Pathology Quiz Mains

Q1
• A 35 yr old male, farmer by profession, presents with C/O
dyspnea on exertion and non-productive cough for 2 years.
• No H/O PND, orthopnea, dependent edema and palpitations.
• H/O on & off fever from onset of symptoms
• H/O easy fatiguability and significant weight loss
• CXR- Reticulonodular changes in B/L upper lung zones. No hilar
lymphadenopathy.
• PFT- Restrictive lung disease pattern with decreased DLco
• BAL specimen reveals- lymphocytosis with CD4
+/CD8
+ =0.9
• Tracheobronchial biopsy- Non caseating granuloma around
smaller airways with lymphocytic predominance
• Most likely diagnosis?

A1
• Hyersensitivity pneumonitis (Farmer’s lung)

Q2
• 27 year old male from Kerala, chronic diarrhoea, significant
weight loss, progressive dependent edema.
• 3 serial stool examinations- negative for cyst/ova
• Small intestinal biopsy- (on next slide)
• Suspecting a common malabsorptive disorder, put on gluten free
diet and sero-genetic studies performed. Revealed negative for
DQ2/DQ8 locus
• Further course of management?
A) Continue gluten free diet on high suspicion of DQ2/DQ8 –ve
celiac disease
B) Repeat stool for cyst/ova
C) Tetracycline therapy
D) Reassure about spontaneous improvement

A2
• Tropical sprue
• C) Tetracycline

Q3
• A 30 year old male with new onset chorea was
diagnosed with an autosomal recessive disorder
involving both hepatocellular and haemolytic
jaundice.
• Identify the disorder and explain the basis of the 2
types of jaundice.

A3
• Wilson’s disease
• Hepatocellular damage due to formation of free
radicals by accumulated copper in the liver.
Haemolysis due to toxicity of copper to RBC
membrane.

Q4
• A 24 yr old K/C/O Hemophilia A develops B/L knee pain with swelling from
past 10 days which has resulted in restricted ROM in both joints.
• He also has C/O new onset weakness, malaise and fatigue from past 3 months.
• X-Ray shows normal knee joint B/L with mild effusion on physical examination.
• Drug history reveals periodic Factor VIII administration and daily Lamivudine
100mg from past 6 months for chronic Hepatitis B which he probably had
acquired during treatment.
• O/E- Conscious and oriented pt with BP=150/100mmHg
Other vitals are normal, multiple nodular lesions on skin
Haemogram-WNL, Bleeding and Clotting profile-WNL
• Next step should be?
1. Factor VIII levels and administration if low
2. B/L knee arthroscopy to look out for hemophiliac arthropathy
3. Renal function test and plan for renal Bx
4. Liver function test and serological test for active HepB viral activity

A4
• 3) Renal function test and plan for renal Bx
Raised BP and skin nodules indicate vasculitis due to
chronic HepB infection. Most probably Polyarteritis
Nodosa.

Q5
• A 25-year-old G1P0 Caucasian woman presented in her 23rd week
of pregnancy with 3 months history of intermittent paresthesias
involving the left arm and face, slurred speech, blurred vision and
headaches. Three days later, she presented with an acute stroke in
the left occipital lobe.
• Laboratory findings were remarkable for a platelet count of
27,000/mm3, hemoglobin 7.4 g/dL, LDH 510 U/L, creatinine 2.5
mg/dL, total bilirubin 1.8 mg/dL, direct bilirubin 0.2 mg/dL, and
haptoglobin <9 mg/dL.
• Review of the peripheral blood smear showed 3-4 schistocytes per
high power field. ADAMTS13 levels were 7%. Tests for Shiga toxin
and Enterohemorrhagic E. Coli were negative.
• Diagnosis?

A5
• Atypical Hemolytic Uremic Syndrome

Q6
• A 30 year old man presented with complaints of progressive
abdominal distension and pain. On examination, tense ascites
was present. No lymphadenopathy was present.
Ultrasonogram of the abdomen revealed hepatomegaly,
ascites with dilated hepatic veins and many collaterals.
• Past medical history- K/C/O of HTN, H/O Generalized pruritus,
headache and dizziness
• Investigations-1)Genetic analysis- The patient was positive for
JAK2 mutation
2) Hb 21.9g/dL; RBC 6.96 × 106/µL Ferritin was 9
mg/mL (26–388), Iron 55µg/dL (65–175), total iron binding
capacity 431 µg/dL (250–450), iron saturation 13 percent(22–
55), and reticulocytes 1.12 percent (0.20–2.44)
• Diagnosis?

