HIGH-YIELD PRINCIPLES
92 Section I: General Principles • Questions
Q U E ST I O N S
1. A 48-year-man with chronic renal failure un-
dergoes a cadaveric renal transplant. One week
later, the patient has an elevated creatinine
level. The surgical team is concerned about
the possibility of acute transplant rejection.
The cell type shown in the image is believed to
be an important mediator of this process. In
which of the following locations does this cell
type complete maturation?
Immunology
Reproduced, with permission, from Berman I. Color Atlas of
Basic Histology, 3rd ed. New York: McGraw-Hill, 2003: 83.
(A) Bone marrow
(B) Lung
(C) Spleen
(D) Thymus
(E) Yolk sac
2. A 23-year-old man comes to the physician with
a bacterial infection. On questioning the pa-
tient reveals a history of recurrent bacterial,
fungal, and viral infections. Blood is drawn and
sent for laboratory analysis, which reveals all
levels of immune cells (eg., T lymphocytes, B
lymphocytes) are low. Which of the following
conditions is most likely to have caused the pa-
tient’s symptoms?
(A) Ataxia-telangiectasia
(B) Chédiak-Higashi disease
(C) Common variable immunodeficiency
(D) Job’s syndrome
(E) Severe combined immunodeficiency
(F) Wiskott-Aldrich syndrome
(G) X-linked agammaglobulinemia
3. A 13-year-old boy is diagnosed with a hyperac-
tive immune system. Normally an antigen will
activate the immune system to trigger a proin-
flammatory response. Following the proinflam-
matory response, anti-inflammatory signals
then dampen the immune response to prevent
it from causing damage. This patient has trou-
ble dampening the immune response after it is
no longer needed. Decreased activity in which
of the following anti-inflammatory cytokines is
most likely the basis for this boy’s condition?
(A) Interferon-γ
(B) Interleukin-1
(C) Transforming growth factor-β
(D) Tumor necrosis factor-α
(E) Tumor necrosis factor-β
4. A 19-year-old man comes to the physician with
a bacterial infection. Without treatment, the
patient’s immune system will most likely be
able to fight off the infection within a few days.
One of the tools the patient’s body uses against
the organism is the membrane attack complex.
The membrane attack complex functions as
which of the following?
(A) A chemoattractant for neutrophils
(B) An anaphylactic signal causing degranula-
tion of mast cells
(C) An opsonization molecule, facilitating
phagocytosis
(D) A proteinaceous pore in the plasma mem-
brane
(E) A scaffold on cell membranes to which an-
tibodies can bind
5. To assess the risk of erythroblastosis fetalis occur-
ring during the future pregnancy of an Rh-nega-
tive woman, a clinician sends a sample of serum
for detection of anti Rh-blood group antibodies.
The laboratory performs an indirect Coombs’
test by mixing the patient’s serum with Rh-posi-
tive RBCs and then adding an anti-IgG anti-
body. In doing so, the laboratory technician ob-
serves agglutination of the RBCs. After receiving
this test result, the clinician would be correct to
conclude which of the following?

(A) The Coombs’ test yielded a negative result,
and therefore the mother does not have
anti-Rh antibodies
(B) The laboratory performed the test incor-
rectly; they should have mixed the patient’s
serum with Rh-negative rather than Rh-
positive RBCs
(C) The patient has had previous pregnancies
and all of her children are Rh-negative
(D) The patient is currently pregnant with an
Rh-positive fetus
(E) The presence of anti-Rh antibodies in the
patient’s serum suggests that she has been
pregnant with an Rh-positive fetus
6. A newborn child is exposed to Streptococcus
agalactiae and subsequently develops meningi-
tis. Which of the following could have contrib-
uted to this child’s bacterial infection?
