Alona Argie P.

Piano BSN IV-Camellia

1. A 15-year-old healthy girl with no major medical problems notes blotchy areas of erythema that are pruritic over the skin of her arms, legs, and trunk within an hour every time she eats seafood, followed by diarrhea. These problems abate within 3 hours, and then physical examination reveals no abnormal findings. Which of the following immunologic abnormalities is she most likely to have? A B C D E Localized anaphylaxis Cell-mediated hypersensitivity Release of complement C3b Hypergammaglobulinemia Immune complex deposition 5. A previously healthy 12-year-old girl develops a sore throat over the past 2 days. On physical examination she has marked pharyngeal erythema with overlying yellowish exudate. A throat culture grows group A betahemolytic Streptococcus. Her pharyngitis resolves, but 3 weeks later she develops chest pain along with fever and malaise. The girl describes aching of her knees, hips, shoulders, and elbows. Multiple subcutaneous skin nodules are noted on physical examination, and she exhibits slight shaking movements of her head and neck. Her antistreptolysin-O and anti-DNAse B titers are elevated. Her creatine kinase MB fraction is elevated. Her findings are most likely the result of which of the following immunologic mechanisms? A Bypass of low-zone tolerance through crossreactivity B Deposition of antigen-antibody complexes in multiple tissue C D Formation of an antibody to immune complexes Exposure of a previously sequestered antigen intensity for 2 days and then fades away after two weeks. Which of the following forms of immunologic hypersensitivity is most likely demonstrated in this patient? A B C D Type I hypersensitivity Type II hypersensitivity Type III hypersensitivity Type IV hypersensitivity

(D) CORRECT. This is a contact dermatitis, typical of exposure to a plant such as poison ivy.

(A) CORRECT. Food allergies are typically a form of type I hypersensitivity reaction. The allergens react with IgE bound to mast cells, mainly in skin and gastrointestinal tract. 2. Type I hypersensitivity responses of the immune system are accompanied by eosinophilia. An appropriate, useful type I response would most likely be directed against which of the following? A B C D E Amyloid protein Spirochetes Neoplasms Inhaled dusts Liver flukes

(E) CORRECT. Parasitic infestations can be accompanied by a type I hypersensitivity reaction. 3. A 54-year-old woman goes to her physician because she has noted that during the past month her fingers become pale and painful upon exposure to cold. On exam she has mild dyspnea, but no wheezing. Her blood pressure is 170/110 mm Hg. Her antinuclear antibody test is positive with a titer of 1:256 and a nucleolar pattern. Her serum urea nitrogen is 15 mg/dL with creatinine of 1.1 mg/dL. Which of the following autoimmune diseases is she most likely to have? A B C D E Discoid lupus erythematosus (DLE) Scleroderma Polymyositis-dermatomyositis Sjogren's syndrome (SS) Rheumatoid arthritis (RA)

E Interaction between genetic predisposition and environmental insults (A) CORRECT. Acute rheumatic fever follows a group A beta hemolytic streptococcal infection. There is crossreactivity of the immune response to streptococcal M proteins, with the heart mainly affected. 6. A 27-year-old woman is given intravenous penicillin to treat infective endocarditis. Within minutes of starting this therapy, she begins to have severe difficulty breathing with respiratory stridor and tachypnea. She suddenly develops an erythematous skin rash over most of her body. Her symptoms are most likely to be produced by release of which of the following chemical mediators? A B C D E Interleukin 1 Bradykinin Complement C5a Histamine Thromboxane

(B) CORRECT. The nucleolar pattern suggests scleroderma (systemic sclerosis) more than the other autoimmune diseases, and likely diffuse scleroderma. Complications of scleroderma include hypertension, though signs of renal failure may not occur unless the complication of malignant hypertension supervenes. She also has features of Raynaud phenomenon and pulmonary fibrosis. 4. Twelve hours after going on a hike through dense foliage, a 40-year-old man notices a slightly raised and tender irregular reddish rash on one forearm that was not covered by clothing. This rash gradually increases in

(D) CORRECT. She is having a type 1 hypersensitivity reaction with systemic anaphylaxis, in part mediated by histamine released from mast cells, which causes vascular permeability. About 20% of all persons will have some reaction to penicillin or similar drugs, and a few of these will be severe.