A6
• The patient is a case of Polycythemia vera,
leading to Budd-Chiari syndrome

A1
• Leprosy
Claw hand
AFB
Leonine facies

A2
• All are EBV related
Atypical lymphocytes- Infectious mononucleosis
Reed Sternberg cell- Hodgkin lymphoma
Burkitt’s lymphoma

A3
• Strawberry
Strawberry gall bladder- Cholesterolosis
Strawberry tongue- Scarlet fever
Strawberry cervix- Trichomoniasis

A4
• Alpha-1-antitrypsin
Cirrhosis
Emphysema
Bronchiectasis
Yolk sac tumour (Schiller-Duval body)

A5
• Extraintestinal manifestations of IBD
Primary sclerosing cholangitis
Ankylosing spondylitis
Clubbing
Erythema nodosum
Sacroiliitis

A6
• MEN-2B syndrome
Thyroid mass (medullary thyroid carcinomas)
Zellballen and Chromaffin test- Pheochromocytoma
Abraham Lincoln- Marfanoid habitus

CATEGORY ROUND
• Hematology
• Immunology
• Oncology
• Neurology
• CVS
• GIT

HEMATOLOGY Q1
• A 20 year old male presented to emergency with complaints of
acute onset of dyspnea, chest pain, cough and fever for 4 days.
Patient also gave history of episodes of severe pain in his hands and
feet and is a chronic alcoholic.
• On physical examination, temperature=102o F, pulse rate = 120 per
min, BP =120/82 mmHg, pallor present, anasarca present, CVS:
normal heart sounds, no murmur Respiratory system: bilateral
crepitations Abdomen: Hepatomegaly present.
• On investigations : Hb= 5gm%, pulse oximetry gives SapO2 <94%;
arterial blood gas reveal PaO2 <80%; Blood urea is 60 mg% , serum
creatinine= 2.5mg% and 24hr urinary protein= 3.5gm%
• Chest X-ray shows bilateral infiltrates
• CT abdomen shown (image on next slide)
• Diagnosis?

A1
• Acute chest syndrome (Sickle cell crisis)

HEMATOLOGY Q2
• A 58 year old man presented with confusion, lethargy and weight
loss. A complete blood count revealed lymphocytosis, anemia, and
thrombocytopenia. A lymph node biopsy revealed diffuse
effacement of nodal architecture admixed with loose aggregates of
lymphocytes. Bone marrow biopsy revealed a hypercellular bone
marrow with replacement of the normal architecture by
lymphocytes. He was treated with 6 cycles of fludarabine,
cyclophosphamide, and rituximab, and achieved a complete
response.
• Eighteen months after the completion of therapy, he presented
with fever, night sweats, and rapidly increasing lymphadenopathy.
CT scan demonstrated several lymph nodes in the cervical, axillary,
and retroperitoneal areas. An excisional lymph node biopsy of a
cervical lymph node showed the following finding (image on next
slide). The involved cells were positive for CD19 and CD20.
• Diagnosis?

A2
• Richter’s syndrome
• Initial case of CLL converted to a case of
Diffuse Large B-cell lymphoma
(back to categories)

IMMUNOLOGY Q1
• A 13-month-old male child was admitted to the pediatric ward with
complaints of pustular lesions on the neck, face and upper chest for 5 days,
primarily on the neck and spread to face and chest. Physical examination
showed multiple pustular lesions associated with itching and abscesses
around the neck, concentrated around the parotid region few of which had
hemorrhaged and crusted. Lesions were also observed around the forehead
and ears accompanied by hypopigmented macules. Patient had high grade,
intermittent fever for 3 days with decreased appetite. Mild cervical
lymphadenopathy was also observed. The patient has a past history of
multiple staphyococcal infections.
• Biochemical investigations revealed a hemoglobin level 6 g/dL, red cell
distribution width 24.5%, total leucocyte count 21,000 cells/mm3 with
increase in neutrophils, platelet count 1,70,000/mm3. Serum IgA 90mg/dL
(80-350mg/dL), serum IgG 700mg/dL (620-1400mg/dL), serum IgM 60mg/dL
(45-250mg/dL) serum IgE levels 10mg/dL (0.002-0.2mg/dL) Serum IgD
0.5mg/dL (0.3-3mg/dL)
• Pus and exudate culture reported growth of methicillin resistant
Staphylococcus aureus (MRSA).

A1
• Hyper IgE syndrome (Job syndrome)

IMMUNOLOGY Q2
• In the indirect pathway of graft rejection, why
is there no response by CD8
+ Tc cells?