(A) A defect in DNA repair enzymes with asso-
ciated IgA deficiency
(B) An X-linked recessive defect in a tyrosine
kinase gene
(C) Improper development of the thymus and
parathyroid glands
(D) Improper transfer of IgG from the mother
to the fetus
(E) Improper transfer of IgM from the mother
to the fetus
7. Haemophilus influenzae and Neisseria menin-
gitidis both possess a polysaccharide outer cap-
sule. Effective vaccination against these species
results in the generation of antibodies that rec-
ognize this polysaccharide capsule. Which of
the following best explains why the childhood
vaccines for H. influenzae type B and N. men-
ingitidis serogroup C are composed of a poly-
saccharide coat conjugated to a protein car-
rier?
(A) The protein carrier increases the half-life
of the vaccine
(B) The protein carrier increases the produc-
tion of IgE immunoglobulins, which con-
fer protection
(C) The protein carrier is added to recruit T
lymphocyte help and increase antibody
production
HIGH-YIELD PRINCIPLES
Chapter 5: Immunology • Questions 93
(D) The protein carrier makes the vaccine less
virulent and thus decreases the risk of a
child developing disease from the immuni-
zation
(E) The protein carrier plays no role and is in-
cluded only for ease of preparation
8. A type B blood group, Rh-positive recipient is
mistakenly transplanted with a kidney from a
type A blood group, Rh-negative donor. Which
of the following best describes the mechanism
of transplant rejection that is most likely to en-
sue in this recipient?
(A) Acute rejection mediated by preformed re-
Immunology
cipient antibodies
(B) Acute rejection mediated by recipient T
lymphocytes
(C) Graft-versus-host disease mediated by do-
nor T lymphocytes
(D) Hyperacute rejection mediated by pre-
formed donor antibodies
(E) Hyperacute rejection mediated by pre-
formed recipient antibodies
9. A 12-year-old girl is brought to the pediatrician
by her mother because of a fever. The physi-
cian notes that the girl has features of albinism
and the mother states that her daughter has al-
ways looked the way she does. The physician
diagnoses the girl with a staphylococcal infec-
tion and prescribes a course of antibiotics.
Three months later, the child returns to the pe-
diatrician with another streptococcal infection.
The patient’s medical records indicate that she
has had repeated bouts of staphylococcal and
streptococcal infections for her entire life. This
patient most likely has which of the following
types of immune deficiency?
(A) Chédiak-Higashi disease
(B) Chronic granulomatous disease
(C) Hyper-IgM syndrome
(D) Selective IgA deficiency
(E) Severe combined immunodeficiency
HIGH-YIELD PRINCIPLES
94 Section I: General Principles • Questions
10. A 60-year-old post-menopausal woman presents
with fatigue, mild jaundice, and tingling in the
lower extremities. Laboratory studies show ele-
vated serum levels of homocysteine and methyl
malonic acid, and complete blood cell count
shows a mild thrombocytopenia. Which of the
following findings would be expected on a pe-
ripheral blood smear from this patient?
(A) A megaloblastic anemia with hyperseg-
mented polymorphonuclear leukocytes
(B) A microcytic anemia with hypersegmented
polymorphonuclear leukocytes
(C) A microcytic hypochromic anemia with
decreased serum iron and increased total
Immunology
iron-binding capacity
(D) A normochromic normocytic anemia with
decreased serum iron and decreased total
iron-binding capacity
(E) Normal peripheral blood smear with nor-
mal serum iron and normal total iron-
binding capacity
11. Antigen processing and presentation within the
context of a major histocompatibility complex
(MHC) class I molecule is essential to generat-
ing a CD8+ T-lymphocyte response. In which of
the diagramed subcellular locations is the self-
peptide loaded onto MHC class I molecules?
E D
B
C
A
Reproduced, with permission, from USMLERx.com.
(A) A
(B) B
(C) C
(D) D
(E) E
12. A 7-year-old boy presents to the clinic with a
staphylococcal infection. He is well known at
the clinic because he has had recurrent staphy-
lococcal infections for most of his life. He is
started on an antibiotic regimen and the infec-
tion subsides. Three weeks later, the boy is di-
agnosed with pruritic papulovesicular dermati-
tis. Which of the following immune deficiency
syndromes would account for this patient’s re-
current staphylococcal infections and pruritic
papulovesicular dermatitis?
