quantities. Morphological sequela of aneuploidy are: 1. Variability in size of nucleus (nuclear polymorphism) larger cell nucleus indicates cellular activity and smaller  nucleus indicates cellular inactivity. 2. Variability in nuclear chromatin content. (Nuclear polychromasia). Both polymorphism and ploychromasia are important criteria characterizing a malignant tumor. Q.41. What are the nuclear criteria of malignancy? Ans. 1. Nuclear polymorphism and nuclear polychromasia. 2. Proliferation measured by mitotic count in a field of  vision. 3. Dyskaryosis. Q.42. What are the chromatin changes seen in nuclear chromatin in different disease states? Ans. 1. Meterochromatin condensation: Checker board type of  chromatin condensation indicates arrested transcription. 2. Dyskaryosis: Irregular pattern of heterochromatin condensation and fine aggregates gives cancer cells a salt and pepper appearance. 3. Perinuclear hyperchromatosis: Chromatin condensation along inner nuclear membrane. Early sign of cell death (apoptosis). Later it leads to total chromatin clumping or nuclear pyknosis.

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MCQs in Objective Pathology with Explanations

4. Karyolysis: Fading of nucleus due to chromatin dissolution. Late sign of induced cell death. 5. Karyorrhexis: Nuclear burst due to chromatin fragmentation. Late sign of programmed cell death. Q.43. What are the different types of nuclear inclusions seen? Ans. 1. Cytoplasmic inclusions:  Migration of portions of cytoplasm in nucleus, associated with dysfunctional cell division in telephase causes a rounded lucency in nucleus →  frosted glass nucleus. For example papillary thyroid carcinoma. 2. Paraplasmic inclusions: Migration of portions of paraplasm in nucleus due to imagination of nuclear membrane or  dysfunctional telophase. 3. Glycogen inclusions:  Seen as nuclear defects after  alcohol fixation—Diabetes. 4. Fatty inclusions: Following paraffin fixation, cause lipid defects in nucleus. Typical of tumors in the form of fatty tissue—Liposarcoma. 5. Immunoglobulin inclusions: PAS-positive globules (FaheyDutcher bodies). Malignant lymphocytic tumors like— Lympholoplasmacytic lymphoma. 6. Viral inclusion: Viral proteins arranged in paracystalline configuration. Q.44. What is the most frequent type of metaplasia seen? Ans. Metaplasia or an adaptive response to stress in which one mature cell type (epithelial or mesenchymal) is converted to another mature cell type is most commonly of columnar  to squamous epithelial type. The commonest form occurs in smokers’ respiratory columnar ciliated mucous secreting epithelium is replaced by more resistant stratified squamous epithelium with loss of mucous secreting function. The change may be focal or wide. Stones in excretory ducts of salivary glands, pancreas or bile ducts may also cause a change from columnar to stratified squamous epithelium. Q.45. What is the role of Vitamin A in maintaining respiratory epithelium? Ans. Vitamin A deficiency (retinoic acid deficiency) may cause squamous metaplasia of respiratory epithelium and excess of Vitamin A is protective against keratinization.

Introduction to Pathology  29

Q.46. Is squamous metaplasia beneficial? Ans. It is a double edged sword as in case of respiratory epithelium important function of mucous secretion is lost. Also malignant cancer can arise in metaplasmic tissue and most common cancer of respiratory epithelium is of squamous type. All this with standing, stratified squamous epithelium is more rugged and causes increased resistance to noxious stimuli. Q.47. Can metaplasia from squamous to columnar epithelium occur? Ans. Yes. Barrett’s esophagus is a condition in which lower esophagus after increased exposure to acid reflux from stomach converts from stratified squamous to glandular columnar type of epithelium cancer arising in this setting is most commonly adenocarcinoma. Q.48. In connective tissue metaplasia also clearly are adaptive response? Ans. Connective tissue formation of the type which is not indigenous to its site is not clearly adoptive. Example is formation of bone in soft tissue in myositis ossificans in fractures. Fat and cartilage can form sometimes too. Q.49. What is the role of stem cells in metaplasia? Ans. Metaplasia results from reprogramming of stem cells present in the tissue or of undifferentiated mesenchymal cells in connective tissue. Precursor cells develop differently there is no change in the phenotype of differentiated, mature cells. Q.50. What are the mechanisms involved in altered precursor cells development in metaplasia? Ans. Many tissue specific and differentiation genes are involved in coding for growth factors, cytokines and E (M components which signal for altered development of precursor  cells, e.g. bone morphogenic proteins, members of TGF-B superfamily, induce chondrogenic and osteogenic expression in stem cells. While suppressing differentiating into muscle or fat these growth factors act as external triggers induce specific transcription factors that lead the cascade of phenotype specific genes towards a full-developed (of  different type) cell. Why the normal pathways are disrupted is not known?

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MCQs in Objective Pathology with Explanations

Examples: Vitamin A → Retinoic acid regulates cell growth, differentiation and tissue pattering. Certain cytostatic drugs: Cause drugs: Cause disruption of DNA methylation patterns and can transform mesenchymal cells from one cell type (fibroblast) to another (muscle, cartilage).

SUPPLEME SUPPL EMENT NTAR ARY Y TOPI OPICS— CS—CEL CELL L INJURY AND INFLAMMATION PRETEST 1. Which of the the following following are true true about cell Injury? Injury? A. Hypothyroidism and scurvy cause delayed wound healing. B. Ultraviolet light promotes healing. C. Cerebral cortex and myocardium can regenerate after  injury. D. Fibrinoid necrosis occurs in TB. E. Enzymatic lysis of adipose tissue causes fat necrosis. 2. Which of the follo following wing are are true? A. The myofibroblastic differentiation of fibroblast causes contraction of granulation tissue. B. Endarteritis obliterans and leukemia can be caused by radiation exposure for a long time. C.  Apoptosis is pathological event. D.  Apoptosis is an energy dependent pigmentation of DNA by non-lysosomal endonucleases. 3. Which of the follo following wing are are true? A. Endothelial cells and plasma cells are capable of  phagocytosis of particulate matter in acute inflammation. B. Lymphocytes and plasma cells contribute in chromic inflammation. C. In vascular phase of inflammatory response, neutrophils and monocytes move towards periphery of microcirculatory vessels a process called pavementing. D. T-lymphocytes produce antibodies. antib odies. E. Transudate is noninflammatory fluid with few cellular  elements.

Introduction to Pathology  31

4. Which of the follo following wing are are true? A. Unidirectional movement of leukocytes towards a stimulus is called diapedesis. B. Macrophages are found in glomeruli. C. Hepatocytes have greater regenerative capacity than myocardial cells. D. Mast cells have metachromatic granules. 5. Which of the follo following wing are are true? A. Features of acute inflammation are in following chronological order: a Co Cont ntra ract ction ion of ar arte teri riol oles es b. Art Arteri eriolar olar dila dilatat tation ion c. Ac Acti tive ve hyp hyper erem emia ia d. Inflammatory exudates e. Swelling and pain f. Slowing of blood flow. B. Cytoplasmic micropinocytotic vesicles are increased for  increasing membrane permeability in acute inflammation. C. C3a, C5a, 5-HT, 5-HT, Kallikrein, Kallikrein , PGE2 are involved in increaincr eased vascular permeability permeability.. D. In a granuloma, there is polymorphonuclear leukocytosis, cell debris and fibrin. E. Collagen type found in dermis, tendon, bone, cornea, and dentin is type IV. 6. Which of the follo following wing are are true? A. Fab fragment consists of light chain and part of heavy chain. B. Papain digestion of monomeric immunoglobulin results in production of an antibody binding fragment. C. Fc, Fragment consists of C-terminal ends of heavy chains. 7. Which of the follo following wing are are true? A. IgM class specific antibody production is a primary antibody response. B. IgA class antibody has 4 J-chains. C. Mast cells degranulation is a property of IgE. D. Lymphocyte surface antigen receptor is a property of  IgD. The deep (or para) cortex is the T-lymphocyte zone of lymph node and enlarges during antigenic stimulation.

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MCQs in Objective Pathology with Explanations

E. The deep (or para) cortex is the T-lymphocyte zone of  lymph node and enlarges during antigenic stimulation. 8. Which of the following following are true about T-lymp T-lymphocyt hocytes? es? A. Helper T-lymphocytes and T4 positive cells. B. Cells bearing both T4 and T9 are common thymocytes. C. Prothymocytes are T10 positive cells. D. Suppressor T-lymphocytes are T9 positive cells. E. In the unstimulated lymph node, there are localized aggregates of lymphocytes in superficial cortex. 9. Which of the follo following wing are are true? A. Following antigenic stimulation, para cortex enlarges resulting in B-lymphocyte proliferation. B. Macrophages have a surface receptor for C3b. C. C5a promotes emigration and accumulation of neutrophil polymorphs and macrophages. D. Extrinsic allergic alveolitis is an immune complex,  Arthus (type 3) reaction to bacterial spores on mouldy hay. E. Rheumatoid arthritis is an organ specific autoimmune disease. 10.. Which of the 10 the following following are true about autoimmu autoimmune ne disease? A. In Di-George syndrome, there is defective B-cell function. function . B. In infantile sex-linked agammaglobulinemia there is selective B-cell defect (Bruton type). C. In severe combined immuno immun o deficiency, there is defective B-cell and T-cell function. D. Wiskott-Aldrich syndrome is characterized by abnormal platelets and defective T-cell function alone.

