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Question 1
Correct
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A 50-year-old woman with painful joints had some blood tests done with her GP. The test showed she had anti-double stranded DNA antibodies.
Which one of these disorders is most likely to be associated with anti-double stranded DNA antibodies?Your Answer: Systemic lupus erythematosus (SLE)
Explanation:CREST syndrome is usually associated with anti-centromere antibodies.
Primary biliary cirrhosis is associated with anti-mitochondrial antibodies.
Sjogren’s syndrome is associated with anti-Ro and anti-La antibodies.
Polymyositis is associated with anti-Jo1 antibodies.
Anti-double stranded DNA antibodies are highly characteristic of systemic lupus erythematosus (SLE). They are a group of anti-nuclear antibodies (ANA) that target double stranded DNA and are implicated in the pathogenesis of lupus nephritis.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 2
Correct
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You are giving a presentation on the immune system as part of your peer-to-peer teaching sessions. Yu are currently discussing phagocytes. Macrophages are derived from which of the following cells:
Your Answer: Monocytes
Explanation:Monocytes spend only a short time in the marrow and, after circulating for 20-40 hours, leave the blood to enter the tissues where they become macrophages. Macrophages form the reticuloendothelial system in the liver, spleen and lymph nodes. The lifespan of macrophages may be as long as several months or even years. In tissues the macrophages become self-replicating without replenishment from the blood. They assume specific functions in different tissues e.g. dendritic cells which are involved in antigen presentation to T-cells. Macrophages may be activated by cytokines such as IFN-gamma, contact with complement or direct contact with the target cell through leucocyte adhesion molecules.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 3
Incorrect
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A 79-year-old male had a humeral shaft fracture during a road traffic accident and is being followed up in a fracture clinic. He complains of inability to use the limb 6 months after the injury. X-rays of that arm shows non union of his fracture.
All the following are responsible for this non-union EXCEPT?Your Answer: Tissue interposed between fracture ends
Correct Answer: Osteoporosis
Explanation:An imbalance between bone resorption and formation is Osteoporosis. In normal bone, formation and resorption are roughly equal, and the density of bone matrix remains constant but there is more resorption in osteoporosis and the matrix density reduces and bones become weaker. Fractures are more likely to occur but healing is unaffected.
Non-union of a fracture occurs when the two sides of a fracture fail to unite after 6 months. Causes include: infection, movement at the fracture site, avascular necrosis, tissue interposed between the fracture and gross misalignment.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 4
Incorrect
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A 57-year-old woman has presented with cough and shortness of breath. Her GP had done some blood tests recently and told her that she had a positive ANA result.
Which of these statements is true about anti-nuclear antibodies (ANAs)? Select only ONE answer.
Your Answer: ELISA testing is the most accurate means of testing for ANAs.
Correct Answer: The presence of ANAs in rheumatoid arthritis is suggestive of Felty’s syndrome
Explanation:Anti-nuclear antibodies are auto-antibodies directed against a variety of nuclear antigens. There are different staining patterns and each pattern is suggestive of a different disorder.
Speckled staining is suggestive of mixed connective tissue disease.
Nucleolar staining is suggestive of scleroderma, while homogenous staining is suggestive of lupus.
Anti-double stranded DNA is suggestive of SLE while anti-histone antibodies are suggestive of drug-induced lupus.
ELISA testing is cheaper but not the most accurate means of testing for ANAs. Indirect immunofluorescence testing is the most accurate.
The presence of ANAs in rheumatoid arthritis is suggestive of Felty’s syndrome. Felty’s syndrome is characterized by a combination of rheumatoid arthritis, splenomegaly and neutropenia.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 5
Incorrect
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Regarding the factor V Leiden gene mutation, which of the following best describes the clinical effect:
Your Answer: It results in increased levels of activated protein C.
Correct Answer: It results in increased levels of activated factor V.
Explanation:Factor V Leiden gene mutation is the most common inherited cause of an increased risk of venous thrombosis. Activated protein C normally breaks down activated factor V and so should slow the clotting reaction and prolong the APTT, but a mutation in the factor V gene makes factor V less susceptible to cleavage by activated protein C, resulting in increased levels of activated factor V.Heterozygotes for factor V Leiden are at an approximately five- to eight- fold increased risk of venous thrombosis compared to the general population (but only 10% of carriers will develop thrombosis in their lifetime). Homozygotes have a 30 – 140-fold increased risk. The incidence of factor V Leiden in patients with venous thrombosis is approximately 20 – 40%. It does not increase the risk of arterial thrombosis.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 6
Incorrect
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Regarding non-Hodgkin lymphoma (NHL), which of the following statements is CORRECT:
Your Answer: Alcohol-induced nodal pain is classical for NHL.
Correct Answer: There is a much greater predilection to disseminate to extranodal sites than in Hodgkin lymphoma.
Explanation:Non-Hodgkin’s lymphoma (NHL) refers to a group of lymphoproliferative malignancies (about 85% of B-cell and 15% of T or NK (natural killer) cell origin) with different behavioural patterns and treatment responses. This group of malignancies encompasses all types of lymphoma without Reed-Sternberg cells being present. The Reed-Sternberg cell is classically seen in Hodgkin’s lymphoma.
NHL is five times as common as Hodgkin’s lymphoma. The peak incidence of NHL is in the 50-70 years age group, it affects men and women equally, but affects the Caucasian population more commonly than black and Asian ethnic groups.
The following are recognised risk factors for NHL:
Chromosomal translocations and molecular rearrangements
Epstein-Barr virus infection
Human T-cell leukaemia virus type-1 (HTLV-1)
Hepatitis C
Congenital and acquired immunodeficiency states
Autoimmune disorders, e.g. Sjogren’s syndrome and Hashimoto’s thyroiditis
The most common clinical features at presentation are:
Lymphadenopathy (typically asymmetrical and painless)
Weight loss
Fatigue
Night sweats
Hepatosplenomegaly
For clinical purposes, NHL is divided into three groups: indolent, high-grade, and lymphoblastic.
Indolent (low-grade) NHL:
The cells are relatively mature
Disease follows an indolent course without treatment
Often acceptable to follow a ‘watch and wait’ strategy
Local radiotherapy often effective
Relatively good prognosis with median survival of 10 years
High-grade NHL:
Cells are immature
Disease progresses rapidly without treatment
Significant number of patients can be cured with intensive combination chemotherapy regimens
Approximately 40% cure rate
Lymphoblastic NHL:
Cells are very immature and have a propensity to involve the CNS
Treatment and progression are similar to that of acute lymphoblastic leukaemia (ALL) -
This question is part of the following fields:
- Haematology
- Pathology
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Question 7
Correct
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How does aspirin mediate its antiplatelet effect:
Your Answer: It irreversibly inhibits cyclo-oxygenase
Explanation:Aspirin irreversibly inhibits cyclooxygenase and blocks the platelet production of thromboxane A2 (TXA2), thus inhibiting platelet aggregation.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 8
Correct
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A patient presents to your clinic with fever of unknown origin. His blood results shows a markedly elevated C-Reactive Protein (CRP) level.
Which of these is responsible for mediating the release of CRP?
Your Answer: IL-6
Explanation:C-reactive protein (CRP) is an acute phase protein produced by the liver hepatocytes. Its production is regulated by cytokines, particularly interleukin 6 (IL-6) and it can be measured in the serum as a nonspecific marker of inflammation.
Although a high CRP suggest an acute infection or inflammation, it does not identify the cause or location of infection.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 9
Correct
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In all of the following conditions, lymphocytosis typically occurs except for:
Your Answer: Corticosteroid therapy
Explanation:In infants and young children, lymphocytosis often occurs in response to infections that would normally produce a neutrophil reaction in adults.
Lymphocytosis occurs in:
1. Viral infections (e.g. infectious mononucleosis, HIV, rubella, mumps, viral hepatitis, cytomegalovirus, herpes simplex or zoster)
2. Bacterial infections (e.g. pertussis, tuberculosis, toxoplasmosis, syphilis)
3. Chronic lymphoid leukaemias
4. Acute lymphoblastic leukaemias
5. Non-Hodgkin lymphoma
6. Thyrotoxicosis -
This question is part of the following fields:
- Immune Responses
- Pathology
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Question 10
Correct
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The blood test reports of a 56-year-old female are sent for your review. She seems acutely sick and has had multiple infections over the past few months. Her complete blood count report shows neutropenia.