7. A 28-year-old woman undergoes allogeneic bone marrow transplantation for acute leukemia. Three weeks later, she has marrow engraftment and her hemoglobin and WBC count are returning to normal. However, she has the appearance of a fine, scaling skin rash over her trunk and upper extremities. These findings are most consistent with which of the following complications? A B C D E Reduced numbers of megakaryocytes Keratinocyte apoptosis Dry gangrenous necrosis Contact dermatitis Abrasions from a fight in the ICU

(T-cell) immunity. Viral, fungal, and bacterial infections occur frequently in the first year of life. 10. A 22-year-old man develops marked right lower quadrant abdominal pain over the past day. On physical examination there is rebound tenderness on palpation over the right lower quadrant. Laparoscopic surgery is performed, and the appendix is swollen, erythematous, and partly covered by a yellowish exudate. It is removed, and a microscopic section shows infiltration with numerous neutrophils. The pain experienced by this patient is predominantly the result of the formation of which of the following two chemical mediators? A B C D E Complement C3b and IgG Interleukin-1 and tumor necrosis factor Histamine and serotonin Prostaglandin and bradykinin Leukotriene and HPETE

(B) CORRECT. The rash is typical for graft versus host disease (GVHD). The donor lymphocytes engraft and attack host tissues, including epidermal keratinocytes, causing apoptosis. The two other tissues often affected by GVHD include liver and GI tract. 8. A 22-year-old woman is bothered by an erythematous rash involving her cheeks and nose every time she spends more than a few minutes outdoors on a sunny day. On physical examination between these episodes, there are no abnormal findings. A biopsy of the skin involved with the rash shows deposition of IgG along the basement membrane by immunofluorescence microscopy, but uninvolved skin does not demonstrate this IgG deposition. Her antinuclear antibody test is negative. She has no other complaints. Her renal function tests are normal. Which of the following is the most likely diagnosis? A B C D E Discoid lupus erythematosus Systemic sclerosis Contact dermatitis Systemic lupus erythematosus Dermatomyositis

(D) CORRECT. The findings are those of acute appendicitis. The acute inflammation is marked by neutrophil exudation. Release of a variety of chemical mediators results in the findings associated with inflammation: calor (warmth), rubur (erythema), tumor (swelling), dolor (pain). Aspirin, by inhibiting the cyclooxygenase pathway, can decrease prostaglandin synthesis. 11. A 40-year-old woman had bilateral silicone breast implants placed two years ago. Since that time, she has noted increased firmness with slight deformity of the breast on the left. The implants are removed, and there is evidence for leakage of the implant contents on the left. Which of the following cell types is most likely to be most characteristic of the inflammatory response in this situation? A B C D E Mast cell Eosinophil Giant cell Neutrophil Plasma cell

(A) CORRECT. This patient has the classic malar rash of lupus, but without a positive ANA or other findings, discoid lupus limited to the skin is the most likely diagnosis. Some patients with DLE (particularly those with a positive ANA) may go on to develop SLE. 9. An 11-month-old infant has had upper and lower respiratory tract infections almost continuously since the time of birth, with organisms including Pneumocystis jiroveci and Pseudomonas aeruginosa identified. The baby also has oropharyngeal candidiasis. The baby succumbs to a cytomegalovirus pneumonitis. At autopsy, the thymus is markedly hypoplastic, and lymph nodes throughout the body are small, with absent germinal centers on microscopic examination. Which of the following mechanisms is most likely to explain these findings? A B C D Adenosine deaminase deficiency Failure of B cell maturation to plasma cells Human immunodeficiency virus infection Autoantibodies to both T and B lymphocytes