ANSWERS 1. A. B. C. D. E. 2. A. B.

True False False False True True False

Introduction to Pathology  33

C. False D. False 3. A. False: Neutrophils, macrophages and eosinophil are the main phagocytes in acute inflammation. B. True C. Flase: The process described is called margination. Pavementing is adhering of inflammatory cells to vascular  endothelium. D. False: B-lymphocytes produce immunoglobulins. E. True 4. A. False: The described process is chemotaxis. Diapedesis is movement of white cells out of the vessel through gaps in endothelial cells. B. True C. True D. True 5. A. True B. True C. True D. False: This description is that of an abscess. Granuloma is characterized by chronic inflammation. E. False: Type neollagen is seen in basement membranes. Type I is seen in the said places. 6. A. True B. False: There are two antibody binding fragments. C. True 7. A. True: IgM appears in a small quantity within 7 days of  exposure to antigen. B. False: IgA is selected by plasma cells as a dimmer, i.e. two molecules, linked together by one polypeptide-J chain. C. True D. True E. True 8. A. True B. True C. True D. False: These are T8 positive cells. E. True

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MCQs in Objective Pathology with Explanations

9. A. False: Following antigenic stimulation of humoral response type, primary nodules enlarge to become germinal centers where B-lymphocytes proliferate. B. True C. True D. True E. False: It is a multisystem connective tissue disease. 10. A. False: There is almost complete failure of development of thymus and parathyroid with resultant defective T-cell function. B. True C. True D. False: Alongwith these two abnormalities, IgM and IgA are also abnormal.

CONCEPTS IMMUNOPATHOLOGY Q.1. Which of the following are true? A. Heparin mediates type I hypersensitivity (Anaphylactic reaction). B. Pernicious anemia and Grave’s disease are examples of immune complex diseases. C. Contact dermatitis is an immune complex disease. D. CREST syndrome is a form of scleroderma. E. SLE is characterized by primary immune deficiency. Ans. A. True: Both histamine and heparin mediate anaphylactoid reaction. B. False: These are two examples of type II hypersensitivity reaction (cytotoxic type). C. False: Contact dermatitis is a type IV hypersensitivity reaction (cell mediated type). Type III reactions are exemplified by serum sickness, SLE and glomerulonephritis. D. False: Scleroderma is progressive systemic sclerosis. CREST syndrome is localized scleroderma characterized by anticentromere antibodies. It is characterized by calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia.

Introduction to Pathology  35

E. False: It is characterized by secondary immune deficiency, other examples being diabetes mellitus and alcohol abuse. Q.2. Which of the following are true? A. Pneumocystis carinii infection can present with osteomyelitis. B.  Acquired Immunodeficiency Syndrome (AIDS) can present with CD4 counts more than 200. C. Common Variable Immunodeficiency (CVI) can present with recurrent giardial infections. D.  Average duration of latent phase in AIDS is 2 years. Ans. A. True: P. carinii   infection of lungs or bone-marrow can occur with CD4 counts of 200 to 500 cells/microliter. With less than 50 calls/microliter counts—CMV, MAI and JC viruse infections result. B. True: AIDS can still be present with CD4 counts more than 200, if patient is HIV positive with an AIDS defining disease. C. True: Other diseases seen are bacterial infections, autoimmune disease, lymphoma and gastric cancer. D. False: Average duration of latent phase in AIDS is 10 years.

INFLAMMATION Q.1. Which of the following are true? A. P-selectin is normally present in Weibel-Palade bodies in endothelial cells. B. Defects in cell adhesion is found in diabetes and corticosteroid use. C. Myeloperoxidase deficiency is associated with increased incidence of bacterial infections. D. Histamine is produced by mast cells and basophils only. E. IL-I is responsible for pain and prostaglandin E2 for  pyrexial response. Ans. A. True. B. True: Also seen in alcohol intoxication and certain congenital deficiencies of adhesion molecules. C. False: Although incidence of bacterial infection may be increased, characteristically candidal infections are increased in myeloperoxidase deficiency.

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MCQs in Objective Pathology with Explanations

D. False: Along with these two types of cells, platelets also store and release histamine. E. False: IL-I is responsible for pyrexial response. Prostaglandin E2 is responsible for pain accompanying acute inflammation. Q.2. Which of the following are true? A.  Apoptosis is generally accompanied by inflammatory response. B. bcl-2 and P-53 are both proapoptotic genes. C. Caspases activate proteases. D. Councilman bodies are found in alcoholic hepatitis. E. Fat necrosis is also called saponification. Ans. A. False: Apoptosis is characterized by the lack of  inflammatory response. B. False. bcl-2 inhibits apoptosis. P-53 stimulate apoptosis. C. True: Caspases activate proteinase as well as endonucleases. D. False: Councilman bodies are found in apoptotic liver  cells in viral hepatitis. E. True. Q.3. Which of the following are true? A. Tissue based basophils are called mast cells. B. Interstitial infiltration is a common response to viral infectious agents. C. Syncytia formation is a response seen in cytopathic/ cytoproliferative inflammation. D. Keloid is characterized by production of collgen of predominantly type IV. E. Basement membrane has a net positive charge. Ans. A. True. B. True: For example in viral hepatitis and viral myocarditis. C. True: The cells are altered in ultrastructure. D. False: Type III collagen is found in keloid. Type IV collagen is found in basement membrane. E. False: Basement membrane has a net negative charge.

Chapter 2  Genetic and En vir onment al Causes  vironment onmental of Diseases

PRETEST 1. Which of the following are true about DNA replication? A. Splicing involves editing out of superfluous information transcribed from introns of genes from mRNA. B. Transcription involves production of polypeptide chains from mRNA. C. Translation involves not copying superfluous introns. 2. Which of the following are correctly matched as per  their pattern of inheritance? A. Glycogen storage disease—Autosomal recessive B. Neurofibromatosis—Autosomal dominant C. Duchenne muscle dystrophy—Autosomal recessive D.  Ataxia telangiectasia—Autosomal dominant 3. Which of the following are true about HLA antigens? A. Class 1 HLA antigens are expressed in all nucleated cells. B. Class 2 HLA antigens are coded for by alleles DP, DQ and DR. C. They reside on chromosome 8. D. HLA DR4 is associated with Hashimoto’s disease. 4. Which of the following diseases are caused by bacteria? A. Onchocerciasis B.  Aspergillosis

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MCQs in Objective Pathology with Explanations

C. Syphilis D. Toxopalsmosis E. Rubella. 5. Which of the following are true about bacterial infections? A. C.Welchi   alphatoxin causes digestive damage to cell membrane. B. C.Difficile  does not produce any toxin. C. Scaleded skin syndrome and toxic shock syndrome causing bacteria are of same genus. D. Vibrio Cholerae produces an enterotoxin. 6. Which of the following are true about environmental pathogens? A.  A cavity lesion on chest X-ray in a coal worker signifies superimposed tuberculosis. B. Liver cannot be damaged by environmental agents. C.  Asbestos-related disease may manifest as bronchogenic carcinoma. D. Bleomycin and busulfan cause interstitial pulmonary fibrosis. E. Both cyanide and carbon monoxide poisoning cause cherry red coloration of blood. 7. Which of the following is true about congenital disease? A.  A teratogen cannot act before pregnancy is discovered. B. Childhood polycystic kidney disease always occur as a lone entity. C. Congenital CNS defects are associated with folate deficiency. D. Criduchat syndrome is a single gene disorder. E. Hb Barts (gamma 4 tetramers) can cause intrauterine death of fetus.

ANSWERS 1. A. True B. False: Transcription is the process where by mRNA, a copy of DNA of gene is produced before a polypeptide is synthesized. C. True

Genetic and Environmental Causes of Diseases

2. A. B. C. D. 3. A. B. C. D. 4. A. B. C. D. E. 5. A. B. C. D. 6. A. B. C. D. E. 7. A.

B.

C. D. E.

39

True True False False True True False: Location is at chromosome 6. False: DR 5 is associated with Hashimoto’s disease and DR4 with rheumatoid disease. False: It is a round worm disease. False: It is a fungal disease. True False: It is a protozoan. False: It is a togavirus. True: Welchi alpha-toxin is a lecithinase that digests cell membrane. True: The toxin causes pseudomembranous colitis. True: The genus is Staphylococcus. True True False: A variety of agents including the carbontetrachloride and oral contraceptives damage liver. False: Mesothelioma is caused by asbestos exposure. True True False: Though usual time when pregnancy is most susceptible is 3rd-8th week, teratogens can act before diagnosis of pregnancy. False: This autosomal recessive disease is usually associated with multiple liver cysts, congenital hepatic hibrosis and proliferation of bile ducts. True False: The defect is different. True

GENETIC DISEASES Q.1. Which of the following are true? A. Brushfield spots are seen on skin in Mongols. B. Tumor’s syndrome patients are usually females and their  somatosomes have Barr bodies.