Which one of the following options is true with regards to neutropenia?Your Answer: It can be caused by both radiotherapy and chemotherapy
Explanation:A total neutrophil count of less than 2 x 109/L is defined as neutropenia. It can be caused by the following:
1. viral infections
2. SLE
3. RA
4. hypersplenism
5. chemo- and radiotherapy
6. vitamin B12 and folate deficiency
7. drug reactions -
This question is part of the following fields:
- Haematology
- Pathology
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Question 11
Incorrect
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A 26-year-old female cuts her hand on a knife while preparing dinner but the bleeding stops within a few minutes.
Which one of the following cells will be among the first to be present at the wound site to be involved in haemostasis?Your Answer: Neutrophils
Correct Answer: Platelets
Explanation:Platelets are the first cells to be attracted to the wound site due to the release of the Von Willebrand factor from the damaged endothelium. Platelets, in turn, release cytokines such as platelet-derived growth factor, which will attract other inflammatory cells to the wound site.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 12
Incorrect
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The least likely feature of anaemia is:
Your Answer: Bounding pulse
Correct Answer: Narrow pulse pressure
Explanation:Non-specific signs of anaemia include:
1. pallor of mucous membranes or nail beds (if Hb < 90 g/L),
2. tachycardia
3. bounding pulse
4. wide pulse pressure
5. flow murmurs
6. cardiomegaly
7. signs of congestive cardiac failure (in severe cases) -
This question is part of the following fields:
- Haematology
- Pathology
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Question 13
Correct
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Caseous necrosis is typically seen in which of the following:
Your Answer: Tuberculosis
Explanation:Caseous necrosis is most commonly seen in tuberculosis. Histologically, the complete loss of normal tissue architecture is replaced by amorphous, granular and eosinophilic tissue with a variable amount of fat and an appearance reminiscent of cottage cheese.
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This question is part of the following fields:
- Inflammatory Responses
- Pathology
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Question 14
Incorrect
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A 56-year-old male with a 10-year history of Diabetes Mellitus and Hypertension was rushed to the Emergency Department due to sudden onset crushing chest pain. ECG showed an ST-elevation myocardial infarct in the left anterior descending artery territory. The patient's condition was stabilised and managed with angioplasty, but he sustained significant myocardial damage.
Which one of the following statements best agrees with the myocardial healing process?Your Answer: The anterior wall will hypertrophy to maintain cardiac output
Correct Answer: The left ventricle will likely hypertrophy first to maintain cardiac output
Explanation:Following a myocardial infarction scar tissue formation will take place at the site of the damaged muscle. This places increased load on the rest of the myocardium causing it to hypertrophy. The left ventricle will hypertrophy first as it is pumping blood against a greater afterload as compared to the right ventricle.
There are three types of cells in the body with regards to the cell cycle: 1. permanent
2. labile
3. stable cellsPermanent cells do not re-enter the cell cycle and remain in G0. If there is a pool of stem cells the stem cells will enter the cell cycle to form more cells. Myocardial cells are a type of permanent cell and there is no pool of stem cells in the heart muscle. The anterior wall will not hypertrophy as it is formed by the right atrium and ventricle and both of these hypertrophy after the left ventricle.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 15
Correct
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A blood transfusion is given to a 52-year-old woman. She develops chills and rigours shortly after the transfusion begins.
The following are her observations: Temperature 40°C, HR 116 bpm, BP 80/48, SaO 2 97 percent on air.
Which of the following treatments is the most appropriate?Your Answer: Stop the transfusion and administer antibiotics
Explanation:Bacterial infections are common in the following situations:
Platelet transfusions are associated with a higher risk of bacterial infection (as platelets are stored at room temperature)
Immersion in a water bath thawed previously frozen components.
Components of red blood cells that have been stored for several weeks
Gram-positive and Gram-negative bacteria have both been linked to transfusion-transmitted bacterial infection, but Gram-negative bacteria are linked to a higher rate of morbidity and mortality.
Yersinia enterocolitica is the most common bacterial organism linked to transfusion-transmitted bacterial infection. This organism can multiply at low temperatures while also utilising iron as a nutrient. As a result, it’s well-suited to proliferating in blood banks.The following are some of the most common clinical signs and symptoms of a bacterial infection transmitted through a blood transfusion. These symptoms usually appear shortly after the transfusion begins:
Fever is very high.
Rigours and chills
Vomiting and nausea
Tachycardia
Hypotension
Collapse of the circulatory systemIf a bacterial infection from a transfusion is suspected, the transfusion should be stopped right away. Blood cultures and a Gram stain should be requested, as well as broad-spectrum antibiotics. In addition, the blood pack should be returned to the blood bank for an urgent culture and Gram-stain.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 16
Incorrect
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A medical student is reviewing the chart of a patient who has recently been diagnosed with leukaemia. The chief resident asks him to identify ONE feature that will most support acute leukaemia diagnosis in contrast to chronic leukaemia.
Which one of the following options will he pick?Your Answer: Hepatosplenomegaly present
Correct Answer: The patient is a child
Explanation:Acute lymphocytic leukaemia (ALL) is more common in children than chronic leukaemias, which generally occur in adults. Bone marrow failure occurs early on in the course of the disease in acute leukaemias, and there is the massive proliferation of undifferentiated cells with functioning cells being crowded out. Hepatosplenomegaly occurs in both acute and chronic forms of leukaemia and is not a differentiating feature.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 17
Incorrect
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A 6-year-old girl is brought to the nephrology clinic by her mother due to facial oedema. Her lab workup shows proteinuria of 7 g/24 hours and serum albumin levels of 15 g/L. A diagnosis of Nephrotic Syndrome is made, and corticosteroid therapy is initiated.
Which one of the following is the most likely cause of nephrotic syndrome in this patient?Your Answer: Focal segmental glomerulosclerosis
Correct Answer: Minimal change disease
Explanation:Minimal Change Disease is the most common cause of Nephrotic Syndrome in the paediatric population. It may be caused by NSAID use. Electron microscopy shows the fusion of foot processes while light microscopy will appear normal.
Focal segmental glomerulosclerosis causes Nephrotic Syndrome in adults. It is associated with Heroin use and HIV infection. There is a limited response to steroids, and the disease progresses to end-stage renal failure in 5-10 years.
Diabetic nephropathy occurs after a long period of diabetes due to the deposition of amyloid protein leading to a decrease in glomerular filtration.
There is no history of Hepatitis B in this patient and no symptoms of liver disease such as jaundice.
Membranous glomerulonephritis would present with features of Nephritic Syndrome. These would be oedema, haematuria; red blood cell casts in the urine and hypertension.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 18
Incorrect
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Eosinophils comprise what percentage of circulating white cells:
Your Answer: 6 - 10%
Correct Answer: 1 - 3%
Explanation:Eosinophils comprise 1 – 3% of circulating white cells. Eosinophils are similar to neutrophils, except that the cytoplasmic granules are coarser and more deeply red staining, and there are rarely more than three nuclear lobes. They are less motile, but longer lived. They enter inflammatory exudates and have a special role in allergic responses, defence against parasites and removal of fibrin formed during inflammation. Thus they play a role in local immunity and tissue repair.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 19
Incorrect
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Regarding thalassaemia, which of the following statements is CORRECT:
Your Answer: Beta-thalassaemias are usually caused by deletion of a beta globin gene.
Correct Answer: Screening for thalassaemia in pregnancy is offered to all pregnant women.
Explanation:Beta thalassemia is caused by mutations in one or both of the beta globin genes. Alpha thalassemia is caused by a deletion or mutation (less commonly) in one or more of the four alpha globin gene copies. β-thalassaemia is more common in the Mediterranean region while α-thalassaemia is more common in the Far East.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 20
Incorrect
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A 15-year-old male is admitted to a rehabilitation centre with a history of multiple strokes, myopathy and learning disabilities since childhood. He is under the care of a multidisciplinary team, and his genetic testing reports show the presence of a mitochondrial disorder.
Which one of the following diseases does this patient most likely have?Your Answer: Glucose-6-phosphate dehydrogenase deficiency
Correct Answer: MELAS
Explanation:Mitochondrial diseases are a group of disorders caused by dysfunctional mitochondria. Most cases are maternally inherited, as we inherit our mitochondrial DNA from our mothers only, although mutations in nuclear DNA cause some cases.
Examples of Mitochondrial Diseases include:
1. Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS)
2. Mitochondrial epilepsy with ragged red fibres (MERRF)
3. Leber’s hereditary optic neuropathy (LHON)
4. Diabetes mellitus and deafness (DAD)
5. Neuropathy, ataxia, retinitis pigmentosa, and ptosis (NARP)
6. Leigh syndrome (subacute sclerosing encephalopathy).Red-green colour blindness and G6PD deficiency have an X-linked recessive pattern of inheritance.