(C) CORRECT. The silicone is a foreign material and produces a foreign body reaction. Persistence of the stimulus recruits macrophages that are activated and transformed to giant cells, in this case foreign body giant cells. 12. A 40-year-old man incurs a burn injury to his hands and arms while working on a propane furnace. Over the next 3 weeks, the burned skin heals without the need for skin grafting. Which of the following is the most critical factor in determining whether the skin in the region of the burn will regenerate? A B C D E Good cardiac output with tissue perfusion Persistence of skin appendages Maintenance of underlying connective tissue Diminished edema and erythema Granulation tissue formation

E Failure of development of 3rd and 4th pharyngeal pouches (A) CORRECT. Severe combined immunodeficiency (SCID) may be due to adenosine deaminase (ADA) deficiency in about half of cases. This disorder leads to malfunction of both humoral (B-cell) and cell-mediated

(B) CORRECT. The skin appendages have epithelium from which the surface epidermis can regenerate. This is why a full thickness burn is much worse

13. A 58-year-old woman has had a cough with fever for 3 days. A chest radiograph reveals infiltrates in the right lower lobe. A sputum culture grows Streptococcus pneumoniae. The clearance of these organisms from the lung parenchyma would be most effectively accomplished through generation of which of the following substances by the major inflammatory cell type responding to this infection? A B C D E Platelet activating factor Prostaglandins Kallikrein Leukotriene Hydrogen peroxide

swollen, particularly her lower leg below the knee. She experiences pain on movement of this leg, and there is tenderness to palpation. Which of the following complications is most likely to occur next after these events? A B C D E Gangrenous necrosis of the foot Hematoma of the thigh Disseminated intravascular coagulation Pulmonary thromboembolism Soft tissue sarcoma

(E) CORRECT. Hydrogen peroxide is reduced by myeloperoxidase to a powerful oxidant that kills bacteria. She has an acute inflammatory response to a bacterial organism, and the majority of inflammatory cells responding will be neutrophils. 14 A 56-year-old man has had increasing dyspnea for 6 years. He has no cough or fever. He had chronic exposure to inhalation of silica dust for many years in his job. A chest x-ray now shows increased interstitial markings and parenchymal 1 to 3 cm solid nodules. His pulmonary problems are most likely to be mediated through which of the following inflammatory processes? A B C D E Neutrophilic infiltrates producing leukotrienes Foreign body giant cell formation Plasma cell synthesis of immunoglobulin Mast cell histamine release Macrophage elaboration of growth factors

(D) CORRECT. She has deep and superficial venous thrombosis as a consequence of venous stasis from immobilization following the accident. The large deep venous thrombi can embolize to the lungs and lead to death. 17. A 40-year-old woman has had a chronic cough with fever and weight loss for the past month. A chest radiograph reveals multiple nodules from 1 to 4 cm in size, some of which demonstrate cavitation in the upper lobes. A sputum sample reveals the presence of acid fast bacilli. Which of the following cells is the most important in the development her lung lesions? A B C D E Macrophage Fibroblast Neutrophil Mast cell Platelet

(E) CORRECT. Growth factors are released from macrophages that have ingested silica crystals, and these factors stimulate collagen production by fibroblasts, producing interstitial fibrosis and nodule formation that reduces the amount of normal lung parenchyma and makes breathing more difficult. 15. A 20-year-old woman has premature labor with premature rupture of fetal membranes at 20 weeks gestation. Prior to that time, the pregnancy had been proceeding normally. A stillbirth occurs two days later. Microscopic examination of the normal-sized placenta reveals numerous neutrophils in the amnion and chorion, but no villitis. These events are most likely to be mediated by the effects from release of which of the following substances? A B C D E Immunoglobulin Prostaglandin Complement Fibrinogen Lymphokines

(A) CORRECT. Epithelioid cells and giant cells are derived from activated macrophages. Tissue macrophages are derived from blood monocytes. These cells are important in the development of granulomatous inflammation. 18. A 20-year-old man has experienced painful urination for 4 days following spring break. A urethritis is suspected, and Neisseria gonorrheae is cultured. Numerous neutrophils are present in a smear of the exudate from the penile urethra. These neutrophils undergo diapedesis to reach the organisms. Release of which of the following chemical mediators is most likely to drive neutrophil exudation? A B C D E Histamine Prostaglandin Hageman factor Bradykinin Complement C5a