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MCQs in Objective Pathology with Explanations

C. True hermaphroditism is always characterized by ovary on one side and testis on the other. D. Sertoli-Leydig cell tumors are never found in females. E. Cystic fibrosis is characterized by fungal lung infections. Ans. A.  False: Brushfield’s spots are seen in iris of Down’s syndrome patients. B. False: They have female phenotype but the somatic cells do not have Barr bodies. C.  False: True hermaphroditism may also be seen in patients with ovotestis, a gonad with both testicular and ovarian tissue. D. False: In female pseudohermaphroditism, androgen producing tumors may be cause. E. False: Characteristic infections seen are P. aeruginosa and S. aureus. Q.2. Which of the following are true? A. Zebra bodies are seen in Tay-Sachs disease. B. Gaucher’s disease and familial hypercholesterolemia are extremely rare genetic diseases. C. Ehlers-Danlos syndrome is always autosomal dominant. D.  Von Recklinghausen’s disease and bilateral acoustic neurofibromatosis are synonymous. E. Fragile X syndrome is an X-linked disorders. Ans. A. False: Zebra bodies are electron microscopic feature of  CNS and RE cells in Niemann-Pick disease. Sphingomyelin accumulates in distended lysosomes as lamellated figures. B. False: Both are relatively common. Gaucher’s (Autosomal recessive) is the most common lysosomal storage disease and familial hypercholesterolemia is the most common inherited disorder (It is an autosomal Dominant disease with a worldwide incidence of 1 in 500). C. False: EDS type VI is an AR defect in lysyl hydroxylase (enzyme responsible for hydroxylation of lysine residues). D. False: Von Recklinghausen’s disease is type I neurofibromatosis characterized by AD mutation in tumor suppressor gene NF-1. Bilateral acoustic neurofibromatosis is a type II neurofibromatosis accounting for 10 percent

Genetic and Environmental Causes of Diseases

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of cases of NF only and is characterized by mutation in tumor suppressor gene NF-2. E.  True: Fragile X syndrome is characterized by triplet nucleotide repeat mutations. Nucleotide sequence CUG repeats typically hundreds to thousands of times. Mutation is on FMR-1 gene on X chromosome.

Chapter 3  Miscellaneous T opics o pics in General Pathology 

PRETEST Q.1. Which of the following are true? A. In anasarca, edema fluid accumulates in dependent parts of body. B. Mechanism behind blushing and response to heat are same. C. Tissue factor is activated without any stimulus in intrinsic pathway. D.  Alpha granules of platelets contain calcium and ATP. E. Hemolytic uremic syndrome (HUS) is a congenital syndrome manifesting in adolescence. Ans. A. False: Anasarca is generalized body edema. B. True: Both are examples of active hyperemia. C. False: Collagen activates tissue factor (factor XII) in intrinsic pathway. D. False: α-granules of platelets contain fibrinogen, fibronectin, factor V and von Willebrand’s factor, factor IV and platelet derived growth factor (PDGF). ADP and calcium alongwith histamine, serotonin and epinephrine are stored in dense bodies. E. False: HUS usually follows gastrointestinal infections with verotoxin producing E. coli   0157:H7 and occurs most commonly in children. Q.2. Which of the following are true? A. Prothrombin Time (PT) can be used to screen liver  disease. B. PTT tests intrinsic pathway only. C. Thrombin time tests for adequate clotting factor.

Miscellaneous Topics in General Pathology  43

D. Fibrin Degradation Products (FDP) are increased in DIC. E. PT is normal and PTT is prolonged in DIC. Ans. A. True: PT tests extrinsic and common pathways, It tests adequate level and synthesis of liver synthesized factors—V, VII, X, prothrombin and fibrinogen. B. False: PTT tests both intrinsic and common pathways. Levels of following factors are tested—XII, XI, IX, VIII, X, V, prothrombin and fibrinogen. C. False: Thrombin time is a test for adequate fibrinogen levels. D. True: FDPs levels test fibrinolytic system. (Protein C and S, antithrombin III). E. False: As most of the clotting factors are depleted in DIC, both PT and PTT are affected (prolonged in DIC). Q.3. Which of the following are true? A. Lines of Zahn are seen in a blood clot. B. Paradoxical emboli can gain access to systemic circulation through a septal defect. C.  About 50 percent of infarcts result from thrombotic or  embolic occlusion of an artery or vein. D. Endotoxins are gram-negative bacterial cell wall lipopolysacharides. E. Waterhous Fridrichsen syndrome results in acute adrenal insufficiency. Ans. A.  False: Lines of Zahn are seen in a thrombus. B. True: This way they gain access from right to left heart. C. False: Most (99%) of infarcts are results of occlusion of a vessel. D. True: Various components like lipoteichoic acid, pepticoglycan, etc. contribute to a similar shock because of gram-positive bacteria. E. True: It is associated with meningococcal septic shock and results in bilateral hemorrhagic infarction of adrenals. Q.4. Which of the following are true? A. Knudson first gave the 2 hit hypothesis of carcinogenesis. B. Bax, bad, bct-xS, bid are proapoptotic genes. C. Tumor grade is clinical marker of degree of malignancy. D. Renal cell carcinoma spreads most commonly through lymphatics.

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MCQs in Objective Pathology with Explanations

Ans. A. True: Initiator and promoter genes hypothesis was first given by Knudson. B. True C. False: It is a histological marker. Clinically, tumors are categorized in stages. D.  As kidney is richly supplied by blood, hematogenous spread is more common. Q.5. Which of the following are true? A. Caplan syndrome involves pneumoconiosis. B. Carbon tetrachloride (CCL4) poisoning is seen more commonly in dry-cleaners. C. Oral contraceptive use increases the risk of breast and cervical cancers. D. Lead poisoning can lead to microcytic anemia. E. Cocaine overuse can cause perforation of nasal septum. Ans. A. True: Silicosis induced pneumoconiosis with rheumatoid arthritis is called Caplan’s syndrome. B. True. C. True: Both have estrogen receptors. D. True: Lead interferes with heme synthesis by inhibiting α-aminolevulinic acid dehydratase and ferrochelase. Microcytic anemia and basophilic stippling result. E. True: It is a well known complication in chronic cocaine abuse.

Chapter 4  Disorders of Gro wth and Dif f  fer  e rentiation

PRETEST 1. Which of the following are true? A. In metaplasia, there is reversible change in one mature cell type to another mature cell type. B. Dysplasia is characterized by loss of epithelial polarity and abnormal mitotic figures. C.  An abnormal nest of adrenals under renal capsule will be classified as neoplasia. D.  A jumbled up mass of cartilage, respiratory epithelium and other tissue types indigeneous to lung lying in lung as a developmental anomaly will be called choristoma. E. Metaplastic changes can occur in appendix in appendicitis and upper esophagus in esophagitis. 2. Which of the following developmentally abnormal conditions lead to decrease in physical growth? A. Down syndrome B. Turner’s syndrome C. Maternal alcohol and tobacco use D. Maternal diabetes mellitus 3. Which of the following is true about hyperplasia and hypertrophy? A. Smooth muscle hypertrophy is seen in pregnancy, urinary obstruction and intestinal stenosis or obstruction. B. In gynecomastia there is seen in pregnancy, urinary obstruction and intestinal stenosis or obstruction. C. Graves disease causes thyroid hyperplasia. D. Sheehan’s syndrome can cause thyroid atrophy.

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MCQs in Objective Pathology with Explanations

E. Psoriasis is a hyperplastic skin disease characterized by rapid turnover of epidermis. 4. Which of the following precancerous diseases are correctly matched with their neoplastic disorders? A. Down syndrome—Kaposi’s sarcoma. B.  Actinic keratosis and xeroderma pigmentosum—Squamous cells carcinoma of skin. C. Cirrhosis (alcoholic, hepatitis B, C)—Hepatocellular carcinoma. D. Immunodeficiency states—Malignant lymphomas. E. Ulcerative colitis—Colonic adenocarcinoma. 5. Which of the following oncogenes are correctly matched with their caused neoplasm? A. erb-B2—Breast ovarian and gastric carcinoma. B. bcl-2—Follicular and undifferentiated lymphomas. C. N-myc—Burkitt’s lymphoma. D. Loss or deletion of BRCA-2 gene on chromosome 13 q—Breast cancer. 6. Which of the following are true? A. PSA and prostatic acid phosphatase are tumor markers for prostatic carcinoma. B. CEA is a marker for colorectal cancers only. C. HTLV-I is associated with adult T-cell leukemia. D. EBV is associated with Burkitt’s lymphoma and nasopharyngeal carcinoma. 7. Which of the following are true? A. 70 percent of tumors are above tentorium in adults and 70 percent are below tentorium in childhood. B.  All multiple endocrine neoplasias are autosomal recessive. C. t(9;22) or philadelphia chromosome is associated with CML. D. In males prostatic cancers are leading in worldwide incidence and lung cancer is highest mortality rate. E. In females breast cancers are the leaders in worldwide incidence and lung cancer in highest mortality rate.

Disorders of Growth and Differentiation

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ANSWERS 1. A. B. C. D. E.