Tay-Sachs Disease and spinal muscular atrophy have an autosomal recessive pattern of inheritance.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 21
Incorrect
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Which of the following is NOT a heritable risk factor for venous thrombosis:
Your Answer: Protein C deficiency
Correct Answer: Von Willebrand disease
Explanation:Approximately one-third of patients who suffer DVT or PE have an identifiable heritable risk factor, although additional risk factors are usually present when they develop the thrombosis. The history of a spontaneous DVT in a close relative increases an individual’s risk of DVT even if no known genetic predisposition can be identified.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 22
Incorrect
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A 42-year-old woman with a history of hyposplenism arrives at the Emergency Department sick and feverish. A complete set of bloods, including a peripheral blood film, is organised.
On a hyposplenic blood film, which of the following features is LEAST likely to be seen?Your Answer: Howell-Jolly bodies
Correct Answer: Teardrop cells
Explanation:The collection of abnormalities found in these patients is referred to as a hyposplenic film.
The following features can be seen on hyposplenic blood films:
Howell-Jolly bodies
Heinz’s bodies
Target cells
RBCs with nuclei on occasion
Lymphocytosis
Macrocytosis
Acanthocytes
Teardrop cells, also known as dacrocytes, are named for their teardrop-shaped shape.Dacrocytosis is a condition in which a large number of these cells are present. Myelofibrosis and beta thalassemia major both have dacrocytes, but hyposplenism does not.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 23
Correct
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A patient presents with a rash for a dermatological examination. A flat circumscribed area of discoloured skin measuring 0.7 cm in diameter is seen on examination.
What is the best description of this rash that you have found on examination?
Your Answer: Macule
Explanation:A macule is a flat, well circumscribed area of discoloured skin less than 1 cm in diameter with no changes in the thickness or texture of the skin.
A vesicle is a visible collection of clear fluid measuring less than 0.5 cm in diameter.
A papule is a solid, well circumscribed, skin elevation measuring less than 0.5 cm in diameter.
A nodule is a solid, well circumscribed, raised area that lies in or under the skin and measures greater than 0.5 cm in diameter. They are usually painless.
A plaque is a palpable skin lesion that is elevated and measures >1cm in diameter.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 24
Correct
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A 30-year-old female presented to the Emergency Department after a fall during a hiking expedition caused severe pain in her left arm and wrist drop. An X-ray revealed a mid-shaft fracture of the humerus, which most likely damaged the radial nerve.
Which one of the following statements best describes the healing process of peripheral nerves?Your Answer: Peripheral nerve fibres regenerate at around 1mm per day
Explanation:Peripheral nerves are nerves that lie outside the brain and spinal cord. Peripheral nerves readily regenerate, while central nervous system axonal injury does not spontaneously regenerate.
If there is damage to the axons of peripheral nerves, the nerves will regenerate at a slow rate of 1 mm per day. The slow regeneration process may lead to muscle atrophy before regeneration is complete.Each peripheral nerve has a single cell body that supplies nutrients to the growing nerve fibre. The cell body does not undergo mitosis; only the axon is regenerated.
Schwann cells of the peripheral nervous system provide support for this process, while the analogous oligodendrocytes of the central nervous system do not. Schwann cells themselves do not cause regeneration. Schwann cells provide myelin for myelinated fibres and surround non-myelinated fibres with their cytoplasm.
If an axon is completely severed, as in the case of amputation, the axonal fibres regenerating from the cell body may never find their original route back to the muscle. Instead, they may form a traumatic neuroma, a painful collection of nerve fibres and myelin.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 25
Incorrect
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A 30-year-old male with a known allergy to natural latex rubber presents with an allergic reaction to a food he has just eaten.
Which ONE of these foods is most likely to cause an associated hypersensitivity in him?Your Answer: Potato
Correct Answer: Banana
Explanation:About one third of patients with allergy to natural latex rubber (NRL) have an associated allergy to some plant-derived foods. It is known as the latex-fruit syndrome and occurs commonly with consumption of fresh fruits. Banana and avocado are the most implicated fruits but it can also be seen with tomato, kiwi and chestnut.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 26
Correct
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A 40-year-old female presents to the orthopaedic clinic complaining of pain and limited range of motion in the right elbow for the past two days. On examination, the right elbow is extremely tender with erythema and warmth of the overlying skin due to acute inflammation.
Which ONE of the following statements is true with regards to acute inflammation?Your Answer: Neutrophils are activated and adhere to the endothelium as a result of interaction with endothelial cell adhesion molecules
Explanation:Acute inflammation is defined as inflammation occurring within minutes to hours in response to an injury lasting for less than two weeks.
Acute inflammation
Rapid onset (minutes to hours)
Quick resolution (usually days)Chronic inflammation
May last weeks, months, or yearsThere are five cardinal signs of inflammation:
1) Pain
2) Redness
3) Warmth
4) Oedema
5) Loss of functionDuring acute inflammation, neutrophils are activated and attracted to the site of inflammation in response to various interleukins and cytokines. This process takes place via the following mechanism:
1) Margination
Neutrophils flow nearer the vessel wall rather than in the axial stream, which is referred to as margination
2) Rolling along the surface of vascular endothelium
3) Adhesion to the endothelium by interaction with adhesion molecules (ICAMS and VCAMS)
4) Diapedesis is the movement of neutrophils from the endothelial cells into the interstitial space by squeezing through the gaps between adjacent endothelial cellsBradykinin and histamine are both responsible for vasodilation which causes oedema and decreases intravascular osmotic pressure.
Neutrophils dominate early (<2 days)
– Many in the bloodstream
– Attach firmly to adhesion molecules
– Apoptosis after 24-48hrs
Monocytes/macrophages dominate late (>2 days)
– Live longer
– Replicate in tissues -
This question is part of the following fields:
- General Pathology
- Pathology
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Question 27
Correct
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A 24-year-old female visits her family physician to complain of painless lumps in her neck. Her physician notes several enlarged, rubbery, non-tender cervical lymph nodes on examination. He immediately refers the patient for a lymph node biopsy, the results of which show the presence of Reed-Sternberg cells.
What is the diagnosis in this case based on the above scenario?Your Answer: Hodgkin’s lymphoma
Explanation:The presence of Reed-Sternberg cells is pathognomonic for Hodgkin’s Lymphoma, which is a disease-causing neoplastic transformation of lymphocytes. There is a bimodal age distribution with peaks in the 20s and 60s. Patients typically present with enlarged, rubbery, non-tender lymph nodes. Symptoms such as fever, night sweats and weight loss may be present.
Pain after alcohol consumption is a pathognomonic sign of Hodgkin’s lymphoma, it is, however, not a ‘B’ symptom. It is rare though, only occurring in 2-3% of patients with Hodgkin’s lymphoma.
The Ann Arbour clinical staging is as follows:
Stage I: one involved lymph node group
Stage II two involved lymph node groups on one side of the diaphragm
Stage III: lymph node groups involved on both sides of the diaphragm
Stage IV: Involvement of extra-nodal tissues, such as the liver or bone marrow
Diagnosis is made by lymph node biopsy, which should be taken from a sufficiently large specimen or excisional biopsy, as opposed to a fine needle biopsy.Multiple myeloma most commonly presents with bone pain, especially in the back and ribs.
In non-Hodgkin’s lymphoma, Reed-Sternberg cells are not present.
Acute lymphoblastic leukaemia will present with features of anaemia, thrombocytopenia and leukopenia.
The most common symptoms of chronic lymphocytic leukaemia are fatigue, night sweats and low-grade fever.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 28
Correct
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A dermatological examination on a patient presenting with a lump shows a small visible skin elevation containing an accumulation of pus.
Which one of these best describes the lump you have found on examination?Your Answer: Pustule
Explanation:A pustule is a small visible skin elevation containing an accumulation of pus.
A carbuncle is a collection of individual boils clustered together.
A bulla is a visible collection of clear fluid measuring greater than 0.5 cm in diameter.
A furuncle, or boil, is a pyogenic infection of the hair follicle commonly caused by infection with Staphylococcus aureus.
A vesicle is a visible collection of fluid measuring less than 0.5 cm in diameter.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 29
Correct
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The most common cause of anaemia worldwide is which of the following?
Your Answer: Iron deficiency anaemia
Explanation:The most common cause of microcytic anaemia and of any anaemia worldwide is iron deficiency anaemia.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 30
Correct
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A 60-year-old female is referred to the Oncology clinic due to the presence of lumps in her neck. There is a non-tender enlargement of several groups of cervical lymph nodes on examination. She is sent for a lymph node biopsy. The results show the presence of lymphoma cells, but there are no Reed-Sternberg cells.