(A) Ataxia-telangiectasia
(B) Bruton’s agammaglobulinemia
(C) Job’s syndrome
(D) Thymic aplasia
(E) Wiskott-Aldrich syndrome
13. Hyper-IgM syndrome usually presents with se-
vere pyogenic infections. The typical immuno-
globulin profile in a patient with this disease
shows an elevated level of IgM in contrast to
the other immunoglobulin isotypes. Which of
the following is the etiology behind the in-
creased level of IgM in a patient with hyper-
IgM syndrome?
(A) A defect in DNA repair enzymes
(B) A defect in LFA-1 adhesion proteins on
phagocytes
(C) A defect in the CD40 ligand on CD4 T
helper cells
(D) Failure of interferon-γ production
(E) Failure of the thymus and parathyroid
glands to develop
14. A 40-year-old man presents to his physician
with numbness and tingling on the dorsal sur-
face of his right hand and forearm and raised
“varicose veins” that are firm to the touch
along the same distribution. He also complains
of weight loss. His serum creatinine level is 2.0
mg/dL. He has no previous medical history of
significance. An immune complex disease is
suspected, and assays for autoantibodies in
neutrophils are conducted. What diseases are
associated with the identification of anti-my-
eloperoxidase and anti-proteinase-3 antibodies,
respectively?
 HIGH-YIELD PRINCIPLES
Chapter 5: Immunology • Questions 95

(A) Kawasaki’s disease, Buerger’s disease
(B) Microscopic polyangiitis, Wegener’s granu-
lomatosis
(C) Polyarteritis nodosa, Buerger’s disease
(D) Takayasu’s arteritis, Wegener’s granuloma-
tosis
(E) Temporal arteritis, Wegener’s granuloma-
tosis
15. A 32-year-old man with Hodgkin’s lymphoma
is scheduled to undergo a bone marrow trans-
plant. HLA typing of his immediate family
shows that his identical twin brother is a suit-
able match for harvesting an allogenic bone
17. A 37-year-old man comes to the physician with
recurrent viral infections. Blood studies show
normal levels of circulating lymphocytes and
neutrophils. A deficiency in which of the fol-
lowing cytokines would most likely lead to this
man’s condition?
(A) Interleukin-2
(B) Interleukin-3
(C) Interleukin-4
(D) Interleukin-5
(E) Interleukin-8
18. Cluster of differentiation (CD) antigens are
glycoproteins present on the cell surface of

Immunology
marrow graft. This type of graft can be classi-
many cell types involved in the immune sys-
fied as which of the following?
tem. They are recognized by monoclonal anti-
(A) Autologous bodies and aid in the identification of various
(B) Combination graft cell types. Which of the following glycopro-
(C) Heterograft teins is present on the cell surface of all thymo-
(D) Syngeneic cytes: helper T-cells, cytotoxic T-cells, and nat-
(E) Xenogeneic ural killer cells?
(A) B7
16. Patients sharing similar clinical symptoms and
(B) CD2
disease pathology may nevertheless present dif-
(C) CD3
ferently based upon age at disease onset. Adult-
(D) CD4
onset rheumatoid arthritis (RA) and juvenile
(E) CD19
rheumatoid arthritis (JRA) are both the result
(F) T-cell receptor
of inflammatory processes. How does the pre-
sentation of JRA differ from the presentation of
adult-onset RA?