2. A. B. C. D. 3. A. B. C. D. E. 4. A. B. C. D. E. 5. A. B. C. D. 6. A. B. C. D. 7. A. B. C. D. E.

True True False: This will be called a choristoma. False: The typical description is of a hamartoma. False: The typical metaplastic changes are seen in bronchi of cigarette smokers and in prostate around areas of infarction. True: Decreased skeletal growth. True: Decrease skeletal growth. True: These cause IUGR. False: Average birth weight is greater than normal. True False: Lobules do not exist in male breast. Gyncomastia is male breast hypertrophy. True True: There is panhypopituitarism and TSH is decreased or absent. True True True True True True True True True False True False: It is also produced by pancreatic cancers and also by breast and gastric cancers. True True True False: All men’s are autosomal dominant. True True True

Chapter 5  Disorders of Met abolism and Homeostasis

PRETEST 1. Which of the following are true about amyloidosis? A.  Amyloidosis of AA type is a complication of rheumatoid arthritis. B.  Amyloidosis may occur as a complication of myelomatosis. C. Rectal mucosal biopsy is positive in 80 percent cases of myelomatosis. D. Congored and Van Gieson staining methods are important in detecting amyloid. E. Hepatic failure is a common cause of death. 2. Which of the following are true? A. Dystrophic calcification occurs in individuals with abnormal calcium metabolism. B. Psammoma bodies are found in tumors such as papillary carcinoma of thyroid and meningiomas. C. Dystrophic calcification is associated with hyperparathyroidism. D. Phenylketonuria is due to deficiency of phenylalanine hydroxylase. E. Cystathione synthetase is deficient in homocystinuria. 3. Which of the following are true? A. Gout is characterized by hypouricemia. B. First metatarsophalangeal joint is commonly affected in gout. C. Cushings syndrome is characterized by hyponatremia

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D.  A deficient diet with excessive alcohol consumption causes vitamin B1  deficiency. E. Vitamin B deficiency may cause CCF. 4. Which of the following are true? A. Wilson’s disease is characterized by low serum copper. B. Distruction of superior mesenteric artery may cause gangrene. C.  Adrenocortical adenoma is a cause of secondary hyperaldosteronism. D. Burns involving 15 percent of skin’s surface will cause cardiogenic shock. 5. Which of the following are true? A. Hay fever causes generalized edema. B. Distruction of superior mesenteric artery may cause gangrene. C.  Adrenocortical adenoma is a cause of secondary hyperaldosteronism. D. Burns involving 15 percent of skin’s surface will cause cardiogenic shock. 6. Which of the following are true? A. Postmortem chot has lines of Zahn and is adherent to vessel wall. B. Pulmonary embolism causing strain on left heart usually produces infarction. C. Streptokinase and thrombin produce thrombolysis. D.  A prosthetic pulmonary valve may give rise to arterial thrombus. E. Fat embolism is fatal in 90 percent of cases and is associated with thrombocytosis. 7. Which of the following are true? A.  Amniotic fluid embolism is associated with prolonged labor but is a relatively mild condition. B. Shock may cause subendocardial MI. C. Corneal reflex and vestibule ocular reflexes are absent in brainstem death. D. Subarachnoid hemorrhage causes sudden death.

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MCQs in Objective Pathology with Explanations

ANSWERS 1. A. True B. True C. False: It is done for diagnosing amyloid. The biopsy should include submucosa and muscle for the maximum chance of detecting amyloid. D. True E. False: Renal failure is a common cause of death in amyloid. 2. A. False: Dystrophic calcium characterized by deposition of calcium is damaged tissue usually occurs in patients with normal calcium metabolism. B. True C. False: Metastasic calcification occurs in hyperparathyroidism. D. True E. True 3. A. False: It is associated with hyperuricemia. B. True C. False: Hypernatremia is caused by increased production of glucorticoids in cushings syndrome. D. True E. True: High out put failure can occur in wet Beri-Beri. 4. A. False: Copper accumulates in increasing amounts in Wilsons disease. B. True C. True D. False: Cerebral boundary zone infarction may follow hypotension. Superior longitudinal simus thrombosis may occur in debilitated children causing engorgement of veins and hemorrhage. 5. A. False: Hay fever is a cause of local edema. Active hyperemia of acute inflammation being responsible. B. True: Hemorrhage infarction of intestine may progress to gangrene. C. False: It will produce primary hyperaldosteronism D. False: Burns cause hypovolemic shock. 6. A. False: The characteristics described are those of antemortem thrombus.

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B. False: Pulmonary embolism is usually a postoperative complication causing strain on right side of heart but rarely causes pulmonary infarction because of dual pulmonary blood supply. C. True D. False: Such emboli will be filtered in lungs and will not enter arterial side. E. False: Fat embolism is fatal in about 10 percent of cases and is associated with thrombocytopenia. 7. A. False: Amniotic fluid embolism is associated with abrupt precipitous labor and is fatal in 80 to 85 percent of cases. B. True C. True: Bile ducts express class II HLA antigens and so many be destroyed in graft-versus-host disease. D. True

Chapter 6  Car dio v ascular Sy s tem Cardio  vascular

PRETEST AND CONCEPTS 1. Which of the following are true? A.  Atrial septal defect usually causes death before puberty if untreated. B.  ASD is commoner in females. C. Infective endocarditis is commoner in drug addicts on right side of heart. D. Hypocholesterolemia is a risk factor for atherosclerosis. E. There is increased risk of deep vein thrombosis in CCF. 2. Which of the following are true? A. Fibrinoid necrosis is a hallmark of malignant hypertension as a hyaline atherosclesoris in benign form. B.  Anistschkow cells are seen in aschoff bodies. C. Buerger’s disease is a disease of medium sized vessels, e.g. tibial and radial. D. Buerger’s disease does not affect surrounding structures. 3. Which of the following are true? A.  Atherosclerotic aortic aneurysms are commoner in aortic arch. B.  Atherosclerotic aortic aneurysms never contain mural thrombi. C. Hypothyroidism and Addison’s disease may lead to hypertension. D. There is fibrinoid necrosis of all vessel wall layer in polyarteritis nodosa. E. Fatty streaks in aorta contain predominantly intracellular  lipid.

Cardiovascular System

53

4. Which of the following are true? A. PDA usually occurs singly. B.  Arterial spasm may acutely exacerbate ischemic heart disease. C. Total coagulative necrosis with loss of nuclei is apparent in MI after 72 hours. D. Libman-Sacks endocarditis is associated with SLE. E. Familial hypercholesterolemia is associated with raised triglycerides levels. 5. Which of the following are true? A. Dissecting aortic aneurysm occurs in Marfans syndrome, the cause of cystic medial necrosis. B. Cranial (gaint-cell) arteritis affect only head and neck vessels. C. Pericarditis is a complication of MI. D. Mitral incompetence is associated with ankylosing spondylitis. E. Trypanosoma cruzi   may cause myocarditis. 6. Which of the following are true? A.  Arteriosclerosis causes systemic hypertension. B. Lesions similar to those seen in heart in rheumatic fever  can be seen in walls of larger vessels. C. Buerger’s disease involves thrombotic occlusion of both arteries and veins of limbs. D. Chronic pyelonephritis may result in systemic hypertension. E. Large crumbling vegetation in mitral valve are least likely to occur in a child during rheumatic fever. 7. Which of the following are true? A. Coarctation of aorta is an example of early cyanosis. B. Right coronary artery predominantly supplies blood to posterior portion of IV septum. C. “Cor Livium” is used to describe syphilitic carditis. D. Morphologic examination of heart, diseased by pericarditis may reveal hemochromatosis. E. Renin angiotensin system prostaglandins and kallikrein kinin system contribute to kidney’s regulation of systemic blood pressure.

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MCQs in Objective Pathology with Explanations

ANSWERS 1. A. B. C. D. E. 2. A. B. C. D.

3.

4.

5.

6.

False: Survival to middle age is usual. True True False: Hypercholesterolemia is a risk factor. True True True: These are also called caterpillar cells. True False: Extension of inflammation from arteries into surrounding veins and nerves leads to their fibrous encasement. A. False: Atherosclerotic aneurysms are commonest in abdominal aorta. Syphilitic aneurysms more commonest in abdominal aorta. Syphilitic aneurysms more commonly affect aortic arch. B. False: Mural thrombus is commonly present and may fill the saccular aneurysms. C. False: These usually cause hypotension. D. True E. True: Lipid is predominantly within the cytoplasm of  foamy macrophages. A. False. It is usually seen in association with other anomalies such as TGA where shunt may improve hemodynamic situation. B. True: Prinzmetal angina. C. True D. True E. False: Tg level is usually normal. A. True B. False: Any artery in the body may be affected. C. True D. False: Aortic incompetence has association with ankylosing spondylitis. E. True: Seen in South America. A. False: It is the result of hypertension. B. True C. True D. True E. True

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55

7. A. False: This is predominantly late cyanosis or acyanotic heart disease. B. True C. True D. False: Hemochromatosis may cause dilated or restrictive cardiomyopathy but not pericarditis. E. True

Chapter 7  Blood and Bone Marro w 

PRETEST 1. Which of the following are true? A. RBC antibodies and enzyme deficiencies always cause hemolytic anemia. B. Sickle cell anemia causes protection against malaria. C.  Autoantibodies causing lysis of blood cells are found in SLE and CLL. D. Deficiency of spectrin cause spherocytosis. E. Factor XII is the fibrin stabilizing factor. 2. Which of the following are true? A. Plasmin derived from plasminogen degrades both fibrinogen and fibrin. B. Hemophilia A and von Willebrand’s diseases are characterized by deficiency of factor VIII. C.  A short history of symptoms and signs of anemia, infection and thrombocytopenia indicate AML. D. Both the thalassemia major and minor are compatible with normal life span. E. Vitamin K dependent coagulation factors are factor II, VII, IX, XI. 3. Which of the following are true? A.  All slow developing anemia’s are asymptomatic. B. Myelophthisis is a reduction in productive capacity of  bone marrow. C. Polycythemia vera is characterized by high erythropoietin levels.