Which one is most appropriate for this case out of the following diagnoses?Your Answer: Non-Hodgkin’s lymphoma
Explanation:Non-Hodgkin’s Lymphoma (NHL) causes neoplastic transformation of both B cell (85%) and T cell (15%) lines.
The most common presentation is with enlarged, rubbery, painless lymph nodes. The patient may also have B symptoms which consist of night sweats, weight loss and fevers. Multiple myeloma most commonly presents with bone pain, especially in the back and ribs.
The presence of Reed-Sternberg cells characterises Hodgkin’s lymphoma. Acute lymphoblastic leukaemia will present with features of anaemia, thrombocytopenia and leukopenia. The most common symptoms of chronic lymphocytic leukaemia are fatigue, night sweats and low-grade fever.
The peak incidence of NHL is in the 50-70 years age group, it affects men and women equally, but affects the Caucasian population more commonly than black and Asian ethnic groups.
The following are recognised risk factors for NHL:
Chromosomal translocations and molecular rearrangements
Epstein-Barr virus infection
Human T-cell leukaemia virus type-1 (HTLV-1)
Hepatitis C
Congenital and acquired immunodeficiency states
Autoimmune disorders, e.g. Sjogren’s syndrome and Hashimoto’s thyroiditis -
This question is part of the following fields:
- Haematology
- Pathology
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Question 31
Correct
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Regarding acute lymphoblastic leukaemia (ALL), which of the following statements is CORRECT:
Your Answer: ALL is the most common malignancy of childhood.
Explanation:Acute lymphoblastic leukaemia (ALL) is caused by an accumulation of lymphoblasts in the bone marrow and is the most common malignancy of childhood. The incidence of ALL is highest at 3 – 7 years, with 75% of cases occurring before the age of 6. 85% of cases are of B-cell lineage. Haematological investigations reveal a normochromic normocytic anaemia with thrombocytopenia in most cases. The total white cell count may be decreased, normal or increased. The blood film typically shows a variable number of blast cells. The bone marrow is hypercellular with >20% blast cells.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 32
Correct
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Mast cells play a significant part in which of the following?
Your Answer: Allergic disease
Explanation:Mast cells play a central role in the response to allergen challenges. The activation of mast cells results in both an early and a delayed phase of inflammation. Mast cells have been implicated in both physiologic and pathogenic processes. Mast cells are important in defence against some bacteria and viruses and contribute to defence against parasites. They are key effector cells in both innate and acquired immunity and are capable of inducing and amplifying both types of responses. Specifically, mast cells are capable of detecting microbial products through surface pattern recognition receptors, and they are involved in the recruitment of other leukocytes, containment of bacterial infections, and tissue repair.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 33
Correct
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A 1-year-old male is brought to the paediatrician by his mother due to swelling of the right knee after a minor fall. On examination, the right knee is swollen, fluctuant and tender. Ultrasound-guided aspiration reveals a massive hemarthrosis. Family history shows that his older brother also has a bleeding disorder.
Which one of the following conditions does the patient most likely have?Your Answer: Haemophilia A
Explanation:A diagnosis of Haemophilia is supported in this patient by the family history and the presence of hemarthrosis-both characteristics of Haemophilia. Haemophilia A is caused by Factor VIII deficiency, leading to impaired coagulation. This disease typically presents after six months when the child starts crawling.
Von Willebrand disease presents with nosebleeds and hematomas. Idiopathic thrombocytopenic purpura presents with bruises that resemble a rash.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency presents with haemolytic anaemia induced by specific drugs or foods.
Factor V Leiden mutation causes blood clotting rather than bleeding.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 34
Incorrect
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A 23-year-old male is referred to your haematology clinic after an acute attack of haemolytic anaemia. He was diagnosed with glucose-6-phosphate dehydrogenase deficiency ten years ago.
Which ONE of the following options is FALSE with regards to this disorder?Your Answer: It is the commonest human enzyme defect
Correct Answer: Acute haemolysis can be triggered by cephalosporin antibiotics
Explanation:Glucose-6-phosphate dehydrogenase deficiency is an X-linked recessive disorder in which there is a deficiency of the enzyme G6PD. This causes instability of red blood cell membranes under oxidative stress leading to haemolysis.
Triggers include:
1) Fava beans
2) Sulphonamides
3) Primaquine
4) Anti-TB drugs
5) InfectionsMost individuals will be asymptomatic until exposed to one of the triggers listed above. It is the commonest human enzyme defect and affects males more than females because of the X-linked inheritance pattern. The use of penicillins and cephalosporins is generally safe.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 35
Incorrect
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A 40-year-old male visits his family physician with the complaint of a high-grade fever for the past five days. A complete blood count report shows the presence of neutrophilia.
Which one of the following facts regarding neutrophilia is accurate?Your Answer: Acute neutrophilia is associated with a ‘right shift’
Correct Answer: It can be caused by eclampsia
Explanation:A total neutrophil count of greater than 7.5 x 109/L is called neutrophilia. Typhoid fever usually causes leukopenia or neutropenia. Both localised and generalised bacterial infections can cause neutrophilia.
Metabolic disorders such as
– gout
– eclampsia
– uraemia
can also cause neutrophilia.Acute neutrophilia, in which immature neutrophils can be seen, is referred to as a left shift and can be seen in conditions such as appendicitis.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 36
Correct
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Question 37
Incorrect
-
The most important Complement protein for antigen opsonization is:
Your Answer: C3a
Correct Answer: C3b
Explanation:Phagocytosis is largely responsible for depletion of cells coated with antibodies. Cells opsonized by IgG antibodies are recognized by phagocyte Fc receptors, which are specific for the Fc portions of some IgG subclasses. In addition, when IgM or IgG antibodies are deposited on the surfaces of cells, they may activate the complement system by the classical pathway. Complement activation generates by-products, mainly C3b and C4b, which are deposited on the surfaces of the cells and recognized by phagocytes that express receptors for these proteins. The net result is phagocytosis of the opsonized cells and their destruction.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 38
Correct
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A dermatological examination of a patient who has presented with a lump shows a collection of boils clustered together.
Which one of these best describes the lump you have found on examination?Your Answer: Carbuncle
Explanation:A furuncle, or boil, is a pyogenic infection of the hair follicle commonly caused by infection with Staphylococcus aureus.
A carbuncle is a collection of individual boils clustered together.
A bulla is a visible collection of clear fluid measuring greater than 0.5 cm in diameter.
A vesicle is a visible collection of clear fluid measuring less than 0.5 cm in diameter.
A pustule is a small visible skin elevation containing an accumulation of pus.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 39
Incorrect
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A 66-year-old male presents to his family physician with the complaint of increasing fatigue and lethargy, along with itching, especially after a hot bath. He also complains of increased sweating and dizziness. On examination, he has a plethoric appearance. Abdominal examination shows the presence of splenomegaly. A basic panel of blood tests is ordered in which her Hb comes out to be 17 g/dL.
Which one of the following treatment options will be most suitable in this case?Your Answer: No treatment is available
Correct Answer: Venesection
Explanation:The clinical and laboratory findings, in this case, support a diagnosis of polycythaemia vera. A plethoric appearance, lethargy, splenomegaly and itching are common in this disease. Patients may also have gouty arthritis, Budd-Chiari syndrome, erythromelalgia, stroke, myocardial infarction or DVT. The average age for diagnosis of Polycythaemia Vera is 65-74 years. It is a haematological malignancy in which there is overproduction of all three cell lines. Venesection is the treatment of choice as it would cause a decrease in the number of red blood cells within the body.
Erythropoietin is given in patients with chronic renal failure as they lack this hormone. Administration of erythropoietin in such patients causes stimulation of the bone marrow to produce red blood cells.
Desferrioxamine is a chelating agent for iron and is given to patients with iron overload due to repeated blood transfusions, e.g. in thalassemia patients.
Penicillamine is a chelating agent for Copper, given as treatment in Wilson’s disease.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 40
Correct
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A 20-year-old male who is a known patient of sickle cell disease presents to the Emergency Room with a sustained erection that is extremely painful.
Out of the following clinical syndromes, which one does this patient most likely have?Your Answer: Priapism
Explanation:Sickling of red blood cells can lead to several different clinical syndromes. If the sickling occurs in the corpora cavernosa, it can lead to a sustained, painful erection of the penis, referred to as priapism. One of the complications is long-term impotence. It is important to seek a urological opinion immediately in this case, but in the interim, treat with perineal ice packs and walk up and down the stairs.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 41
Correct
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Which of the following is NOT mainly characterised by intravascular haemolysis:
Your Answer: Beta-Thalassaemia
Explanation:Causes of intravascular haemolysis:
Haemolytic transfusion reactions
G6PD deficiency
Red cell fragmentation syndromes
Some severe autoimmune haemolytic anaemias
Some drug-and infection-induced haemolytic anaemias
Paroxysmal nocturnal haemoglobinuria -
This question is part of the following fields:
- Haematology
- Pathology
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Question 42
Incorrect
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C5 - C9 deficiency increases susceptibility to infection with which of the following:
Your Answer: Encapsulated bacteria
Correct Answer: Neisseria spp.