(A) JRA is simply the presence of RA that be-
gins before the age of 21 years
(B) Patients with JRA are less likely to have sys-
temic symptoms, but the likelihood of
high levels of serum rheumatoid factor is
the same
(C) Patients with JRA are more likely to have
large joint involvement, but the likelihood
of concurrent systemic symptoms is the
same
(D) Patients with JRA are more likely to have
systemic symptoms and high levels of se-
rum rheumatoid factor
(E) Patients with JRA are more likely to have
systemic symptoms and large joint involve-
ment
HIGH-YIELD PRINCIPLES
96 Section I: General Principles • Questions
19. A 2-year-old girl with a lifelong history of mal-
absorptive and foul-smelling diarrhea, weak-
ness, and general failure to thrive has just un-
dergone a small intestine biopsy (see image).
Her parents believe her problems began at 6
months of age, when she started eating solid
foods, but have significantly worsened over the
past few months. The only recent change in
her diet is that she eats a bowl of cereal every
morning with her parents before they go to
work. She tried a dairy-free diet a month ago,
but it did not improve her symptoms. Which of
the following is the most likely diagnosis?
Immunology
Reproduced, with permission, from Chandrasoma P, Taylor
CR. Concise Pathology, 3rd ed. New York: McGraw-Hill,
1998: Figure 39-3.
(A) Abetalipoproteinemia
(B) Celiac sprue
(C) Lactase deficiency
(D) Viral enteritis
(E) Whipple’s disease
20. A pediatrician becomes concerned after learn-
ing the family and medical history of an infant
who is currently suffering from pneumonia,
with a presumed diagnosis of Streptococcus
pneumoniae infection. Over the past year, the
patient has suffered from erysipelas as well as a
previous bout of pneumococcal pneumonia;
both were treated successfully with antibiotics.
The patient’s mother says that her son’s mater-
nal uncle also suffered from repeated bacterial
infections and was successfully treated with an-
tibiotics. On physical examination, it appears
that the patient does not have tonsils. His
mother denies a previous tonsillectomy. Analy-
sis of the boy’s serum would most likely yield
which of the following results?
(A) Absence of T lymphocytes
(B) <200 CD4+ T lymphocytes/mm3
(C) IgA, IgG, and IgM levels normal
(D) IgG and IgM levels markedly decreased,
no IgA
(E) IgG and IgM levels normal, IgA markedly
decreased
21. A 25-year-old man presents to his doctor with a
2-day history of blood in his urine. A kidney bi-
opsy is obtained. When the tissue is stained
with fluorescent anti-IgG antibodies, the stain-
ing reveals a linear pattern. Which of the fol-
lowing is the most likely diagnosis?
(A) Acute poststreptococcal glomerulonephri-
tis
(B) Alport’s syndrome
(C) Goodpasture’s syndrome
(D) IgA nephropathy
(E) Membranous glomerulonephritis
22. A clinician is concerned that an Rh-negative
mother may be pregnant with an Rh-positive
fetus. The potential pathology that the clini-
cian is concerned about is classified as which
of the following immune reactions?
(A) Graft-versus-host disease
(B) Type I hypersensitivity
(C) Type II hypersensitivity
(D) Type III hypersensitivity
(E) Type IV hypersensitivity
23. A 14-year-old boy presents to the physician with
recurrent pyogenic infections. Physical exami-
nation shows that the boy has pruritic papulo-
vesicular dermatitis. Blood is drawn and sent for
laboratory evaluation of platelets and immuno-
globulin levels. The results show a markedly low
platelet count, a low serum IgM level, and an
elevated IgA level. This patient most likely has
which of the following conditions?
(A) Bruton’s agammaglobulinemia
(B) Chédiak-Higashi disease
(C) Job’s syndrome
(D) Thymic aplasia
(E) Wiskott-Aldrich syndrome

24. A 32-year-old woman comes to the emergency
department complaining of sudden blindness.
On obtaining a thorough history, it is learned
that the patient’s right leg has “given out” from
time to time, causing the patient to have epi-
sodes of weakness and falling. Periventricular
white matter plaques are found on MRI.
Which of the following cells are primarily
damaged in this disease?