(E) CORRECT. The C5a component of complement, along with TNF, leukotrienes, and bacterial products is chemotactic for neutrophils. 19. An episode of marked chest pain lasting 4 hours brings a 51-year-old man to the emergency room. He is found to have an elevated serum creatine kinase. An angiogram reveals a complete blockage of the left circumflex artery 2 cm from its origin. Which of the following substances would you most expect to be elaborated around the region of tissue damage in the next 3 days as an initial response to increase myocardial function and promote healing?

(B) CORRECT. This mediator of acute inflammation promotes labor through its effects on smooth muscle and blood vessels. 16. After two weeks in the hospital following a fall in which she incurred a fracture of her left femoral trochanter, a 76-year-old woman now has a left leg that is

A B C D E

Histamine Immunogloblulin G Complement component C3b Leukotriene B4 Vascular endothelial growth factor

substances on endothelial cells is most instrumental in promoting this inflammatory reaction? A B C D E Interferon gamma Hageman factor Lysozyme E-selectin Prostacyclin

(E) CORRECT. The VEGF stimulates angiogenesis to aid in establishing collateral circulation and restoring blood flow to the myocardium in this patient with an acute myocardial infarction. 20. A 90-year-old woman has developed a fever and cough over the past 2 days. Staphylococcus aureus is cultured from her sputum. She receives a course of antibiotic therapy. Two weeks later she no longer has a productive cough, but she still has a fever. A chest radiograph reveals a 3 cm rounded density in the right lower lobe whose liquefied contents form a central airfluid level. There are no surrounding infiltrates. Which of the following is the best description for this outcome of her pneumonia? A B C D E F Hypertrophic scar Abscess formation Regeneration Bronchogenic carcinoma Chronic inflammation Granulomatous cavitation

(D) CORRECT. Selectins are adhesive molecules expressed on endothelial cell surfaces and attract leukocytes, mainly neutrophils. P-selectin is expressed rapidly, while E-selectin is expressed within several hours. 23. An inflammatory process that has continued for 3 months includes the transformation of tissue macrophages to epithelioid cells. There are also lymphocytes present. Over time, fibroblasts lay down collagen as the focus of inflammation heals. These events are most likely to occur as an inflammatory response to which of the following infectious agents? A B C D E Mycobacterium tuberculosis Pseudomonas aeruginosa Cytomegalovirus Giardia lamblia Treponema pallidum

(B) CORRECT. The formation of a fluid filled cavity following an infection with S. aureus suggests that liquefactive necrosis has occurred. The cavity is filled with tissue debris and viable and dead neutrophils (pus). Localized, pus filled cavities are called abscesses. 21. A 35-year-old woman has been taking acetylsalicylic acid (aspirin) for arthritis for the past 4 years. Her joint pain is temporarily reduced via this therapy. However, radiographs of her knees reveals continuing joint destruction with loss of articular cartilage and joint space narrowing. This pain reduction is most likely to be the result of diminishing which of the following chemical mediators? A B C D E Leukotriene B4 Interleukin-1 Prostaglandin Bradykinin Hageman factor

(A) CORRECT. Mycobacterial organisms are difficult to kill, because of their lipid coat of mycolic acid. Hence a neutrophilic response has little effect. This persistent infection requires macrophage activation that leads to granuloma formation. 24. A 37-year-old man has had nausea and vomiting for 5 weeks. He experienced an episode of hematemesis yesterday. On physical examination he has no abnormal findings. Upper GI endoscopy is performed, and there is a 1.5 cm diameter lesion in the gastric antrum with loss of the epithelial surface. These findings are most typical for which of the following pathologic processes? A B C D E Abscess Serositis Granuloma Gangrene Ulcer

