Approximately 4 days after a romantic encounter with a new partner at a ski

lodge, a 32-year-old man develops mild urethral discomfort

followed, a few hours later, by painful urination accompanied by a purulent
discharge. He consults a physician the following day. Physical
examination demonstrates red, swollen urethral lips and a purulent, yellowishgreen urethral discharge. Gram's stain of the discharge
performed in the doctor's office demonstrates neutrophils packed with gramnegative kidney bean-shaped diplococci.

Explanation - Q: 1.1

Close

The correct answer is B. The only medically important gram-negative cocci

are in the genera Neisseria and Moraxella. Neisseria meningitidis is the
etiologic agent of meningococcal meningitis and meningococcemia and
Neisseria gonorrhoeae is the etiologic agent of gonorrhea. Moraxella
catarrhalis is a cause of pharyngitis, otitis media, and sinusitis in children.
Chlamydia(choice A) is an intracellular organism that would not be visible
with the Gram's stain.
Staphylococcus(choice C) and Streptococcus(choice D) are gram-positive
cocci and would not be associated with this set of symptoms.
Treponema(choice E) is a spirochete that would not be visible on Gram's
stain.

Explanation - Q: 1.2

Close

The correct answer is C. This patient has a classic presentation for

gonorrhea. In men, the infection typically produces urethritis with a purulent
urethral discharge 2 to 14 days after sexual contact. In women, gonorrhea
may be nearly or completely asymptomatic, or may cause dysuria, increased
frequency of urination, and vaginal discharge. Rectal infection in men or
women may be asymptomatic or cause perianal discomfort and rectal
discharge.
AIDS (choice A) is a viral infection that would not cause these symptoms,
and would not be diagnosed with a Gram's stain.
Chlamydia urethritis (choice B) would not cause a purulent discharge
because Chlamydia trachomatis is an intracellular parasite of mucosal cells,
and it would not be visible on a Gram's stain.
Lymphogranuloma venereum (choice D) is also caused by Chlamydia
trachomatis, but by different serotypes than those that typically cause
chlamydial STD in the U.S. Because Chlamydia is an intracellular pathogen, it
would not cause a purulent discharge.
Syphilis (choice E) characteristically causes production of a chancre at the
site of inoculation rather than an urethritis, and the causative organism is a
narrow spirochete that can only be visualized by darkfield microscopy or
direct fluorescence.
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Question 3 of 5

Following culture of the causative organism, which of the following biochemical

attributes would be most definitive in determining the causative
species?
/A. Catalase production

/B. Nitrate reduction

/C. Production of acid from glucose but no
/D. Production of acid from maltose
/E. Production of cytochrome c oxidase

other sugars

Explanation - Q: 1.3

Close

The correct answer is C. Neisseria gonorrhoeae is distinguished from all

other members of the genus by its utilization of glucose, but not maltose.
The entire genus Neisseria produces catalase (choice A); it is therefore not a
characteristic that distinguishes the species, but only the genus.
Nitrate reduction (choice B) is not a useful criterion, as it is absent in both
Neisseria meningitidis and N. gonorrhoeae.
Production of acid from maltose (choice D) is an attribute of Neisseria
meningitidis, but not of N. gonorrhoeae.
Production of cytochrome c oxidase (choice E) is an attribute of the entire
genus Neisseria, as well as several gram-negative bacilli, such as
Campylobacter, Helicobacter, and Vibrio.
Question 4 of 5

Genetic coding found for resistance to beta-Iactam antibiotics resides in which of

the following locations?
/A. Chromosome
/B. Conjugative plasmids
/C. Cytoplasmic membrane
/D. Non-conjugative plasmids
/E. Phage genome

Explanation - Q: 1.4

Close

The correct answer is D. In Neisseria gonorrhoeae, the plasmids that code

for the production of beta lactamases possess the ori T, but not the tra
operon. Other plasmids in the cell mediate production of the conjugal bridge
by their possession of the tra operon, and the plasmids containing the drug
resistance genes are mobilized across the preformed conjugal bridge along
with the fertility factor plasmid.
The chromosome (choice A) is the site of coding of genes for penicillinbinding proteins, but most enzyme-mediated drug resistances are coded for

on plasmids.
Conjugative plasmids (choice B) is not correct. Although in most cases of
enzyme-mediated drug resistance, the coding exists on plasmids, in the
specific case of Neisseria gonorrhoeae, the genes exist on plasmids that do
not have the tra operon and are thus, non-conjugative plasmids.
The cytoplasmic membrane (choice C) is not correct because although this is
the location of penicillin-binding proteins, and mutations in these proteins are
responsible for low-level penicillin resistance in some species, there is no
"genetic coding" i.e., DNA in this location. Furthermore, this is not the
mechanism of drug resistance in Neisseria at the present time.
The phage genome (choice E) is not correct because although phage may
impart other important pathogenic features to bacteria, they are not generally
associated with drug resistances.