(A) Astrocytes
(B) Ependymal cells
(C) Oligodendrocytes
(D) Schwann cells
(E) T cells
25. Women have about a 2.7 times greater lifetime
risk of developing at least one autoimmune dis-
ease than men. Which of the following state-
ments, if true, would support the higher rate of
systemic lupus erythematosus in women than
in men?
(A) Androgens such as testosterone have an in-
hibitory role in the process of clearing im-
mune complexes
(B) Both estrogens and androgens have the
same potency in inhibiting the clearing of
immune complexes
(C) Estrogen has an inhibitory role in the pro-
cess of antibody production of B cells
(D) Estrogen has an inhibitory role in the pro-
cess of clearing immune complexes
(E) Estrogen has a stimulatory role in the pro-
cess of clearing immune complexes
26. A 2-year-old boy is brought to the physician by
his parents because of recurrent sinus infec-
tions. The parents also state that the boy has
had multiple lung infections. Which of the fol-
lowing results would most likely be found on
further testing?
(A) A deficit in IgA level
(B) A low IgM level, with increased IgA
(C) A negative nitroblue tetrazolium dye test
(D) An increase in IgE level
(E) A normal Ig level for all isotypes
HIGH-YIELD PRINCIPLES
Chapter 5: Immunology • Questions 97
27. A 50-year-old man presents to his clinician be-
cause of bilateral itching, burning, and redness
of the lower extremities. He states that he wore
shorts while gardening outside his house re-
cently and could have come in contact with
poison ivy. Which of the following statements
regarding this patient’s immune response is
most correct?
(A) Goodpasture’s syndrome is a disease with a
similar reaction pathogenesis
(B) Histamine is the primary mediator leading
to this type of reaction
(C) The pathogenesis implicates previously
sensitized B lymphocytes
Immunology
(D) The patient has never been exposed to poi-
son ivy
(E) The patient is suffering from a type I hy-
persensitivity reaction
(F) The patient must have been exposed to a
poison ivy plant prior to this instance
28. Antibodies are one of the major players in the
adaptive immune response. All antibody mole-
cules consist of two heavy chains and two light
chains, and the specific type of heavy and light
chain will determine the antigen binding site.
In all antibodies, the two heavy chains and the
two light chains are identical. Like most pro-
teins, much of their functional capabilities and
antigen binding characteristics stem from their
three-dimensional structure. Which of the fol-
lowing holds the heavy and light chains to-
gether to make the three-dimensional structure
of the antibody?
(A) Disulfide bonds
(B) Hydrogen bonds
(C) Ionic bonds
(D) Triple covalent bonds
(E) Van der Waals forces
HIGH-YIELD PRINCIPLES
98 Section I: General Principles • Questions
29. A 23-year-old woman comes to the physician
for a routine checkup. She has generally been
well over the past year, although she notes that
she has “had a few falls lately.” On physical ex-
amination, the lesion shown in the image is
found on her skin. Blood is drawn for labora-
tory evaluation. The results show that the
woman has very low levels of IgA. Based on her
presentation, this patient will most likely also
present with which of the following symptoms?
Immunology
Reproduced, with permission, from Wolff K, Johnson RA,
Suurmond D. Fitzpatrick’s Color Atlas & Synopsis of Clinical
Dermatolgy, 5th ed. New York: McGraw-Hill, 2005:
Figure 9-22.
(A) Cerebellar problems
(B) Granulomas
(C) Low levels of all other immunoglobulin
isotypes
(D) Tetany
(E) Visual hallucinations
30. A 50-year-old man comes to the physician with
hemoptysis and diffuse joint pain. He states
that both his father and cousin had similar
symptoms and were diagnosed with micro-
scopic polyangiitis, a disease affecting medium-
to small-sized arteries that is believed to have
an autoimmune component to its pathogene-
sis. Which of the following autoantibodies
might be present in this patient?
(A) Anticentromere antibodies
(B) Antineutrophil cytoplasmic autoantibodies
(C) Anti-Smith antibodies
(D) Anti-SS-A (Ro) antibody
(E) Anti-SS-B (La) antibody