Explanation:If the complement sequence is completed, an active phospholipase (the membrane attack complex, MAC) is produced, which punches holes in the cell membrane and causes cell lysis. Because the MAC appears to be the sole means to destroy the Neisseria family of bacteria, C5 – C9 deficiency increases susceptibility to Neisseria infections.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 43
Correct
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Regarding acute lymphoblastic leukaemia (ALL), which of the following statements is CORRECT:
Your Answer: 75% of cases occur before the age of 6 years.
Explanation:Acute lymphoblastic leukaemia (ALL) is caused by an accumulation of lymphoblasts in the bone marrow and is the most common malignancy of childhood. The incidence of ALL is highest at 3 – 7 years, with 75% of cases occurring before the age of 6. 85% of cases are of B-cell lineage. Haematological investigations reveal a normochromic normocytic anaemia with thrombocytopenia in most cases. There is great variation in the chance of individual patients achieving a long-term cure based on a number of biological variables. Approximately 25% of children relapse after first-line therapy and need further treatment but overall 90% of children can expect to be cured. The cure rate in adults drops significantly to less than 5% over the age of 70 years.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 44
Incorrect
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Regarding beta-thalassaemia, which of the following statements is CORRECT:
Your Answer: The anaemia of beta-thalassaemia major is usually apparent from birth.
Correct Answer: Beta-thalassaemia trait is associated with a raised HbA2.
Explanation:Beta-thalassaemia major is caused by a complete or almost complete failure of β-globin chain synthesis, severe imbalance of α:β-chains with deposition of α-chains in erythroblasts, ineffective erythropoiesis and extramedullary haemopoiesis. The severe anaemia becomes apparent at 3 – 6 months when the switch from γ-chain to β-chain synthesis normally occurs. Beta-thalassaemia minor is a variable syndrome, milder than thalassaemia major, with later onset and characterised by moderate hypochromic microcytic anaemia with raised haemoglobin A2. Beta-thalassaemia trait is characterised by mild hypochromic, microcytic anaemia with raised red cell count and raised haemoglobin A2.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 45
Incorrect
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Which of the following laboratory findings is NOT typical of Hodgkin lymphoma:
Your Answer: Neutrophilia
Correct Answer: Basophilia
Explanation:Features may include:Normochromic normocytic anaemia is most common; bone marrow failure involvement is unusual in early disease, but if it occurs bone marrow failure may develop with leucoerythroblastic anaemiaOne-third of patients have a neutrophilia; eosinophilia is frequentAdvanced disease is associated with lymphopenia and loss of cell-mediated immunityPlatelet count is normal or increased in early disease and reduced in later stagesESR and CRP are usually raised (ESR is useful in monitoring disease progress)Serum LDH is raised initially in 30-40% of casesDiagnosis is made by histological examination of an excised lymph nodeThe distinctive multinucleate polypoid RS cell is central to the diagnosis of the four classic types of HL (95% of cases)
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This question is part of the following fields:
- Haematology
- Pathology
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Question 46
Incorrect
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A 49-year-old woman with haemoglobin of 6 g/dL following persistent vaginal bleeding receives blood transfusion. She developed pain and burning at her cannula site and complains of a feeling of “impending doom”, nausea, and severe back pain shortly after transfusion was started. Her temperature is 38.9ºC.
What is the most appropriate treatment?Your Answer: Supportive measures and paracetamol
Correct Answer: Stop the transfusion and administer IV fluids
Explanation:Acute haemolytic transfusion reactions present with: Feeling of ‘impending doom’ as the earliest symptom, fever and chills, pain and warmth at transfusion site, nausea and vomiting, back, joint, and chest pain. Transfusion should be stopped immediately and IV fluid (usually normal saline) administered.
Supportive measures and paracetamol can be given since patient has fever but it is not the immediate first step.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 47
Incorrect
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Which of the following best describes the process of opsonisation:
Your Answer: Direct neutralisation of bacterial toxins and viruses by antibodies
Correct Answer: The coating of foreign particles with molecules which allow easier recognition of that cell by phagocytes
Explanation:An opsonin is any molecule that enhances phagocytosis by marking an antigen for an immune response, for example, immunoglobulin or complement. Opsonisation is the molecular mechanism whereby molecules, microbes, or apoptotic cells are chemically modified to have a stronger attraction to the cell surface receptors on phagocytes and natural killer cells. With the antigen coated in opsonins, binding to immune cells is greatly enhanced. Opsonisation also mediates phagocytosis via signal cascades from cell surface receptors.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 48
Correct
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How does abciximab mediate its antiplatelet effect:
Your Answer: It is a GPIIb/IIIa inhibitor.
Explanation:Abciximab, eptifibatide and tirofiban are GPIIb/IIIa inhibitors, inhibiting platelet aggregation by preventing the binding of fibrinogen, von Willebrand factor and other adhesive molecules.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 49
Correct
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A patient presents with a rash for dermatological examination. A large area of purplish discolouration of the skin that measures 2 cm in diameter and does not blanch when pressure is applied is seen .
What is the best description of this rash that you have found on examination?
Your Answer: Ecchymoses
Explanation:Ecchymosis are discolouration of the skin or mucous membranes caused by extravasation of blood. They are usually red or purple in colour and measure greater than 1 cm in diameter and do not blanch on applying pressure.
A macule is a flat, well circumscribed area of discoloured skin less than 1 cm in diameter with no changes in the thickness or texture of the skin.
Petechiae are discolouration of the skin measuring less than 3 mm in diameter
Purpura are discolouration of the skin measuring between 0.3 cm and 1 cm in diameter.
Erythema is redness of the skin or mucous membranes caused by hyperaemia of superficial capillaries caused by skin injury, infection or inflammation. Erythema blanches when pressure is applied whereas ecchymosis, purpura and petechiae do not.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 50
Correct
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A 20-year-old male receives a small cut over his hand while climbing a fence causing it to bleed. Upon applying pressure for a few minutes, the bleeding stops. Which one of the following physiological components of the blood is responsible for the primary haemostasis reaction, such as in this case?
Your Answer: Platelet plug formation
Explanation:Haemostasis is your body’s defence against an injury that causes bleeding. It stops bleeding in three main steps:
1) Primary haemostasis – formation of a weak platelet plug
– The primary reaction of the body is to cause local vasoconstriction at the site of injury and decrease blood flow to the affected area
– the release of cytokines and inflammatory markers lead to adhesion of platelets and aggregation at the site of injury forming a platelet plug
– the injured vessel wall has exposed subendothelial collagen that releases von Willebrand factorAny damage to the vessel wall causes the release of the Von Willebrand factor, which is necessary for platelet adhesion. Tissue Thromboplastin is also released, which activates the coagulation pathway, a component of secondary haemostasis. The coagulation cascade ultimately results in the conversion of fibrinogen to fibrin.
2) Secondary haemostasis
3) FibrinolysisFibrin (factor Ia) is a long, thin protein with branches produced at the end of the coagulation cascade when fibrinogen (factor I) is converted to fibrin, which stabilizes the blood clot.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 51
Correct
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Which one these is an example of a cause of an exudate?
Your Answer: Subphrenic abscess
Explanation:An exudate is an inflammatory fluid emanating from the intravascular space due to changes in the permeability of the surrounding microcirculation.
Some common causes of exudates are: pneumonia, empyema, lung cancer, breast cancer, cancer of the pleura, SLE, rheumatoid arthritis, pericarditis, subphrenic abscess, chylothorax.
Myxoedema, nephrotic syndrome, congestive cardiac failure, and liver cirrhosis all cause TRANSUDATE.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 52
Correct
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A 35-year-old man suffered a severe road traffic accident and has been brought to the hospital. As part of his treatment, he requires a blood transfusion and experiences a transfusion reaction.
The most common type of transfusion reaction is which of the following?Your Answer: Febrile transfusion reaction
Explanation:During or shortly after transfusion, febrile transfusion reactions, also known as non-haemolytic transfusion reactions, present with an unexpected temperature rise (38oC or 1oC above baseline, if baseline is 37oC). This is usually a one-off occurrence. The fever is sometimes accompanied by chills.