(C) CORRECT. Prostaglandins are produced via the cyclooxygenase pathway of arachidonic acid metabolism. Aspirin and non-steroidal anti-inflammatory drugs block the synthesis of prostaglandins, which can produce pain. Acetaminophen, which does not have the effect upon platelets that aspirin does, would be a better choice for the arthritis pain. 22. A small sliver of wood becomes embedded in the finger of a 25-year-old man. He does not remove it, and over the next 3 days the area around the sliver becomes red, swollen, and tender. Neutrophils migrate into the injured tissue. Expression of which of the following

(E) CORRECT. The loss of an epithelial surface is called an ulceration. The presence of hydrochoric acid in the stomach promotes this process when epithelial injury occurs. 25. A 17-year-old driver of a pickup truck is involved in a collision. He incurs blunt force abdominal trauma. In response to this injury, cells in tissues of the abdomen are stimulated to enter the G1 phase of the cell cycle from the G0 phase. Which of the following cell types is most likely to remain in G0 following this injury? A B C Smooth muscle Endothelium Skeletal muscle

D E

Fibroblast Hepatocyte

26. A 19-year-old woman is in the early second trimester at 16 weeks gestation with her first pregnancy. On a routine prenatal visit, the nurse cannot detect fetal heart tones and an ultrasound reveals no fetal cardiac activity or fetal movement. The mother has noted no recent illness or other factors to account for this fetal demise. She is given a pharmacologic agent to induce abortion. By which of the following mechanisms is this induction most likely to be accomplished? A B C Leukotriene-induced neutrophil aggregation Complement-induced hemolysis Histamine-induced edema

(A) CORRECT. This non-caseating granulomatous inflammation is typical for sarcoidosis. Granulomas are a form of type IV hypersensitivity reaction. There are cytokines such as interferon gamma produced by lymphocytes that recruit blood monocytes and stimulate macrophages to develop a granulomatous response. 29. A 55-year-old man has a history of hypercholesterolemia with coronary artery disease and suffered a myocardial infarction 2 years ago. He now presents with crushing substernal chest pain. Which of the following laboratory tests is most useful in diagnosing the cause of his chest pain? A B C D E F Increased white blood cell count Elevated sedimentation rate Decreased serum complement Increased serum creatine kinase Decreased platelet count Increased serum cholesterol

D Endotoxin-induced disseminated intravascular coagulation E Prostaglandin-induced muscular contraction

CORRECT. Skeletal and cardiac muscle cells do not typically proliferate in response to injury, and necrotic cells are replaced by connective tissue. Remaining striated muscle cells, however, can undergo hypertrophy. 27. A 19-year-old woman is in the early second trimester at 16 weeks gestation with her first pregnancy. On a routine prenatal visit, the nurse cannot detect fetal heart tones and an ultrasound reveals no fetal cardiac activity or fetal movement. The mother has noted no recent illness or other factors to account for this fetal demise. She is given a pharmacologic agent to induce abortion. By which of the following mechanisms is this induction most likely to be accomplished? A B C Leukotriene-induced neutrophil aggregation Complement-induced hemolysis Histamine-induced edema

(D) CORRECT. CK is an enzyme released from the damaged striated muscle. CK-MB would be more specific for cardiac muscle, while CK-MM mainly comes from skeletal muscle.

D Endotoxin-induced disseminated intravascular coagulation E Prostaglandin-induced muscular contraction

(E) CORRECT. Prostaglandins are generated through the cyclooxygenase pathway and induce smooth muscle contraction in the uterus. 28. A 45-year-old woman has had a chronic, nonproductive cough for 3 months, along with intermittent fever. She has a chest radiograph that reveals multiple small parenchymal nodules along with hilar and cervical lymphadenopathy. A cervical lymph node biopsy is performed. Microscopic examination of the biopsy shows noncaseating granulomatous inflammation. Cultures for bacterial, fungal, and mycobacterial organisms are negative. Which of the following chemical mediators is most important in the development of her inflammatory response? A B C D E Interferon gamma Bradykinin Complement C5a Histamine Prostaglandin E2