Question 5 of 5

If this man had not sought treatment and had infected his pregnant wife, his baby
would be at most risk for developing which of the following
unless prophylactic measures were taken?
/A. Condylomata lata
/B. Ecthyma gangrenosum
/C. Granuloma inguinale
/D. Granulomatosis infantiseptica
/E. Ophthalmia neonatorum
Explanation - Q: 1.5

Close

The correct answer is E. The Centers for Disease Control (CDC)

recommends routine use of 1% silver nitrate, erythromycin, or tetracycline
ophthalmic ointments or drops instilled in each eye after the delivery of an
infant to prevent ophthalmia, which might be caused by Neisseria, Chlamydia,
or Treponema.
Condylomata lata (choice A) is a manifestation of the secondary stage of
syphilis, when flat, wart like growths appear on the mucosa.
Ecthyma gangrenosum (choice B) is the characteristic skin lesion associated
with Pseudomonas infections.
Granuloma inguinale (choice C) is a disease of the genitalia caused by
Calymmatobacterium (Klebsiella) granulomatis.

Granulomatosis infantiseptica (choice D) is an infection of the fetus in utero

with Listeria monocytogenes.

A 19-year-old man presents to his college health clinic complaining of a painless

sore on his penis. The patient states that 4 weeks prior to
presentation, he had unprotected sexual intercourse with a new partner. About
two weeks after this encounter, he developed a red spot on the
glans of his penis. It has always remained small and now has created a "crater"
on the tip of his penis. He denies dysuria, fevers, chills, meatal
discharge, or any similar previous episodes. Three months ago he had an HIV
test, which was negative. Upon examination, the physician
elicits bilateral inguinal adenopathy that is firm but not tender to palpation. There
is no discharge elicited from the urethral meatus. On the right
side of the glans penis is a small chancre with indurated edges. The base of the
lesion is clean, and no fluid can be expressed upon applying
pressure. Rectal examination shows normal sphincter tone with a firm,
appropriately sized, non-tender prostate. Urine dipstick is negative for
any sign of infection.
Explanation - Q: 2.1

Close

The correct answer is E. This patient has primary syphilis. Syphilis, a

sexually transmitted disease, may present 2-4 weeks after exposure and
begins as a hyperemic or erythematous spot. This painless papule or pustule,
develops on the glans, corona, foreskin, shaft, suprapubic area, or scrotum. It
may break down to form an indurated, punched-out lesion. The syphilitic
(hard) chancre is relatively deep, has indurated edges and a clean base, and
is not tender on pressure. The lesion may be so small and transient that it is
missed. Without treatment, the lesion will heal spontaneously and slowly.
Inguinal adenopathy may be tender or nontender and is typically firm and
"rubbery."
The ulcer associated with chancroid (choice A) is painful, and is deep, with
an undermined border and a friable base that bleeds easily. The adenopathy
is painful and, with chronic infection, may cause lymphatic obstruction.
Incubation is one to four days.
Chlamydia(choice B) causes urethritis, and not genital ulcers. It typically
presents 7-21 days after exposure, with dysuria and mild-to-moderate whitish
or clear urethral discharge.
Genital herpes (choice C) typically presents as penile lesions of grouped
vesicles on an erythematous base that do not follow a neural distribution. The

lesions are tender to touch and the associated adenopathy is bilateral, mildly
tender, non-fixed, and slightly firm. The primary episode is more severe than
recurrent attacks and the incubation period is 2 -10 days.
Granuloma inguinale (choice E) initially presents as a papule that ultimately
forms a non-tender, erythematous ulcer with hemorrhagic secretions. There is
inguinal swelling or pseudobubo, which is actually a subcutaneous
granulomatous process rather than a true lymphadenopathy. Untreated, it
enlarges by direct extension, or may erode through the skin.