The most common type of transfusion reaction is febrile transfusion reactions, which occur in about 1 in every 8 transfusions.
The most common event leading to symptoms of febrile transfusion reactions is cytokine accumulation during storage of cellular components (especially platelet units). White cells secrete cytokines, and pre-storage leucodepletion has reduced this risk.
Recipient antibodies (raised as a result of previous transfusions or pregnancies) reacting to donor human leukocyte antigen (HLA) or other antigens can also cause febrile transfusion reactions. Donor lymphocytes, granulocytes, and platelets all contain these antigens.
Treatment is reassuring. Other causes should be ruled out, and antipyretics like paracetamol can help with fever relief. If another cause of fever is suspected, the transfusion should be stopped; however, if other causes of fever have been ruled out, it can be restarted at a slower rate.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 53
Incorrect
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How does dipyridamole mediate its antiplatelet effect:
Your Answer: It blocks the ADP receptor on the platelet surface.
Correct Answer: It is a phosphodiesterase inhibitor.
Explanation:Dipyridamole inhibits both the reuptake of adenosine and phosphodiesterase, preventing the degradation of cAMP and thus blocking the platelet aggregation response to ADP.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 54
Correct
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A patient presents to your Emergency Department with a laceration on their buttocks requiring closure with sutures.
What stage of wound healing is the first to reach completion?Your Answer: Haemostasis
Explanation:The stages of wound healing are: haemostasis, inflammatory, proliferative and remodelling (maturation) phases in that order. The first stage in the healing process of a laceration is haemostasis. Haemostasis is the process of the wound being closed by clotting.
The inflammatory phase occurs just after and up to 48 hours after injury– Blood vessels dilate to allow white blood cells, antibodies, growth factors, enzymes and nutrients to reach the wounded area leading to the characteristic signs of inflammation seen.
Epithelialisation and angiogenesis are not phases of wound healing but occur during the proliferative phase. This ia after haemolysis and inflammation phases have occurred.
The maturation phase is the final phase and occurs when the wound has closed. It involves remodelling of collagen from type III to type I. Apoptosis remove unwanted cells, cellular activity reduces and the number of blood vessels in the wounded area regresses and decreases. This can continues for up to 1 year after injury.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 55
Correct
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A 20-year-old male has an anaphylactic reaction following a wasp sting.
What type of hypersensitivity reaction is this?
Your Answer: Type I
Explanation:Anaphylaxis is an example of a type I hypersensitivity reaction.
It is IgE mediated.
It requires a prior exposure to the antigen. The initial exposure sensitizes the body to the antigen and a second exposure to that antigen leads to an anaphylactic reaction.
Massive calcium influx into the cells leads to mast cell degranulation.
The Immunoglobulin antigen complex binds to Fc receptors on the surface of mast cells. The result is mast cell degranulation and release of histamine, proteoglycans and serum proteases from cytoplasmic granules.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 56
Incorrect
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Regarding chronic idiopathic thrombocytopaenic purpura (ITP), which of the following statements is INCORRECT:
Your Answer: The antibody in ITP is often directed against the glycoprotein IIb/IIIa or Ib complex.
Correct Answer: ITP is classically associated with massive splenomegaly.
Explanation:Chronic ITP is a relatively common disorder. The highest incidence is in women aged 15 – 50 years. It is the most common cause of thrombocytopaenia without anaemia or neutropaenia. It is usually idiopathic but it may been seen in association with other conditions. Platelet autoantibodies (usually IgG) result in the premature removal of platelets from the circulation by macrophages of the reticuloendothelial system. In many causes the antibody is directed against the glycoprotein IIb/IIIa or Ib complex. The normal platelet lifespan of 10 days is reduced to a few hours. Total megakaryocyte mass and platelet turnover are increased to approximately five times normal. Despite the destruction of platelets by splenic macrophages, the spleen is normally not enlarged. In fact, an enlarged spleen should lead to a search for other possible causes for the thrombocytopenia.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 57
Correct
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Which of the following immunoglobulins is most important for mast cell degranulation:
Your Answer: IgE
Explanation:IgA is the major Ig in secretions, particularly from the gastrointestinal tract (but also in saliva, tears, sweat and breast milk).
IgE is important for mast cell degranulation in allergic and antiparasitic response. In the allergic response, the plasma cell produces IgE-antibodies, which, like antibodies of other immunoglobulin isotypes, are capable of binding a specific allergen via its Fab portion.
IgG is the most abundant in plasma (comprising 80% of normal serum immunoglobulin) and the main circulatory Ig for the secondary immune response. -
This question is part of the following fields:
- Immune Responses
- Pathology
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Question 58
Incorrect
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Which of the following statements is correct with regards to immunoglobulin?
Your Answer: Each immunoglobulin molecule has one kappa light chain and one delta light chain.
Correct Answer: The isotype of immunoglobulin is determined by the heavy chain.
Explanation:The composition of immunoglobulin molecules is two identical heavy and two identical light chains. These chains are linked by disulphide bridges and are each have highly variable regions which give the immunoglobulin its specificity. In addition, they have constant regions and there is virtual complete correspondence in amino acid sequence in all antibodies of a given isotype.
Five isotypes of immunoglobulin exist – these are IgG, IgA, IgM, IgE and IgD. They are determined by the heavy chain (gamma, alpha, mu, epsilon or delta respectively). The light chains are either kappa or lambda. -
This question is part of the following fields:
- Immune Responses
- Pathology
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Question 59
Incorrect
-
Approximately what proportion of lymphocytes are B-cells:
Your Answer: 0.65
Correct Answer: 0.2
Explanation:B-cells (20% of lymphocytes) mature in the bone marrow and circulate in the peripheral blood until they undergo recognition of antigen. B-cell immunoglobulin molecules synthesised in the cell are exported and bound to the surface membrane to become the B-cell receptor (BCR) which can recognise and bind to a specific antigen (either free or presented by APCs). The BCR is also important for antigen internalisation, processing and presentation to T helper cells. Most antibody responses require help from antigen-specific T helper cells (although some antigens such as polysaccharide can lead to T-cell independent B-cell antibody production). When the B-cell is activated, the receptor itself is secreted as free soluble immunoglobulin and the B-cell matures into a memory B-cell or a plasma cell (a B-cell in its high-rate immunoglobulin secreting state). Plasma cells are non-motile and are found predominantly in the bone marrow or spleen. Most plasma cells are short-lived (1 – 2 weeks) but some may survive much longer. A proportion of B-cells persist as memory cells, whose increased number and rapid response underlies the augmented secondary response of the adaptive immune system.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 60
Incorrect
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A 26-year-old male presents to your clinic with the complaint of recurrent fevers over the past three months. On documentation of the fever, it is noted that the fever increases and decreases in a cyclical pattern over a 1-2 week period. After the appropriate investigations, a diagnosis of Pel-Ebstein fever is made.
Which ONE of the following conditions is most likely to cause this patient's fever?Your Answer: Glandular fever
Correct Answer: Hodgkin lymphoma
Explanation:The release of cytokines from Reed-Sternberg cells can cause fever in patients with Hodgkin lymphoma, which increases and decreases in a cyclical pattern of 1 to 2 weeks. This is called Pel-Ebstein or Ebstein-Cardarelli fever, specifically seen in Hodgkin lymphoma. The fever is always high grade and can reach 40 degrees or higher.
Cyclical fever in other conditions is common but is not termed as Pel-Ebstein fever. This term is reserved only with Hodgkin lymphoma.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 61
Incorrect
-
Which of the following is NOT typically associated with eosinophilia:
Your Answer: Ascariasis infection
Correct Answer: Whooping cough
Explanation:An eosinophil leucocytosis is defined as an increase in blood eosinophils above 0.4 x 109/L.It is most frequently due to:
Allergic diseases (e.g. bronchial asthma, hay fever, atopic dermatitis, urticaria)
Parasites (e.g. hookworm, ascariasis, tapeworm, schistosomiasis)
Skin diseases (e.g. psoriasis, pemphigus, urticaria, angioedema)
Drug sensitivity -
This question is part of the following fields:
- Immune Responses
- Pathology
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Question 62
Incorrect
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A 7-year-old girl is admitted to the hospital with a persistently high temperature. To help her reduce her fever, you decide to give her paracetamol and ibuprofen.
What are the effects of paracetamol and ibuprofen on fever?Your Answer: Reduction in interleukin synthesis
Correct Answer: Reduction in prostaglandin synthesis
Explanation:Interleukin-1, which is released by leukocytes and acts on the thermoregulatory centre of the hypothalamus, causes fever. Because prostaglandins mediate this process, antipyretics such as NSAIDs, paracetamol, and aspirin reduce prostaglandin levels by inhibiting cyclooxygenase enzymes. Malignant disease secretes interleukins, which cause the B-symptoms seen in lymphoma, for example. Bacterial toxins can also cause interleukins to be produced.