Blood and Bone Marrow  57

D. Certain antibiotics and benzene compounds, which share chemical configurations have been associated with leukemia development. E. Thrombocytopenia and acute leukemias, both can present with petechiae. 4. Which of the following are true? A. Characteristic changes seen in some viral infections is formation of numerous immunoblasts involved in lymph nodes. B. Hemolytic anemia is associated with unconjugated hyperbilirubinemia. C.  Acute hemorrhage is characterized by reticulocytosis and chronic small blood loss by iron deficiency. D. Resection of ascending colon will cause vit B12 deficiency. 5. Which of the following are true? A. The lack of B- or T-cell membranes in AML indicates poor  response to treatment. B. Sodium fluoride sensitive non-specific esterase distinguishes monoblasts from myeloblasts. C. Precursors in M2 AML cannot be distinguished histochemically. D.  Acute leukemias cause massive splenomegaly. E. Secondary carcinoma is the commonest cause of lymph node enlargement. 6. Which of the following are true about plasma cell tumors? A. Heavy chain disease is a rare condition involving neoplastic proliferation of lymphoid cells in small intestine mucosa. B. Bence Jones protein consists of light chains of immunoglobulins. C. 75 percent of myelomas produce only light chains. D. Blood viscosity is increased in Waldenstrom’s macroglobulinemia. E. Solitary plasmacytoma typically produces a solitary tumor in a long bone. 7. Which of the following are true? A. In celiac disease, splenic atrophy occurs. B. Letterer-Siwe disease is a form of histiocytosis.

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MCQs in Objective Pathology with Explanations

C. In lymphocyte predominant Hodgkin’s disease, R-S cells are plenty. D. Thymic or mediastinal lymphoblastic symptoms of T-cell type commonly occurs in children. E. Patients being treated for Hodgkin’s may have fungal infections.

ANSWERS 1. A. False: RBC antibodies or enzyme deficiencies may be harmless and not cause hemolysis. B. True C. True D. True: There is genetically determined abnormality in a membrane polypeptide called spectrin. E. False: Coagulation factor XIII is the fibrin stabilizing factor. 2. A. True B. True C. False: The characteristic picture is seen in AML. D. False: Thalassemia major patients die in young adulthood or before. E. True 3. A. True B. True C. False: Erythropoietic levels are high in secondary polycythemia. D. True E. True 4. A. True B. False: Hyperbilirubinemia is conjugated C. True D. False: Red cell fragmentation occurs in microangiopathic hemolysis. 5. A. False: It indicates good response. B. True C. False D. False E. True 6. A. True B. True

Blood and Bone Marrow  59

C. False: Only 15 percent of myelomas produce only light chains. D. True: Neoplastic cells produce IgM. E. True 7. A. True B. True: Macrophages proliferate in this disease. C. False: RS. cells are scant in this form and the main cell type is lymphocyte. D. True E.  True: The chemotheraphy may cause immune suppression with opportunistic fungal infections.

BLOOD AND BONE MARROW CONCEPTS Q.1. Which of the following are true? A. Iron deficiency anemia is seen most commonly in younger age group population in developed countries. B.  Anemia of chronic disease is characterized by increased TIBC and decreased serum iron. C.  All cases of sideroblastic anemia are forms of myelodysplastic syndrome. D.  Anemia of blood loss is always accompanied and lasts till hypovolemia. E. Mitosis of RBC precursors is delayed in megaloblastic anemia. Ans. A. False: Although Iron deficiency is common in underdeveloped world in children, the worldwide incidence is higher in older population. B. False: Anemia of chronic disease is characterized by decreased serum iron, decreased TIBC, decreased percentage saturation, and increased serum ferritin. Second type of microcytic anemia-iron deficiency anemia, has increased TIBC and similar other lab findings. C. False: Sideroblastic anemia cases have ring sideroblasts in bone marrow and only some cases are a form of myelodysplastic. D. False: Anemia of blood loss (acute) develops if patient survives acute blood loss and undergoes hemodilution. In chronic cases, iron deficiency anemia can result.

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MCQs in Objective Pathology with Explanations

E. True: There is impaired DNA synthesis and impaired mitosis. Q.2. Which of the following are true? A. Lymph nodes are tender in acute and chronic nonspecific lymphadenopathies. B.  Acute leukemias are characterized by more than 20 percent blasts in bone marrow. C. In non-Hodgkin’s lymphomas, most of the malignant show T-cell phenotype. D. Burkitt’s lymphoma is common in Africa and America. E. Waldenstrom macroglobinemia is characterized by lytic bone lesions. Ans. A. False: They are tender in acute but not in chronic nonspecific lymphadenitis. B. True. C. False: B-cell non-Hodgkin’s lymphomas are most common. In fact follicular lymphoma is the most commom NHL. They tend to present with diffuse disease and have a better prognosis than other diffuse lymphoma. D. True: Small non-cleaved lymphoma (Burkitt’s lymphoma) occurs in African type with jaw involvement. Microscopic appearance is typically starry-sky with 8;14 translocation. E. False: Waldenstrom’s is also called lymphoplasmacytic lymphoma and is a cross between multiple myeloma and small lymphocytic lymphoma ………… No lytic bone lesions are seen.

Chapter 8  R espir e spirator y Sy s tem

PRETEST AND CONCEPTS 1. Which of the following are true? A. Cystic fibrosis and pulmonary edema predispose the patient to respiratory infections. B. Carcinoma of larynx is usally of squamous cell type and is complicate by lung infections. C. Malignant mesothelioma of pleura usually contain asbestos bodies. D. Lobar pneumonia is caused by organisms of high virulence. E. Pneumocystis carinii   pneumonia is associated with other respiratory infections. 2. Which of the following are true? A. Clara cells and pneumocytes are present in terminal bronchioles. B.  Adult respiratory distress syndrome causes proliferation of type I pneumocytes. C. PFFR FEVI/VC and FEVI are reduced in asthma. D. Bronchiectasis is associated with cystic fibrosis and Kartageners syndrome. E. Exposure to uranium and radon cause positive association with carcinoma of lung. 3. Which of the following are true? A. Carcinoid tumors are dumb bell shaped tumors nodules protruding through bronchial walls. B. Centibular emphysema is commonly present in lower  lobes of lungs.

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MCQs in Objective Pathology with Explanations

C. Sarcoidosis consists of noncaseating granulomas away from site of inflammations. D. Small cell carcinomas are associated with cigarette smoking. E. Silicosis is caused by particles less that 5 mm in diameters. 4. Which of the following are true? A. Chronic bronchitis can be associated with coagulase positive staphylococci. B. Right to left shunts produce pulmonary hypertension. C. Progressive pulmonary tuberculosis can occur in the form of cavitary fibrocaseous tuberculosis, military tuberculosis and tubercular bronchopneumonia. D. Hamman Rich syndrome is synonymous with acute interstitial pneumonitis. E. Lipoid pneumonia is always associated with intrinsic cause of pulmonary lipidosis. 5. Which of the following are true? A. Silicosis may result from exposure to gold in gold mines and also occurs in stonemasons and pottery workers. B. Respiratory epithelium is normal in chronic bronchitis. C.  Adenocarcinomas of lung contain intracytoplasmic mucin. D. Tuberculin test tests humoral immunity. E. Hyaline membrane disease and ARDS are characterized by formation of hyaline membrane in alveoli because of  entirely different etiologies. 6. Which of the following are true? A. Status asthmaticus is characterized by continuous attack of asthma, with severe respiratory distress. B. Left to right shunts are associated with a sustained rise in pulmonary artery pressure. C.  Aspiration pneumonia is characterized by suppurative bronchopneumonia with foreign body gaint cell. D. No allergen can be implicated in intrinsic asthma. E. Whooping cough in childhood can result in bronchiectasis later.

Respiratory System

63

ANSWERS 1. A. True B. True C. False: Asbestos bodies are usually found in underlying lung tissue. D. True: Streptococcus pneumoniae is the usally causative organism. E. True: CMV or aspergillosis is usually present too. 2. A. False: Clara cells, secreting a proteinaceous fluid are found in terminal bronchioles pneumocytes are present in alveoli. B. False. Type-II pneumocytes may proliferate. C. True D. True E. True 3. A. True: These are neuroendocrine tumorlets seen in lungs. B. False: These are usually present in upper lobes in contrast to panlobular emphysema that occurs in lower lobes. C. True: This feature differentiates it from other granulomatous inflammations. D. True E. True: Larger particles cannot reach alveoli. 4. A. B. C. D. E. 5. A. B. C. D. E.

True False: Hypotension can be caused by them. True True False: Lipoid pneumonia can be caused by extrinsic as well as intrinsic cases. True False: Chronic bronchitis causes hyperplasia of mucin secreting cells. True False: Tuberculin test is index of cell mediated immunity. True

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MCQs in Objective Pathology with Explanations

6. A. True B. False: Only lober pneumonia is characterized by sustained rise in pulmonary artery pressure. C. True D. True E. True: After an attack there can be pulmonary collapse and imperfect resolution of pneumonia causing bronchiectasis.