A2
In the indirect pathway of allorecognition, the Ag is
presented by the APCs of the host. MHC-I expressed
on these APCs can only recognize endogenous
antigens, thus it fails to recognize the exogenous Ag
of graft and there is no CD8
+ Tc cell response

ONCOLOGY Q1
• SNAIL and TWIST are two genes, known as
metastasis oncogenes. As the name implies,
mutations in these genes predisposes already
transformed cells to metastasis, thereby
worsening the prognosis of the tumour.
• What function do these oncogenes mediate?

A1
• Epithelial-to-mesenchymal transition (EMT)

ONCOLOGY Q2
• Despite only a small subset of tumour cells having
oncogenic mutations (mutations in IDH1 and IDH2) in
enchondromas, why do all the tumour cells show
neoplastic transformation?

A2
Mutation in IDH1 and IDH2 lead to the enzyme,
isocitrate dehydrogenase, to acquire a new
enzymatic activity, thus producing 2-
hydroxyglutarate.
This oncometabolite diffuses into neighbouring cells
with normal IDH genes, thereby causing oncogenic
epigenetic changes in genetically normal neighbours
i.e. Transformation by association

NEUROLOGY Q1
A 69 year old woman with recent progressive decline in
carrying out activities of daily living frequently sits
motionless and staring into space; she also has frank
visual hallucinations. She has difficulty initiating
movement and she exhibits muscular rigidity and
resting tremor of her left hand. Her neocortex is
shown. What is the diagnosis and which
immunohistochemical stain should be used to
confirm her diagnosis?
(image on next slide)

A1
Dementia with Lewy bodies
Immunohistochemical stain- Alpha synuclein

NEUROLOGY Q2
• A 25 year old male presented to opd with complaint of
episodic muscle weakness and was first recognized at age
of 9. Weakness was generalized affecting lower limbs
significantly . It occured sometime after moderate physical
exercise and at times was so severe that patient had to stay
in bed. On physical examination, patient had micrognathia
and muscle force and development were normal; no other
abnormal signs or symptoms. Knee jerks were decreased ;
Serum potassium levels were normal but Serum myoglobin
and creatine kinase activity was enhanced. On stress
treadmill test, ventricular bigeminy and multiform
ventricular systole were found.
• Diagnosis?

A2
• Andersen-Twail syndrome

CVS Q1
• A 66 year old female presented to her local hospital with a three
week history of malaise, severe vomiting and pericarditic chest pain
and fever. On the day of admission she had become increasingly
short of breath and collapsed, presenting in a shocked state to her
local hospital. She was commenced on inotropic support. Despite
this BP was 85/60. On investigations;
• Cardiac CT- Showed a large LV aneurysm with a defect in the LV free
wall and a large pericardial effusion
• Echo- Confirmed the effusion. No echocardiographic evidence of
tamponade
• ECG- Showed evidence of a recent inferolateral wall MI
• How could the patient have survived a ventricular rupture?

A1
• Dressler syndrome (post-MI pericarditis)
leading to intense inflammation and
formation of adhesions in the pericardium,
thus preventing fatal extravasation of blood.

CVS Q2
A 16-year-old girl with a six-month history of weakness and fatigability of the
upper extremities, claudication of the lower limbs and diffuse arthralgia,
presented to the emergency department after sudden decrease in visual acuity.
Physical examination revealed high blood pressure (240/130 mm Hg) in both legs.
There were no signs of volume overload manifested by clear chest and absence of
peripheral edema. Renal bruits were not audible. The pulses in bilateral dorsalis
pedis and posterior tibial arteries were weak, and bilateral radial pulses were
absent. Fundoscopic examination showed papillary edema. The neurological
examination was unremarkable.
Laboratory investigations revealed raised CRP and ESR, serum creatinine: 0.5
mg/dL
Urinalysis: moderate proteinuria, without hematuria or pyuria,
ANA and Anti dsDNA Negative.
Ultrasound showed a small left kidney with renal asymmetry. Renal CT
angiography was done which is shown below
Percutaneous angioplasty was done and biopsy taken which is shown below.
What is the diagnosis?

A2
Takayasu arteritis

GIT Q1
• A five year old girl presented fever and cough for two days,
abdominal pain and vomiting. After two other days she
presented periorbital swelling and skin rash. Laboratory
findings on admission showed hypoalbuminemia
and eosinophilia. Screening for Helicobacter pylori
and cytomegalovirus resulted negative. Abdominal
ultrasonography showed moderate ascitis and in chest X ray
revealed effusion in both lungs. Gastroscopy showed severe
erosions in fundus and in upper part of stomach body. The
lower part of stomach and antrum was normal.
• Diagnosis?
• What is the underlying pathology (basis) of the disease?