Pyrexia of unknown origin (PUO) is defined as a fever of greater than 38.3 degrees Celsius that lasts for more than 2-3 weeks with no clear diagnosis despite extensive investigation.
Investigation necessitates a thorough understanding of the conditions that can cause febrile illness, which may be missed during an initial investigation, as well as a thorough history, examination, and investigation centred on that list.
Pyrexia of unknown origin has a wide differential diagnosis, which includes:
Infection
Bacterial
Pyogenic abscess
Tuberculosis
Infective endocarditis
Brucellosis
Lyme disease
Viral
HIV
Epstein Barr Virus
Cytomegalovirus
Parasite
Toxoplasmosis
Malignancy
Leukaemia
Lymphoma
Renal cell carcinoma
Hepatocellular carcinoma
Vasculitides
Still’s disease
Granulomatosis with polyangiitis (formerly Wegener’s)
Systemic lupus erythematosus
Giant cell arteritis
Rheumatoid arthritis
Polymyalgia rheumatica
Miscellaneous
Drug induced fevers
Familial Mediterranean fever
Thyrotoxicosis
Inflammatory bowel disease
Sarcoidosis
Factitious fever
Exaggerated normal circadian fluctuationThe patient might need to be admitted to the hospital for observation and further investigation. Because infection is still a possibility, blood cultures should be repeated on a regular basis, and inflammatory markers should be closely monitored. CT, PET, and MRI imaging have largely replaced diagnostic laparotomy as a diagnostic tool.
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This question is part of the following fields:
- Pathology
- Pathology Of Infections
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Question 63
Correct
-
A 69-year-old woman with new-onset back pain was diagnosed with osteopenia, osteolytic lesions, and vertebral collapse after undergoing a radiographic examination. Her laboratory results revealed anaemia and hypercalcemia. These findings most likely indicate what condition?
Your Answer: Myeloma
Explanation:Bone pain, pathologic fractures, weakness, anaemia, infection, hypercalcemia, spinal cord compression, and renal failure are all signs and symptoms of multiple myeloma (MM). The patient’s condition matched the signs and symptoms of myeloma.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 64
Incorrect
-
While on morning rounds in the medical ward, the attending physician asks a medical student about the differences between transudates and exudates and their causes. The student explains that a transudate is an excess fluid that leaks out of an intravascular compartment due to an imbalance between oncotic and hydrostatic pressures.
Which ONE of the following conditions will he mention as the cause of a transudate?Your Answer: Empyema
Correct Answer: Meig’s syndrome
Explanation:Transudative effusions are caused due to systemic causes leading to increased hydrostatic pressure or decreased oncotic pressure. These include:
1) Meig’s Syndrome (Ovarian tumour causing ascites and pleural effusion)
2) Congestive heart failure
3) Nephrotic Syndrome
4) Myxoedema
5) Cirrhosis
6) SarcoidosisAn exudate is caused by local inflammation and results from increased vascular permeability. Causes include:
1) Rheumatoid arthritis
2) Pneumonia leading to empyema
3) Malignancies
4) Pericarditis -
This question is part of the following fields:
- General Pathology
- Pathology
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Question 65
Incorrect
-
Which of the following is NOT an effect of cytokine activity:
Your Answer:
Correct Answer: Opsonisation of bacteria for phagocytosis
Explanation:Cytokines are a family of chemical messengers, secreted by leucocytes, that act over short distances by binding specific receptors on target cell surfaces. They include: interleukins (act between leucocytes), interferons (inhibit replication of viruses within cells and activate macrophages and natural killer cells), growth factors, and tumour necrosis factors (kill tumour cells). Effects include: induction of fever and acute phase response, stimulation of leucocyte differentiation and maturation, leucocyte recruitment and activation and increased antibody production.
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This question is part of the following fields:
- Inflammatory Responses
- Pathology
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Question 66
Incorrect
-
Haemophilia B results from a deficiency in:
Your Answer:
Correct Answer: Factor IX
Explanation:Haemophilia B is a bleeding disorder caused by a deficiency of clotting factor IX. It is the second commonest form of haemophilia, and is rarer than haemophilia A. Haemophilia B tends to be similar to haemophilia A but less severe. The two disorders can only be distinguished by specific coagulation factor assays.
The incidence is one-fifth of that of haemophilia A. Laboratory findings demonstrate prolonged APTT, normal PT and low factor IX.
Haemophilia B inherited in an X-linked recessive fashion, affecting males born to carrier mothers.
There is also a variation called Leyden, in which factor IX levels are below 1% until puberty, when they rise, potentially reaching as high as 40-60% of normal. This is thought to be due to the effects of testosterone at puberty. -
This question is part of the following fields:
- Haematology
- Pathology
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Question 67
Incorrect
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Which of the following clinical features is a feature of a chronic extravascular haemolytic anaemia:
Your Answer:
Correct Answer: Gallstones
Explanation:Clinical features of haemolytic anaemia include:
Anaemia
Jaundice (caused by unconjugated bilirubin in plasma, bilirubin is absent from urine)
Pigment gallstones
Splenomegaly
Ankle ulcers
Expansion of marrow with, in children, bone expansion e.g. frontal bossing in beta-thalassaemia major
Aplastic crisis caused by parvovirus -
This question is part of the following fields:
- Haematology
- Pathology
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Question 68
Incorrect
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A patient presents with a lump for a dermatological examination. There is a circumscribed skin elevation measuring 0.3 cm in diameter seen on examination.
Which one of these best describes the lump you have found on examination?Your Answer:
Correct Answer: Papule
Explanation:A papule is a solid, well circumscribed, skin elevation measuring less than 0.5 cm in diameter.
A nodule is a solid, well circumscribed, raised area that lies in or under the skin and measures greater than 0.5 cm in diameter. They are usually painless.
A bulla is a visible collection of clear fluid measuring greater than 0.5 cm in diameter.
A furuncle, or boil, is a pyogenic infection of the hair follicle commonly caused by infection with Staphylococcus aureus.
A pustule is a small visible skin elevation containing an accumulation of pus.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 69
Incorrect
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A 57-year-old male presents to the orthopaedic clinic complaining of pain and swelling in the left knee joint. On examination, the left knee is swollen, tender and erythematous. The patient is booked for joint aspiration, and a diagnosis of pseudogout is made following the aspiration.
Which types of crystals would be seen in the joint aspirate to lead to this diagnosis?Your Answer:
Correct Answer: Positively birefringent brick-shaped crystals
Explanation:Gout and pseudogout are both characterised by crystal deposition in the affected joints. The deposition of urate crystals causes gout, while calcium pyrophosphate crystals cause pseudogout. The crystals can be distinguished microscopically because urate crystals are negatively birefringent needle-shaped crystals, whilst calcium pyrophosphate crystals are positively birefringent brick-shaped crystals.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 70
Incorrect
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Which of the following diseases is caused by a build-up of lymphoblasts in the bone marrow?
Your Answer:
Correct Answer: Acute lymphoblastic leukaemia
Explanation:Acute lymphoblastic leukaemia (ALL) is a clonal (malignant) bone marrow disorder in which early lymphoid precursors multiply and replace the marrow’s normal hematopoietic cells. ALL is most common between the ages of 3 and 7, with 75 percent of cases occurring before the age of 6.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 71
Incorrect
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You are about to perform a blood test on a patient suspected of having systemic lupus erythematosus. Which antibodies will indicate a positive result of systemic lupus erythematosus?
Your Answer:
Correct Answer: Anti-nuclear antibodies
Explanation:Antinuclear antibodies (ANA) are autoantibodies to the cells’ nucleus.
The ANA test is the most sensitive diagnostic test for verifying the disease’s diagnosis.
Other autoantibodies that may be found in SLE patients include rheumatoid factor, antiphospholipid antibodies, and antimitochondrial antibodies.
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This question is part of the following fields:
- Inflammatory Responses
- Pathology
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Question 72
Incorrect
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Which of the following laboratory findings is NOT typical of von Willebrand disease (VWD):
Your Answer:
Correct Answer: Thrombocytopaenia
Explanation:Laboratory findings typically show (although this varies depending on VWD type):
Abnormal PFA-100 test
Low factor VIII levels (if low a factor VIII/VWF binding assay is performed)
Prolonged APTT (or normal)
Normal PT
Low VWF levels
Defective platelet aggregation
Normal platelet count -
This question is part of the following fields:
- Haematology
- Pathology
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Question 73
Incorrect
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Chronic myeloid leukaemia is most common in middle-aged and elderly people. It is responsible for 20% of all leukemias.