Explanation - Q: 2.2

Close

The correct answer is E. Syphilis is caused by the spirochete Treponema

pallidum. It gains access through intact or abraded skin or mucous
membranes.
Calymmatobacterium granulomatis(choice A) is the causative agent of
granuloma inguinale.
Chlamydia trachomatis(choice B) is the bacteria responsible for nongonococcal urethritis.
Chancroid is caused by Haemophilus ducreyi(choice C).
The herpes simplex virus (choice D) is associated with genital herpes. Eighty
percent of the genital lesions are caused by the type II virus. These lesions
are painful, and associated with systemic symptoms such as malaise,
anorexia, and fever.

Question 3 of 6

The treatment of choice for this infection is an intramuscular injection of penicillin

G. Which of the following antibiotics has antimicrobial activity
that is similar to that of the penicillins?
/A. Aminoglycosides
/B. Cephalosporins
/C. Erythromycin
/D. FIuoroquinolones
/E. Sulfonamides
Explanation - Q: 2.3

Close

The correct answer is B. The penicillins are classified as beta-lactam drugs.

This is because of their core structure, which contains a thiazolidine ring
attached to a beta-lactam ring that carries a secondary amino group. The
mechanism of action of these agents involves damage to the bacterial cell
wall. The steps involved in this are (1) attachment to specific penicillin-binding
proteins that serve as drug receptors on bacteria, (2) inhibition of cell wall
synthesis by blocking transpeptidation of peptidoglycan, and (3) activation of
autolytic enzymes in the cell wall, which results in lesions that cause bacterial
death. The cephalosporins also have a similar basic structure that
incorporates the beta-lactam ring and therefore, their mechanism of action is
similar to the penicillins.
The aminoglycosides (choice A) are bactericidal by virtue of irreversible
inhibition of protein synthesis. They penetrate the bacteria's cell wall and then
bind to the 30S subunit of the bacterial ribosome to inhibit ribosomal protein
synthesis.
Erythromycin (choice C) is both inhibitory and bactericidal. It works by
binding to the 50S subunit (specifically onto the 23S rRNA) of the ribosome.
Protein synthesis is inhibited as aminoacyl translocation reactions and the
formation of initiation complexes are blocked.
The quinolones and fluoroquinolones (choice D) are potent inhibitors of
nucleic acid synthesis. They block the action of DNA gyrase (topoisomerase
II), the enzyme responsible for packing and unpacking supercoiled DNA.
Sulfonamides (choice E) are bacteriostatic, and work by competitive
inhibition. These medications compete with p-aminobenzoic acid (PABA) for
the enzyme dihydropteroate synthetase to block a step in the pathway of the
formation of purines, and therefore, ultimately, nucleic acids.

Question 4 of 6

If the patient were not treated, and instead developed advanced disease, which
of the following most accurately describes the likely findings
on physical examination?
/A. Normal pupils
/B. The pupils accommodate but do not react to light
/C. The pupils accommodate and react to light
/D. The pupils do not accommodate and do not react to light
/E. The pupils do not accommodate but react to light
Explanation - Q: 2.4

Close

The correct answer is B. Tertiary syphilis can affect the central nervous
system (this is termed neurosyphilis) and spirochetes may be found in the
cerebrospinal fluid. This may lead to tabes dorsalis, which is a neurological
deficit caused by the destruction of the dorsal columns and dorsal roots of the
spinal cord. Patients may also develop general paresis, due to invasion and
destruction of brain parenchyma. Frequently, those patients with
neurosyphilis will exhibit Argyll-Robertson pupils. This pathological finding
consists of pupils that will accommodate but have an absent pupillary reflex to
light. With accommodation, the eyes move medially and the pupils constrict
when focusing on a close object. However, the pupils fail to constrict in
response to a bright light, i.e., the pupillary reflex is absent.
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Question 5 of 6

If his disease were left untreated, which of the following regions of the spinal cord
would most likely be affected in this patient?
/A. Anterior white commissure and ventral horns
/B. Dorsal columns and dorsal roots
/C. Dorsal columns, Iateral corticospinal tracts, spinocerebellar tracts
/D. Lateral corticospinal tracts and ventral horns
/E. Ventral horns
Explanation - Q: 2.5