A1
• Menetrier disease
• Excessive secretion of TGF-alpha

GIT Q2
• A 68-year-old woman was presented to the OPD with fatigue,
dizziness and melena for 2 years. She denied previous history of
liver, renal, or autoimmune system disease. Physical examination
found nothing special except for appearance of anemia and mild
tenderness under xiphoid.
• Laboratory findings showed a hemoglobin of 4.9 g/dl; a hematocrit
of 20 vol%; occult fecal blood test was positive; other examinations
like hepatic function, platelet count, prothrombin time, and
international normalized ratio were in reference ranges. Contrast
computed tomography scan of the abdomen revealed liver abscess
but no other significant GI pathology. The endoscopic appearances
showed erythematous stripes on the longitudinal rugal folds
radiating out from the pylorus (image on next slide)
• Diagnosis?

A2
• Gastric Antral Vascular Ectasia (GAVE)
(Watermelon stomach)

A1
• Lead poisoning
Burtonian line
Paint
Cabot’s ring
Wrist drop

A2
• Asthma
Mucus plug
Creola bodies
Charcot-Leyden crystals
Curschmann spirals

A3
• MERRF (Myoclonal epilepsy with ragged red
fibres)
Phonograph record- Mitochondria
Ragged red fibres
Mitochondrial inheritance

A4
• Craniopharyngioma
Bitemporal hemianopia
Motor oil
Precocious puberty
Diabetes insipidus

A5
• Tuberous sclerosis
Angiomyolipoma
Butterfly shaped Adenoma sebaceum
Tubers
Ash leaf macules

A6
• Congenital syphilis
Skin rash
Keratitis
Saber shin
Rhagades

Q1
• A 36 yr old female presents in gynae OPD with chief complaints
of cyclical pain during her menses from past 3 years. She has had
multiple consultations in indigenous medicine but not relieved.
• Pain typically starts a few days before her scheduled menses and
lasts till a few days after bleeding stops. Pain is vague, dull
aching involving lower abdomen and pelvic area. Poorly
responsive to NSAIDs intake.
• Of late, she has also started having reddish discolouration of
urine and severe chest pain which increases on inspiration,
particularly synchronous with her menstrual complaints.
• CXR- (image on next slide)
• USG- Left sided adnexal mass, cystic with ground glass texture
• Diagnosis?

A1
• Disseminated endometriosis
• Ovarian, lung and bladder endometriosis

Q2
• A 46 year old man, who is a chronic smoker, has had increasing
dyspnea with non productive cough for the past year. On
physical examination he is afebrile and has clubbing of digits.
PFT reveals a mild restrictive abnormality along with reduced
DLCO.
• A transbronchial biopsy is performed and microscopic
examination shows numerous alveolar macrophages, plump
epithelial cells, mild interstitial fibrosis, and loss of respiratory
bronchioles. Lamellar bodies and iron pigment are present
within these macrophages. Following is the histological picture
• What is the diagnosis?

A2
• Desquamative interstitial pneumonia

Q3
• A 35 year old man has had an outbreak of pruritic lesions over
the extensor surfaces of the elbows and knees during the past
month. He has a history of malabsorption that requires him to
eat a special diet, but he has had no previous skin problems.
The skin lesion is shown below along with the histopathology.
What is the characteristic finding that will be seen on
immunofluorescence?

A3
• Focal granular deposits of IgA at the tips of
dermal papillae

Q4
• A 50 yr old female
presents in ENT OPD with
chief complaints of a
lump on the hard palate
with extension to left
buccal mucosa,
numbness of the upper
jaw and palate, difficulty
swallowing and a new
onset deviation of angle
of mouth to the right
with drooling of saliva.
• The mass was biopsied
• What could it be most
likely?

A4
• Adenoid cystic carcinoma of salivary gland

Q5
• Despite it having an extremely high incidence
in India, why is Western Africa relatively free
from vivax malaria?

A5
• The Western African population has a very low
incidence of the Duffy antigen, via which P. vivax
binds to the red blood cell.
(Sickle cell will not be accepted)

FINAL ROUND
• 3 quizmasters acted as patients.
• Teams had to go to the patients one after the
other to elicit a history from them. Total time
given was three minutes per patient.
• After the history, the teams could choose to
buy the examination findings and/or
investigation findings from their points.

Case 1
• 2 month old male presented in the pediatric
emergency with abnormal shaky movements of
forelimbs. The resident on duty examined the
patient and checked capillary glucose, which was
70 mg/dl. The patient has had fever for the past
two days, responding to antipyretics. No history
of nausea with or without vomiting, rash, burning
micturition or loose stools. Antenatal and
perinatal history is unremarkable. There is a
history of multiple respiratory infections which
the parents call pneumonia. However, no
documents have been brought.