Which of the following statements about CML is NOT TRUE?Your Answer:
Correct Answer: Serum B12 is typically low
Explanation:Chronic myeloid leukaemia is most common in middle-aged and elderly people. It is responsible for 20% of all leukemias. The majority of CML patients experience fatigue, weight loss, and excessive sweating.
The Philadelphia chromosome is found in over 90% of CML cases. A balanced translocation between chromosomes 9 and 22 is known as the Philadelphia chromosome.
Because white cells produce a B12 binding protein, serum B12 levels in CML are typically high.
In CML, the neutrophil alkaline phosphatase score is usually low.
Almost all patients with CML eventually progress to blast crisis, though this can take up to ten years. If any of the following features are present in a CML patient, a blast crisis is diagnosed:
In the blood or bone marrow, there are more than 20% myeloblasts or lymphoblasts.
On a bone marrow biopsy, large clusters of blasts were discovered.CML can be treated with tyrosine kinase inhibitors like imatinib and dasatinib if a chloroma (a solid tumour made up of myeloblasts that grows outside of the bone marrow) is present.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 74
Incorrect
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A 61-year-old woman returns to get the results of recent blood tests she had done for non-specific malaise, lethargy, and weight loss.
The only abnormality discovered during the blood tests was a 580 x 10 9 /l increase in platelets. Her platelets were also elevated on a blood test taken 6 months earlier, according to her previous results. You're aware of the recent emergence of elevated platelet levels as a cancer risk marker and decide to look into it.
Which of the following cancers is most likely to cause isolated thrombocytosis?Your Answer:
Correct Answer: Colorectal cancer
Explanation:Raised platelet levels have emerged as a cancer risk marker, according to a large population-based study published in 2017(link is external). According to the study, 12 percent of men and 6% of women with thrombocytosis were diagnosed with cancer within a year. These figures increased to 18% in men and 10% in women if a second platelet count was taken within 6 months of the first and showed an increased or stable elevated platelet count.
The researchers discovered that thrombocytosis linked to cancer is most common in colorectal and lung cancers, and it is linked to a worse prognosis. Furthermore, one-third of the cancer patients in the study had no other symptoms that would have prompted an immediate cancer referral.
The exact mechanism by which these cancers cause thrombocytosis is unknown, but one theory proposes the existence of pathogenic feedback loops between malignant cells and platelets, with a reciprocal interaction between tumour growth and metastasis, as well as thrombocytosis and platelet activation. Another hypothesis is that thrombocytosis occurs independently of cancer but aids in its spread and progression.
The findings show that routinely testing for thrombocytosis could cut the time it takes to diagnose colorectal and lung cancer by at least two months. In the UK, this could result in around 5500 earlier cancer diagnoses per year.
Because the positive predictive value of thrombocytosis in middle age for cancer (10%) is higher than the positive predictive value for a woman in her 50s presenting with a new breast lump (8.5%), this is clearly an important research paper that should be used to adjust future clinical practise. The current NICE guidelines predate these new research findings, so we’ll have to wait and see how they affect cancer referral guidelines in the UK.
Because there are so many possible cancers associated with thrombocytosis, the treating clinician should take a thorough history and perform a thorough clinical examination if a patient is diagnosed with it. Further investigation and the most appropriate referral route should be aided by this information.
It’s worth noting that the patients in the study had their blood tests done for a medical reason rather than as a random screening test.
If there are no other symptoms to guide investigation and referral (one-third of the patients in the study had no other symptoms), keep in mind that the two most common cancers encountered were colorectal and lung cancer, so a chest X-ray and a faecal immunochemical test (FIT) for faecal blood may be reasonable initial investigations.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 75
Incorrect
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Which of the following does NOT typically cause a neutrophil leucocytosis:
Your Answer:
Correct Answer: Glandular fever
Explanation:Causes of neutrophil leucocytosis:
Bacterial infection
Inflammation and tissue necrosis (e.g. cardiac infarct, trauma, vasculitis, myositis)
Metabolic disorders (e.g. uraemia, acidosis, eclampsia, gout)
Pregnancy
Acute haemorrhage or haemolysis
Neoplasms of all types
Drugs (e.g. corticosteroid therapy, lithium, tetracyclines)
Asplenia
Myeloproliferative disorders (e.g. CML, essential thrombocythaemia, polycythaemia vera, myelofibrosis)
Rare inherited disorders -
This question is part of the following fields:
- Immune Responses
- Pathology
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Question 76
Incorrect
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A dermatological examination on a patient presenting with a skin lesion which shows a solid, well circumscribed, lump measuring 0.8 cm in diameter. Which one of these best describes the lump you have found on examination?
Your Answer:
Correct Answer: Papule
Explanation:Macule— a small patch of skin that is altered in colour, but is not elevated.
Patch — a large area of colour change, with a smooth surface.
Papule— elevated, solid, palpable lesion that is ≤ 1 cm in diameter. They may be solitary or multiple. Papules may be:
Nodule — elevated, solid, palpable lesion > 1 cm usually located primarily in the dermis and subcutis (deeper layers of the skin). The greatest portion of the lesion may be above or beneath the skin surface.
Vesicle — a small blister. It is a circumscribed lesion ≤ 1 cm in diameter that contains liquid (clear, serous or haemorrhagic).
Cyst — papule or nodule that contains fluid or semi-fluid material so is fluctuant
Plaque — a circumscribed, palpable lesion more than 1 cm in diameter; most plaques are elevated.
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 77
Incorrect
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By the third day of wound healing, which sort of inflammatory cell has predominated:
Your Answer:
Correct Answer: Macrophages
Explanation:The inflammatory phase of healing is sometimes called the lag phase because wound strength does not begin to return immediately. The inflammatory phase is completed within three days except in the presence of infection or other factors associated with impaired wound healing. Mononuclear leukocytes accumulate and are transformed into macrophages. The maturation of blood-derived monocytes into macrophages is heralded by several events, including secretion of vimentin, which is a structural filament protein involved in wound healing.
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This question is part of the following fields:
- Pathology
- Wound Healing
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Question 78
Incorrect
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In which of the following would you NOT typically see a neutropaenia:
Your Answer:
Correct Answer: Asplenism
Explanation:Causes of neutropaenia:
Drug-induced (e.g. chemotherapy, chloramphenicol, co-trimoxazole, phenytoin, carbamazepine, carbimazole, furosemide, chloroquine, clozapine, some DMARDs)
Benign (racial or familial)
Cyclical
Immune (e.g. SLE, Felty’s syndrome, hypersensitivity and anaphylaxis)
Leukaemia
Infections (e.g. HIV, hepatitis, fulminant bacterial infection)
General Pancytopaenia
Hypersplenism, aplastic anaemia, malignant infiltration of bone marrow, megaloblastic anaemia, chemotherapy, myelodysplasia -
This question is part of the following fields:
- Immune Responses
- Pathology
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Question 79
Incorrect
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Fibrinoid necrosis is typically seen in which of the following:
Your Answer:
Correct Answer: Malignant hypertension
Explanation:Fibrinoid necrosis occurs in malignant hypertension where increased arterial pressure results in necrosis of smooth muscle wall. Eosinophilic and fibrinous deposits are seen.
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This question is part of the following fields:
- Inflammatory Responses
- Pathology
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Question 80
Incorrect
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A 54-year-old man who is acutely unwell has his blood sent for test and the results come back with a CRP of 115.
Which of these statements about C-reactive protein is FALSE?
Your Answer:
Correct Answer: It is produced in the bone marrow
Explanation:C-reactive protein(CRP) is synthesized in the liver in response to increased interleukin-6 (IL-6) secretion by macrophages and T-cells.
Some conditions that cause CRP levels to a rise include: bacterial infection, fungal infection, severe trauma, autoimmune disease, Organ tissue necrosis, malignancy and surgery.It is useful in the clinical setting as a marker of inflammatory activity and can be used to monitor infections.
CRP levels start to rise 4-6 hours after an inflammatory trigger and reaches peak levels at 36-50 hours.
In the absence of a disease process, the normal plasma concentration is less than 5 mg/l.
CRP is useful for monitoring inflammatory conditions (e.g. rheumatoid arthritis and malignancy), can be used as a prognostic marker in acute pancreatitis, and serial measurement can be used to recognize the onset of nosocomial infections in the intensive care settling.
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This question is part of the following fields:
- General Pathology
- Pathology
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SESSION STATS - PERFORMANCE PER SPECIALTY