Close

The correct answer is B. Tabes dorsalis, seen in patients with neurosyphilis,

is a slowly progressive degenerative disease that involves the dorsal columns
and dorsal roots. Demyelination of the dorsal columns leads to a loss of
tactile discrimination and position and vibration sensations. Pain and
paresthesias can occur with irritative involvement of the dorsal roots. These
patients can present with a positive Romberg sign.
Lesions of the anterior white commissure and ventral horns (choice A)

occurs in syringomyelia.
Lesions of the dorsal columns, lateral corticospinal tracts, and spinocerebellar
tracts (choice C) occurs with subacute combined degeneration and
Friedreich's ataxia.
Lesions of the lateral corticospinal tracts and ventral horns (choice D) occurs
in amyotrophic lateral sclerosis (ALS).
Lesions of the ventral horns (choice E) occur in poliomyelitis.

Explanation - Q: 2.6

Close

The correct answer is C. In order to evaluate for the presence of syphilis,

two strategies may be employed. One is the microscopic visualization of the
spirochete from the skin lesion and the other is a serologic (blood) test to
identify evidence of the body's reaction to syphilis. Fluorescent treponemal
antibody-absorption is a treponemal-specific serological test that will remain
positive for life. With this test, the patient's serum is filtered to separate out
any treponemal antibodies that are not specific to T. pallidum. The patient's
serum is poured onto a slide covered with T. pallidum antigens, then the slide
is washed, leaving the anti-treponemal antibody-antigen complexes on the
slide. Fluorescent antibodies that react with human immunoglobulins are then
added, and bind to the antibody-antigen complexes on the slide. The slide is
then examined with an ultraviolet microscope, any fluorescence indicates a
positive test.
Darkfield microscopy (choice A) and the direct fluorescent antibody T.
pallidum test, or DFA-TP (choice B) are both techniques that utilize fluid from
either the chancre or the maculopapular rash (if secondary syphilis). Darkfield
microscopy uses direct visualization of the organism. DFA-TP consists of
mixing anti-T. pallidum antibodies conjugated to fluorescein with a sample of
fluid. If the sample contains the spirochete, the antibodies will bind and allow

visualization of the spirochete with an ultraviolet microscope. Once the lesion

heals, there will be no spirochetes to see.
VDRL (choice E) and RPR (choice D) are non-treponemal serological tests
that are used for screening and to monitor the success of treatment. They
employ an antigen that is a mixture of cardiolipin, cholesterol, and lecithin.
Their titers rise following infection, and parallel disease activity. As the
disease improves, RPR and VDRL levels will decrease, therefore, titers are
followed to monitor treatment. Nontreponemal serological tests are
nonspecific, and other conditions may give a positive result.
A 27 year-old man visits his primary care physician because of testicular pain. He
states that over the last 3 weeks he has been feeling a
vague and heavy sensation in his right testicle. He denies any dysuria, urethral
discharge, testicular trauma, prior testicular surgery, fevers, or
chills. His genital examination is normal except for scrotal examination. His right
testicle is enlarged with an irregular, non-tender mass that
appears to be arising from and obliterating the normal testicular architecture. The
mass is not reducible, does not transilluminate, and does not
change with Valsalva maneuver. The spermatic cord can be palpated superiorly
to the mass and is normaI. Urinalysis is normaI.
Question 1 of 5

Which of the following is the most likely diagnosis?

/A. Acute epididymitis
/B. Hydrocele
/C. Inguinal hernia
/D. Testicular cancer
/E. Varicocele
Explanation - Q: 3.1

Close

The correct answer is D. This patient has the classic signs and symptoms of
testicular cancer. The most common symptom of testicular cancer is painless
enlargement of the testis. Enlargement is usually gradual, and a sensation of
testicular heaviness is not unusual. The mass is typically firm and nontender,
and the epididymis should be easily separable from it.
Acute epididymitis (choice A) is an infection of the epididymis acquired by the
retrograde spread of organisms down the vas from the urethra. Patients
present with heaviness and a dull, aching discomfort in the affected
hemiscrotum that can radiate up to the ipsilateral flank. On examination, the
epididymis will be markedly swollen and exquisitely tender to touch,
eventually becoming a warm, red, enlarged, scrotal mass. Fevers and chills