Examination 1
General Physical Examination:
• Irritable infant with weak cry
• Vitals: Afebrile
• Heart rate = 50 bpm
• Carpopedal spasm on measuring the blood pressure
• Severe pallor present
• No evidence of icterus, cyanosis, clubbing or lymphadenoathy
• Left sided ptosis with down and out deviation of left eye and non reactive pupil
• Absent nasolabial fold on right side with deviation of angle of mouth to left side
• Drooling of saliva present
Per abdomen: Liver palpable 4 cm below the costal margin
Liver span is 10 cm (97th centile at 8.9 cm for age)
Splenomegaly present

Investigation 1
• Total blood calcium = 6 mg/dL
• Ionized blood calcium= 2.8 mg/dL
• PTH and VitD3 levels were raised
Haemogram

Case 2
• 25 year old female presents with shoulder and
elbow stiffness which followed episodes of pain
and reduced mobility of the joints 6 months back,
which was relieved by NSAIDs. She also gives
history of hair loss for the past 2 months, for
which she has been on iron-biotin
supplementation, but with no relief. Of late, she’s
started feeling very warm in the forearms and
arms. She also gives history of retrosternal
burning pain on retiring for bed which gets
relieved on taking antacids. Her perinatal, family
and menstrual histories are unremarkable.

Examination 2
• Average built female with BMI = 20.5 kg/m2
• Oriented and cooperative
• Vitals are stable
Head to Toe examination:
• Expressionless face with loss of skin wrinkles
• Shiny and tense skin with xerotic areas
• Beaky nose
• Thin lips with restricted mouth opening
• Multiple carious teeth with lingual plaque present
• Dilated skin capillaries visible over face and oral mucosa
• Digits: Skin induration on fingers and fixed flexion contractures at PIP joints
• Sharply demarcated gangrenous changes of finger tips of right index and middle fingers
• A large hard nodular lesion palpable over the medial epicondyle of right elbow with ulcerative
changes of overlying skin.

•Plain radiograph of hands:
Dissolution of terminal
phalanges with multiple
radiodense opacities

• Skin Biopsy:
Marked
thickening of
the dermal
collagen with
loss of adnexal
structures and
attenuation of
periadnexal fat

Case 3
• 45 year old male with a history of on and off fever for
the past 4 months, generalised weakness for the past 3
months, anorexia and significant weight loss for the
past 3 months and easy bruisability for the past 2
months. The bruises appear typically over the trunk,
facial region and shoulder and follow trivial trauma
(photo on next page). The patient is obese in general,
with concentration of fat around the belly, in the back
and around the face. The patient has a history of
intravenous drug abuse. The patient has suffered from
episodes of chest infections in the past for which he
was given Septran. All other history is unremarkable.

Examination 3
• Oriented and cooperative patient.
• Vitals: stable
• BMI = 17.5 kg/m2
Head to Toe examination:
• Pallor present (as in lower palpebral conjunctiva)
• Periorbital edema and bruising present
• Facial wasting
• Dorsocervical pad of fat (Buffalo hump) is present
• Waist- Hip ratio is 1.2
• Multiple cervical and axillary lymph nodes palpable, >2 cm in size, mobile
• Small reddish- purple to brown nodular lesions present on face and trunk extending to arms and
forearms bilaterally
• Per orally – Reddish purple discolouration of oral mucosa resembling bruises of multiple ages.
White cheesy exudates sticking to the walls of the buccal cavity with and erythematous
base, similar exudates spreading to soft palate and posterior pharyngeal wall.
Systemic examination: Examination of rest of the systems is unremarkable

Investigation 3
•Haemogram
•FNAC of lymph nodes: Reactive
hyperplasia with mononuclear
cells
•Microbiological examination of
oral exudates: Gram staining
reveals gram positive hyphae and
yeast cells with budding. Culture
on SDA reveals white creamy
pasty colonies.
•24-hour Urine cortisol levels : 30
mcg/24 hour (ref: 20-70 mcg/24
hr)
•Dexamethasone Suppression Test
(1 mg): plasma cortisol = 1.5
mcg/dL (normal < 2mcg/dL)

• Biopsy of skin lesions:
Proliferation of
spindle cells and
endothelial cells with
RBC extravasation
and hemosiderin-
laden macrophages
with mononuclear
infiltration

Investigation 4
X-ray: Coronary
aneurysm seen

Pathology Quiz Mains

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