Chapter 9  Liv er Liver er,, Biliar y T ract and Exocrine Pancreas

PRETEST 1. Which of the following are true? A.  Acute viral hepatitis can cause fatty liver. B. Mallory bodies are found in infective hepatitis. C. Predominant HBsAg expression in serum and hepatocytes is found in a symptomatic HBV carrier. D. Before cirrhosis could occur, hepatocyte regeneration with fibrosis has to take place. E. Enlarged liver pressing on portal vein can cause portal hypertension. 2. Which of the following are true? A. In ulcerative colitis, sclerosing cholangitis can occur. B. Oral contraceptives have been associated with liver cell adenomas. C. Typhoid fever organisms can survive in gallbladder in a carrier state. D. Serum amylase is reduced in acute pancreatitis. E.  Alpha-1 antitrypsin is due to defect in copper metabolism. 3. Which of the following are true? A. Cholesterol gallstones are most frequent. B. Carcinoma pancreas is associated with smoking and diabetes mellitus. C. Splenic atrophy occurs in portal hypertension. D. Jaundice is seen usually when serum bilirubin concentration exceeds 40 micro mole per liter. E.  Acute pancreatitis may cause hypocalcemia.

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MCQs in Objective Pathology with Explanations

ANSWERS 1. A. False: Fatty liver is caused by protein, energy, malnutrition, alcoholism and obesity. B. False: Mallory bodies are found in alcoholic hepatitis and sometimes in Indian childhood cirrhosis. C. True D. True E. False: Portal hypertension is caused by interference with hepatic microcirculation. 2. A. True: Patient may develop cholangiocarcinoma. B. True C. True D. False: It is raised E. False: Wilsons disease is one in which serum ceruloplasmin levels are decreased. 3. A. False: Mixed stones are most frequent. B. True C. False: There is splenomegaly due to congestion. D. True E. True

Chapter 10  Aliment ar y T ract Alimentar

PRETEST 1 Which of the following are true? A.  Adenolymphoma is a highly malignant tumor of parotids. B. Heavy alcohol intake is a risk factor for esophageal carcinoma. C.  Atrophic gastritis is characterized by loss of specialized gastric mucosal cells especially parietal cells. D. Prognosis of squamous cells carcinoma of oral cavity depends on its site. E. Chronic gastritis starts as chronic superficial gastritis. 2. Which of the following are true? A. Linitis plastica is a condition in which deep layers of  stomach wall are thickened. B.  Achlorhydria is a risk factor for peptic ulcer. C. Crohn’s disease gives a cobblestone appearance to colon. D. Ulcerative colitis causes colonic mucosal pseudopolyps. E. Pseudomembranous colitis is caused by Vibrio cholerae. 3. Which of the following are true? A. Primary malabsorption syndromes are celiac disease, tropical sprue and Whipple’s disease. B.  Abetalipoproteinemia is primary malabsorption syndrome. C. Long-standing ulcerative colitis is a risk factor for colonic carcinoma. D. Tubular adenomas are usually small rounded nodules on a stalk. E. Crohn’s disease is associated with increased risk of  small bowel cancer.

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ANSWERS 1 A. False: Adenolymphoma is entirely benign, occurs in middle aged men. B. True C. True D. True: Prognosis worsens as the site of cancer becomes further back in oropharynx E. True 2. A. True B. False: Risk factors for gastric cancer include blood group “O”, cigarette smoking, high gastrin secretion (e.g. in Zollinger-Ellison syndrome). C. True D. True E. False: The condition is caused by Clostridium difficile. 3 A. True B. False: It is a biochemical defect using interference of  absorption. C. True D. True E. True: Quite rare though.

GIT AND LIVER/BILIARY TRACT/PANCREAS CONCEPTS Gastrointestinal Tract Pathology Q.1. Which of the following are true? A. Schatzki rings are seen in Plummer-Vinson syndrome. B. Bird-beak sign can be seen in barium swallow in Chagas’ disease. C. Mallory-Weiss tears and esophageal varices have similar presentations. D. Barrett’s esophagus is associated with increased risk of squamous cell carcinoma. E. Pyloric stenosis can present with projectile vomiting. Ans. A. False: Schatzki rings are weblike narrowing at gastroesophageal junction. Plummer-Vinson syndrome is a separate entity occurring in middle aged women; accompanying iron deficiency anemia and increased

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B. C.

D.

E.

risk of carcinoma, these are esophageal webs which can occur anywhere in the esophagus. True: Chagas’ disease is associated with achalasia of  esophagus in which this sign is seen. False: Although both are associated with alcohol abuse, Mallory-Weiss tears typically occur acutely as a result of retching/vomiting. Varices result from portal hypertension and usually present with more significant bleeding. False: Barrett’s esophagus is columnar metaplasia of  lower esophagus because of gastroesophageal reflux. It is associated with adenocarcinoma of esophagus. True: Pyloric stenosis is congenital hypertrophy of  pylorus and presents with projectile vomiting and abdominal “Olive”.

Q.2. Which of the following are true? A. Enlarged gastric rugae are seen in both Menetrier  disease and Zollinger-Ellison syndrome. B. Gastric stress ulcers occur with higher incidence in ICU patients. C. Fundic type chronic gastritis (type A) is associated with H. pylori   infection. D. Cirrhosis and COPD are associated with duodenal type of peptic ulcer. E. Malignant ulcer of the gastrum is more common in people with blood group O. Ans. A. True: Both are examples of hypertrophic gastropathy. B. True. These are multiple, small, round, superficial ulcers of stomach and duodenum. C. False: Fundic type of chronic gastritis is associated with auto-antibodies to parietal cells or/and intrinsic factor.  Antral type (Type 2) is associated with H. pylori  infection. D. True: Other associations are MEN type I and 2 syndromes. E. False: People with blood broup A have higher incidence of gastric carcinoma. Those with blood group O have higher incidence of duodenal peptic ulcer. Q.3. Which of the following are true? A. Pseudomembranous colitis is easily treatable. B. Low fiber diet leads to increased intraluminal pressure in intestines.

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C. Turcot syndrome involves familial adenomatosus polypi, CNS tumors (gliomas). D. Right sided colonic cancer is associated with iron deficiency anemia and left sided with reduced caliber stools. E. Excretion of 5-HIAA is increased in urine in intestinal carcinoid. Ans. A. False: Although vancomycin and/with metronidazole can be given, surgery is usually required. B. True: This in turn causes increased incidence of  diverticulosis. C. True. D. True: Right sided colonic cancer is associated with bleeding and occult blood in stools and left sided with change in bowel habits (constipation or diarrhea, obstruction, etc.) E. True: It is a metabolite of serotonin. Q.4. Which of the following are true? A. Both volvulus and intussusception are associated with infarction of involved intestinal segment. B. Hirschsprung’s disease can present with vomiting. C. Whipple’s disease is of infectious etiology. D. Incidence of extraintestinal manifestations is more in ulcerative colitis than Chrohn’s disease. E. Ischemic colitis can present with bloody diarrhea. Ans. A. True. B. True: Constipation and abdominal distension are more common though. C. Organism is Trophermya whippelii . D. True: These include arthritis, spondylitis, primary sclerosing cholangitis, erythema nodosum, pyoderma gangrenosum, etc. E. True.

Pancreatic Pathology Q.1. Which of the following are true? A. Scorpion stings can cause acute hemorrhagic pancreatitis. B. Type I D M patients are absolutely dependent on insulin to prevent ketoacidosis and coma.

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C. Kimmelstiel-Wilson disease occurs in diabetic nephropathy. D. Both C-peptide and insulin are increased in insulinoma. E. 60 percent of pancreatic carcinomas occur in smokers and in pancreatic head. Ans. A. True B. True C. True: It is also called Nodular glomerulosclerosis. It is characterized by nephritic syndrome, nodular (PAS positive) deposits in mesangial matrix and thickened basement membranes. D. True E. True

Gallbladder and Biliary Tract Q.1. Which of the following are true? A. Clonorchis (Opisthorchis) sinensis or ascaris infections can lead to increased incidence of gall-stones. B.  Ascending cholangitis can cause conjugated hyperbilirubinemia. C.  An enlarged palpable gallbladder is more likely to be caused by obstruction due to malignancy than by stones. D. Calcification of gallbladder due to chronic inflammation has high association with carcinoma. E. Klatskin tumor is carcinoma of bifurcation or right and left hepatic bile ducts. Ans. A. True: Chronic infections can cause calcium and uncon jugated bilirubin deposition. B. True: It is caused usually by gram-negative bacterial infection extended up to liver. C. True: Courvoisier law. D. True: It is called porcelain gallbladder. E. True: Bile duct cancer at this site is associated with poor  prognosis.

Liver Pathology Q.1. Which of the following are true? A. Clinical jaundice occurs with bilirubin levels >2-3 mg/ml.