may develop.
A hydrocele (choice B) is a fluid collection within the tunica vaginalis
surrounding the testis. It presents as a painless swelling of the scrotum that
transilluminates. This transillumination is often necessary to differentiate a
hydrocele from a testicular carcinoma.
An inguinal hernia (choice C) is the result of a weakness in the floor of the
inguinal canal. It may be an incidental finding on physical examination or may
present with pain in the groin with Valsalva maneuver. If a scrotal mass is
present, it may contain a loop of bowel protruding through the weakness in
the inguinal canal. A mass associated with an inguinal hernia can usually be
differentiated from the testicle itself.
A varicocele (choice E) is an abnormal dilatation of the veins of the
pampiniform plexus and the internal spermatic vein of the spermatic cord.
Left-sided varicoceles are most common, occurring in approximately 15% of
normal adult males. The dilated veins are best palpated with the patient in the
standing position and aided by a Valsalva maneuver. The vessels are
palpated superior to the testicle and are described as feeling like "a bag of
worms."
Question 2 of 5

Prior to removal of the testicle (radical orchiectomy), what two blood tests must
be performed on this patient?
/A. AIdosterone and beta hCG (human chorionic gonadotropin)
/B. AIpha-fetoprotein (AFP) and beta hCG
/C. Complete blood count (CBC) and calcium
/D. Prostate-specific antigen and alpha-fetoprotein
/E. Testosterone and alpha-fetoprotein
Explanation - Q: 3.2

Close

The correct answer is B. Many germ cell tumors produce specific oncofetal
protein markers, either AFP or hCG, that can be detected in patients' serum
or tissue. Ninety percent of patients with nonseminomatous testis tumors will
have elevations of one or both markers and 5-10% with pure seminomas will
demonstrate elevations of hCG only. The amount of tumor burden is
proportional to the degree of marker elevation. It is important to draw these
levels prior to surgery. After removal, the tumor markers are monitored to
determine if there is residual disease (i.e., progression to retroperitoneal
lymph nodes).
Aldosterone (choice A) is produced within the outer cortical zona

glomerulosa of the adrenal cortex. Production is under the influence of

angiotensin II and the renin-angiotensin system. Aldosterone acts at the distal
tubule of the nephrons to cause sodium retention and potassium secretion. It
plays no role in the evaluation or monitoring of disease progression for
testicular cancer.
A complete blood count (choice C) measures the patient's white blood cells,
hemoglobin, hematocrit, and platelet counts. These values are not normally
altered in patients with testicular cancer. Calcium levels may be abnormal in
patients with malignancy and some paraneoplastic syndromes. Testicular
tumors are not generally associated with paraneoplastic syndromes.
Prostate-specific antigen (PSA) (choice D) is a tumor marker for prostate
cancer. It is secreted by the prostate and may be elevated in patients with
prostate cancer. It has no role in the work-up of testicular cancer.
Testosterone levels (choice E) are not altered with testicular cancer. There is
no need to measure this substance in these patients.
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Question 3 of 5

Radical orchiectomy requires an inguinal incision and removal of the testicle and
spermatic cord. Which of the following nerves runs parallel to
the spermatic cord within the inguinal canaI?
/A. Femoral
/B. IIioinguinal
/C. Lateral femoral cutaneous
/D. Obturator
/E. Pudendal
Explanation - Q: 3.3

Close

The correct answer is B. The inguinal canal is an oblique passage through

the inferior part of the anterior abdominal wall. The chief protection of the
inguinal canal is muscular. Its main constituent is the spermatic cord in the
male and the round ligament of the uterus in females. It contains the
ilioinguinal nerve in both sexes. This nerve is derived from the L1 segment,
enters the abdomen posterior to the medial arcuate ligament, and passes
inferolaterally, anterior to the quadratus lumborum muscle. The nerve pierces
the transversus abdominis muscle near the superior iliac spine, travels within
the inguinal canal, and passes through the superficial (external) inguinal ring
to supply the skin of the groin and scrotum or labium majora.
The femoral nerve (choice A) is the largest branch of the lumbar plexus. It