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B. Hemolytic disease of newborn presents at or just after  birth. C. In macronodular cirrhosis, nodules are greater than 3 cm. D. HBe antigen is an antigenic determinant of HBV core and is an important indicator of transmissibility. E.  Alcoholic cirrhosis develops in 50 percent of alcoholics. Ans. A. True. B. True: Hemolysis starts in utero. C. False: The size is 3 mm or more, not cm. D. True: Anti-HBeAb is an indicator of low infectivity and appears several days later than acute infection onset. E. False: It occurs in upto 15 percent of alcoholics. Q.2. Which of the following is true? A. In Wilson’s disease, there is decreased biliary excretion of copper. B. Hemachromatosis can lead to micronodular cirrhosis and 200 times increased risk of hepatocellular carcinoma. C. Emphysema of lungs is usually seen with liver cirrhosis in alpha-T antitrypsin deficiency. D. Reye syndrome is associated with steatosis. E. Nutmeg liver is seen in acute venous obstruction of  hepatic vein by a thrombus. Ans. A. True B. True C. True D. True E. False: Nutmeg liver is usually associated with chronic passive congestion of liver. Acute hepatic vein thrombosis is Budd-Chiari syndrome. There is hepatomegaly and ascites with abdominal pain and usually death.

Chapter 11  Male and FFemale emale Genit al T ract Genital and Endocrine Sy s tem

PRETEST 1. Which of the following are true? A. Pregnancy at an earlier age is associated with increased risk of ovarian carcinoma. B. Ovarian cancer spreads to contralateral ovary peritoneal cavity and para-aortic lymph nodes. C. Endometrial hyperplasia is associated with decreased estrogen stimulation. D. Cervical carcinoma is usually squamous cell type. E. Carcinoma in situ (CIS) cervix is increasing in detected incidence. 2. Which of the following are true? A. Estrogen stimulation is increased in endometrial carcinoma. B. Ruptured ovarian cyst can give rise to granulomatous inflammation. C. Carcinoma can arise in ovarian endometriosis. D. Complete hydatidiform mole is usually triploid on chromosome analysis. E. Hydatidiform mole can cause hyperthyroidism. 3. Which of the following are true? A. Multiple peptic ulcers may be seen in islet cell tumor  of pancreas. B. Parathyroid adenoma may cause nephrocalcinosis.

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C.  Adrenocorticoid tumor may cause feminization. D. Hashimoto’s thyroiditis is associated with hypothyroidism. E. Iodine deficiency is the commonest cause of nontoxic goiter  4. Which of the following are true? A. Dyshormogenesis results from genetically programmed lack of an essential hormone. B. Cushings syndrome is characterized by decreased  ACTH secretion. C. Craniopharyngioma and rathke’s cyst are benign lesions. D. Medullary carcinoma thyroid may be associated with multiple endocrine adenomas in other organs. E. Follicular carcinoma of thyroid is least likely to spread by blood. 5. Which of the following are true? A. Type I diabetes mellitus is the juvenile onset type. B.  Addison’s disease is characterized by low ACTH levels. C. Pheochromocytomas are derived from adrenal cortical cells. D. Graves thyroiditis is caused by excess of TSH. 6. Which of the following are true? A. Kimmelstiel Wilson lesions in kids are seen in diabetes mellitus. B. DM can cause pre-eclamptic toxanemia of pregnancy. C. Insulin is produced by alpha cells of islets of Langerhans. D. Di George syndrome is an acquire disease.

ANSWERS 1. A. False: Pregnancy at an earlier age is associated with decreased risk. B. True C. False: The estrogenic stimulation is increased. D. True E. True

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2. A. True B. True: Released keratin leads to granulomatous inflammation. C. True: Commonest form in adenocarcinoma. D. False: Complete mole is always diploid partial one can be triploid. E. True: A thyroid stimulator molecule is part of HCG secreted by mole. 3. A. True: Excess gastrin secretion is the cause. B. True C. False: Virilization is caused by excess of androgens. D. True E. True 4. A. True: Enzyme deficient can be a dehalogenase. B. False: Excess ACTH results in cushing and may cause hyaline change in anterior pituitary. C. True: These occurs in suprasellar lesion and may result in anterior pituitary damage by pressure necrosis. D. True E. False: Medullary carcinoma is the one least likely to have hematogenous metastasis. 5. A. True B. False: ACTH levels are raised in an attempt to get adrenals to produce more steroid hormones. C. False: Adrenal medulla cells are involved. D. False: Graves disease is caused by autoantibodies mimicking TSH. 6. A. True: It is synonyms of nodular glomerulosclerosis. B. True C. False: Insulin is produced by beta cells and alpha cells produce glucagons. D. False: In Di George syndrome, there is congenital absence of parathyroid glands.

Chapter 12  Br eas Breas eastt

1. Which of the following are true? A. Most common site of breast cancer is upper quadrant (50%). B. Breast cancer has a better prognosis, if it is of tubular  type and is positive for estrogen receptors. C.  Apocrine metaplasia is associated with increased incidence of breast cancer. D. Fibroadenomas are usually multiple. E. Mammary duct ectasia and intraductal papilloma may cause bloody nipple discharge. 2. Which of the following are true? A. Gynecomastic occurs in III decade of life. B. Intralobar carcinoma has a comedo variant. C. Paget’s disease of nipple may effect skeletal system. D. Phyllodes tumor occurs in younger age group. 3. Which of the following are true? A. Paget’s disease is a feature of cystic mastopathy. B. Formation of new breast lobules and apocrine metaplasia occur in cystic mastopathy. C. Giant intracanalicular fibroadenoma may progress to sarcoma. D. Medullary carcinoma is characterized by a lymphocyte infiltrate.

ANSWERS 1. A. True B. True C. False: This (pink cell change) is not associated with any increased risk.

Breast 

77

D. False: They are mostly solitary. E. True: Careful examination is required to differentiate the two. 2. A. False: It occurs mostly in puberty and old-age. B. False: Comedo variant occurs in intraductal carcinoma C. False: Skeletal Paget’s disease is an entirely different entity. D. False: Median age is 45, can occur at any age. 3. A. False B. True C. True D. True: It is associated with better prognosis.

Chapter 13  Male Genital T ract

1. Which of the following are true? A. Metastases in prostate carcinoma are osteoblastic. B.  Alkaline phosphatase can be increased in late stage in serum. C. Seminoma consists of sheets of large pale cells and lymphocytes. D. Differentiated teratoma resembles ovarian cystic teratomas but is malignant in males. E. Sperm count less than 70 × 10/liter is associated with infertility. 2. Which of the following are true? A. XXY pattern is associated with infertility. B. Small testes with Leydig cell pseudohyperplasia and loss of tubules is associated with male infertility. C. Embryonal carcinoma represents an anaplastic variant of teratoma. D. Lymphomas are the most common malignant testicular  tumors in adult males. E. Idiopathic gangrene of scrotum (Fournier’s) is caused by group B streptococci. 3. Which of the following are true? A. Lymphogranuloma venerum is caused by Chlamydia trachomatis serotypes L1-L3. B. LGV causes condylomata acuminata. C. Yolk sac tumor of testes contain characteristic perivascular tumor cells. D. Yolk sac tumor of testes expresses alpha feto-protein.

Male Genital Tract  79

ANSWERS 1. A. True B. True: It is because of bone metastasis. In intitial stages only acid phosphatase is increased. C. True D. True E. False 2. A. True B. True C. True: It has got a bad prognosis. D. True E. False: Fecal organisms are the usual causative agents. 3. A. True B. False: Human papilloma virus causes condylomata acuminata. C. True D. True

CONCEPTS Genital Pathology, Breast Q.1. Which of the following are true? A. Pelvic inflammatory disease is usually hematogenously acquired. B. Cervical carcinoma is the most common malignant tumor of female genital tract. C. Leiomyomas are the most common tumors of female genital tract. D. The most common primary site for secondaries in ovaries is GIT. E. Partial mole is usually diploid. Ans. A. False: PID is an ascending infection usually, often due to gonorrhea and/or Chlamydia, from cervix to endometrium, fallopian tubes and pelvic cavity. It is an important cause of pelvic and even peritoneal inflammation, abscess formation and scarring. B. False: Cervical carcinoma is the third most common malignancy of FGT. Endometrial adenocarcinoma is the most common malignancy of FGT and usually presents with postmenopausal bleeding.

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C. True. D. False: Though stomach and colon are the common primary sites for secondaries in ovary, primaries in endometrium and breast spread to ovaries more commonly. E. False: Partial mole is usually triploid. Complete moles are diploid. Q.2. What are the pre-invasive lesions of breast cancer? Ans. Pre-invasive lesions that may progress to breast cancer  include ductal carcinoma in situ and lobular carcinoma in situ. Invasive cancer occurs in several histological variants. They are ductal carcinoma, tubular carcinoma, mucinous carcinoma, tubular carcinoma, medullary carcinoma and inflammatory carcinoma. Q.3. Which of the following are true? A. Squamous cell carcinoma of penis can occur because of not doing circumcision before adolescence. B. Spermatocele contains sperms in its fluid. C. Testicular tortion can cause painful hemorrhagic infarction. D. Seminoma occurs in older men. E. Prostate cancer is commoner than lung cancer in the men in PSA. Ans. A. False: Squamous cell carcinoma of penis has nothing to do with early or late circumcision. It is related to HPV infection and is uncommon. B. True: Spermatocele is a dilated efferent duct in epididymus containing sperms. C. True: Tortion of testis is twisting of spermatic cord. D. False: Seminoma is a radiotherapy and chemotherapy sensitive cancer of young men that causes bulky testicular mass. Spermatocytic seminoma can occur in older men. E. True: Prostate cancer is the most common cancer of  men in the USA. It occurs in the peripheral zone of  prostate (posterior part). Serum PSA are raised.

Chapter 14  Kidney and Urinar y T ract

PRETEST 1. Which of the following are true? A. Younger age-group males are more susceptible to urinary tract infection. B. Renal carcinoma generally spread to bones. C. Urinary calculi are more common in temperate than tropical climates. D. Diseases of glomerulus cause non-selective proteinuria, if glomerulus is damaged more severely. E. Transitional cell carcinoma has a positive association with bilharziasis. 2. Which of the following are true? A. Kidneys are shrunken in chronic glomerulonephritis. B.  Amyloidosis usually causes nephritic syndrome. C. Nephroblastoma (Wilm’s tumor) commonly metastasizes to lungs. D. Bilateral renal agenesis usually occurs as a lone entity. E.  Adult polycystic kidney disease causes renal failure in earlier life. 3. Which of the following are true? A. Wegener’s granulomatosis affects kidneys and lungs. B. Rapidly progressive glomerulonephritis is characterized by proliferation of parietal epithelium of Bowman’s capsule and forms crescents filling the capsular space. C. Diabetic kidney is characterized by crystals in collecting tubules.

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MCQs in Objective Pathology with Explanations

D. Irregular cortical scars may be seen in chronic pyelonephritis. E. Clear cell carcinoma is a childhood tumor. 4. Which of the following are true? A. Bilateral hydronephrosis is never caused by urethral obstruction. B. Pyonephrosis can be caused by a staghorn calculus in pelvis. C. Infective endocarditis can cause multiple small abscesses in kidney. D. Bony metastasis never occurs in clear cell.

ANSWERS 1. A. False: Incidence is more in females from puberty to middle age. B. True: Other tumors spreading to bone include breast, prostate, thyroid and lungs. C. False: Because of more concentration of urine, these are commoner in tropical countries. D. True: This is in contrast to selective proteinuria that is commoner in minimal change disease. E. False: Cigarette smoking is related to TCC whilst bilharziasis, if long standing, can cause the rare squamous cell carcinoma of bladder. 2. A. True B. True C. True D. False: Its associated with pulmonary hypoplasia and spinal cord defects. E. False: The renal affections become apparent in adult life. Childhood polycystic kidney disease is manifested in younger aged individuals. 3. A. True: It is a necrotizing vasculitis. B. True C. False: Crystals are found in metabolic diseases such as gout. Diabetic kidney is characterized by papillary necrosis. D. True

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E. False: Urethral obstruction causes bilateral hydronephrosis. 4. A. False: Urethral obstruction causes bilateral hydronephrosis. B. True C. True: Septic emboli may detach in infective endocarditis. D. False

RENAL PATHOLOGY CONCEPTS Q.1. Which of the following are true? A. Glomerular disease, when it causes nephritic syndrome, is associated with microalbuminuria only. B. Rapidly progressive GN is another name for crescent GN. C. IgA nephropathy is most common cause of gross hematuria in children, young adults and non-smokers. D. Membranous glomerulonephritis is most common cause of nephrosis in adults. E. Renal cell carcinoma may be associated with feminization or masculinization. Ans. A. False: Nephritic syndrome is characterized by proteinuria but amount is less than 3.5 gm/24 hrs. B. True: RPGN is characterized microscopically by hypercellular glomeruli with crescent formation in Bowman’s capsule. C.  True: IgA nephropathy is most common cause of GN worldwide. It tends to produce recurrent gross hematuria in children and young adults. D. True. E. True. Paraneoplastic syndrome like this may occur from ectopic hormone production. Other syndromes include Cushing’s (corticosteroid), polycythemia (erythropoietin) and hypertension (Renin).

Chapter 15  Skin, Sof t T issue i ssue and Sk ele elet e let al Sy s tem

PRETEST 1. Which of the following are true? A. Pemphigus is a viral infection. B. Diverticulitis is associated with dermatitis herpetiformis, C. Basal cell carcinoma is a highly metastasizing neoplasm. D. Bowen’s disease and squamouscellcarcinoma in situ are closely related. E. Increased basal layer melanocytes are seen in lentigo. 2. Which of the following are true? A. Nodular melanoma has a vertical growth phase only. B.  Acute hemolysis can occur in non-immune patients following quinine treatment in P. falciparum malaria. C. Lentigo maligna is a misnomer in that it is benign condition. D. Malignant tertian malarial fever is caused by P. falci parum. E. Tropical splenomegaly regresses with long-term antimalarial therapy. 3. Which of the following are true? A.  A lack of active vitamin D is seen in osteoporosis. B. Paget’s disease of bone causes raised serum alkaline phosphatase. C. Chondrosarcoma can recur locally and may kill the patient by involvement of a vital structure. D. Synovial sarcoma arises in joints. E. Rhabdomyosarcoma mostly arises in skeletal muscles of extremities.

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ANSWERS 1. A. False: The etiology is autoimmune. B. False: Dermatitis herpetiformis is associated with celiac disease. C. False: BCC is a locally aggressive tumor. D. True E. True 2. A. True: Malignant melanoma has both horizontal and vertical growth phases. B. True C. False: Lentigo maligna (Hutchinson’s melanotic freckle) is essentially a malignant melanoma-in-situ melanoma-in-situ.. D. True E. True 3. A. False: Lack of vitamin D in children causes Rickets and in adults, osteomalacia. B. True C. True D. False: Synovial sarcoma arises mostly in bone or soft tissue just adjacent to joint especially lower extremity. E. False

SKIN AND SKELETAL SYSTEM PATHOLOGY CONCEPTS Q.1. Whic Which h of the follow following ing are true? true? A. Osteophytes are also called Heberden’s nodes and Bouchard’s nodes. B. Morning stiffness in rheumatoid arthritis is worsened by activity. C. Some patients of psoriasis develop rheumatoid arthritis like condition. D. Pseudogout usually involves great toe. E. Bone remodeling occurs up till adolescence. Ans. A. True: Osteophytes or reactive bony spurs occur in osteoarthritis and are called Heberden’s nodes, if they involve DIP joints and Bouchard’s nodes, if they involve PIP  joints. B. False: Morning stiffness is allayed by activity. C. True: Psoriatic arthritis is a seronegative spondylarthropathy (HLA B-27 associated).

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MCQs in Objective Pathology with Explanations

D. False: Pseudogout (Chondrocalcinosis) is deposition of  calcium pyrophosphate crystals (positively birefringent, rhomboid shape) and commonly involves knees of older  adults. E. False: Bone remodeling occurs throughout life. Q.2. What abnormali abnormalities ties are associated with with Osteogenesis Osteogenesis imperfecta? Ans. OI has variable genetics and is characterized by little bones, blue sclera, deafness, teeth abnormalities and hypermobile  joints. Q.3. What is is the ‘brown ‘brown tumor tumor of bone’? bone’? Ans. Osteitis fibrosa cystica is a disease with generalized bone resorption with changes as in hyperparathyroidism. In the bones, there may be hemorrhage and reactive fibrosis leading to brown tumors. Q.4. What is is the most common tumor tumor of bones? bones? Ans. Metastases to bone are the commonest bone malignancies. malignancie s. Primary sites include prostate, heart, lung, thyroid and kidneys. Q.5. Whic Which h of the follow following ing are true? true? Ans. A. Type 2 (white) skeletal muscle uses aerobic aerobi c metabolism of fatty acids. B. Inflammatory myopathies usually have lymphocytic infiltrate on microscopy. C. Eaton-Lambert syndrome is a type of myasthenic syndromes. D. Guillain-Barre syndrome can sometimes lead to death of the patient. Ans. A. False: Type 1 (red) skeletal muscle is used in postural weight bearing and uses fat metabolism. Type Type 2 (white) skeletal muscle is used for purposeful movement and uses anaerobic glycolysis of glycogen. B. True: Inflammatory myopathies include polymyositis, dermatomyositis. C. True: Eaton-Lambert syndrome is a paraneoplastic syndrome of small cell carcinoma of lungs lu ngs with proximal muscle weakness. D. True: Death because of respiratory muscle paralysis may occur.

Chap Ch apte terr 16  Ne r vous Sy s te m

PRETEST AND CONCEPTS 1. Which of the follo following wing are are true? A.  A frontal lobe tumor will cause ca use interventricular interventricul ar septum to shift to left of midline. B.  Acute subdural hematoma rarely causes death. C. Chronic subdural hematoma may present weeks after a trivial injury injury.. D. Fracture of skull, particularly in temporal bone may tear  off meningeal vessels. E. Occipital poles are a common site of hypertensive intracerebral hemorrhage. 2. Which of the follo following wing are are true? A. Vertebral artery is a common site of berry aneurysm. B. Congenital or berry aneurysms are due to a defect in the medial coat at sites of bifurcation of the intracerebral arteries. C. Chronic suppurative otitis media may cause cerebral venous sinus thrombosis. D. CMV infection can’t be recognized histopathologically. 3. Which of the follo following wing are are true? A. Herpes simplex infection of CNS causes acute necrotizing encephalitis. B. Type 1 poliomyelitis virus affects motor cells of anterior  horns of spinal cord. C. Gasserian ganglion is a common site of infection by herpes simplex. D. Rabies is characterized by Negri bodies in Purkinje cells of cerebellum.