forms in the abdomen within the substance of the psoas major muscle and
descends posterolaterally through the pelvis to the midpoint of the inguinal
ligament. It then passes lateral to the femoral vessels, outside the femoral
sheath enclosing them. At no point in its course does it enter the inguinal
canal.
The lateral femoral cutaneous nerve (choice C) originates from L2 and L3
and is a direct branch of the lumbar plexus. It enters the thigh deep to the
lateral end of the inguinal ligament, near the anterior superior iliac spine. It
supplies the skin on the anterior and lateral aspects of the thigh.
The obturator nerve (choice D), originating from L2, L3, and L4 of the lumbar
plexus, is the nerve of the adductor muscles of the thigh. This nerve
descends through the psoas major muscle, leaving its medial border at the
brim of the pelvis. It pierces the psoas fascia, crosses the sacroiliac joint,
passes lateral to the internal iliac vessels and ureter, and enters the pelvis
minor. It leaves the pelvis through the obturator foramen and enters the thigh.
The obturator nerve supplies motor innervation to the obturator externus,
which is responsible for laterally rotating the thigh. This nerve also provides a
small cutaneous branch, which is responsible for sensation to the medial
aspect of the thigh.
The pudendal nerve (choice E) arises from the sacral plexus by separate
branches of the ventral rami of S2, S3, and S4. It accompanies the internal
pudendal artery and leaves the pelvis between the piriformis and coccygeus
muscles. It hooks around the sacrospinous ligament to enter the perineum
through the lesser sciatic foramen. Here, it supplies the muscles of the
perineum, including the external anal sphincter, and ends as the dorsal nerve
of the penis or clitoris.
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Question 4 of 5

Patients with advanced stages of this condition may be treated with bleomycin.
Which organ system toxicity is unique to bleomycin?
/A. Bone marrow
/B. Cardiac
/C. Neurologic
/D. Pulmonary
/E. Renal
Explanation - Q: 3.4

Close

The correct answer is D. Bleomycin, a chemotherapeutic agent, works by

binding to and then breaking DNA strands. Toxicities include pneumonitis and
pulmonary fibrosis. Patients should have pulmonary function testing (PFT)

prior to the administration of this medication.

Bone marrow toxicity (choice A), i.e., myelosuppression, is seen with many
different chemotherapeutic agents and is not unique to bleomycin.
Cardiac toxicity (choice B) is a rare complication of chemotherapy. It is
associated with the administration of doxorubicin.
Toxicity to the nervous system (choice C) is not usually encountered with
bleomycin.
Platinum-based chemotherapeutic regimens are most effective against
testicular tumors. Cisplatin is a known nephrotoxic agent and its use is limited
in patients with renal insufficiency. Carboplatin is another platinum-based
medication not associated with renal toxicity (choice E).
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Question 5 of 5

A biopsy taken from an infant with this condition would most likely reveal which of
the following?
/A. Lymphoma
/B. Mixed cell type
/C. Seminoma
/D. Teratoma
/E. Yolk sac tumor
Explanation - Q: 3.5

Close

The correct answer is E. Testicular tumors are classified as either germ cell
or non-germ cell tumors. Germ cell tumors comprise 95% of all testicular
tumors. The two major divisions are seminomas and nonseminomas. The
nonseminoma division includes yolk sac, embryonal carcinoma, teratoma,
choriocarcinoma, and mixed tumors. Yolk sac tumors, also called endodermal
sinus tumors or orchioblastomas, are nonseminomatous germ cell tumors
that have a peak incidence in the infant and childhood age group. Grossly,
these tumors appear yellow. Histologically, they contain Schiller-Duval bodies
that resemble 1-2 week old embryos, i.e., a cavity surrounded by
syncytiotrophoblasts and cytotrophoblasts. Yolk sac tumors metastasize
hematogenously, compared to other germ cell tumors, which spread via the
lymphatics.
Lymphoma (choice A) is the most common metastatic (secondary) tumor of
the testis and the most common testis tumor in men > 50 years old.
Mixed cell type (choice B) refers to tumors that contain a combination of

nonseminoma and/or seminoma. These account for up to 40% of testicular

germ cell tumors. If a tumor contains both seminoma and nonseminoma, it is
treated as a nonseminoma.
Seminoma (choice C) accounts for approximately 35% of germ cell tumors.
There are three histological subtypes, classic seminoma, anaplastic
seminoma, and spermatocytic seminoma. The classic variant accounts for
85% of all seminomas and is most common in the fourth decade of life.
Teratomas (choice D) contain derivatives of all three cell layers: ectoderm,
endoderm, and mesoderm. Microscopically, they appear as clear or mucinous
cystic areas interspersed with solid tissue including bone, muscle, or
cartilage. The peak incidence is in the 25-35 year old age group.