Pathology Picture Book

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Pathology Picture Book
Hello, and welcome to my course

• presented by
• Aaron Auerbach MD/MPH

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Aarons helpful hints for the boards 1

• The boards like to test gross images

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Question 13
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Question 13

• A 6-year-old boy was treated with antifebrile
  medication for flu. Ten days later, he
  developed projectile vomiting and neurological
  signs followed by coma and death. At autopsy,
  the liver, had the appearance illustrated in the
  photograph. Had a liver biopsy been done several
  days prior to death, which of the following EM
  findings would have been most helpful in making
  the correct diagnosis.
• Absence of perioxisomes
• Structurally abnormal mitochondria
• Myelin figures
• Giant lysosomes
• Intermediate filament aggregates

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What is your diagnosis?
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Answer B.

• This is a case of Reyes syndrome. In kids with
  a viral illness, who were treated with aspirin,
  this disease causes fatty liver and
  encephalopathy. Grossly, the liver is yellow.
  Histologically there liver has diffuse steatosis.
  On EM, the liver cell mitochondria are enlarged
  and mis-shapen.

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Aarons helpful hints for the boards 2

• The boards like to test you on disease
  associations

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Question 111
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Question 111

• Which of the following diseases can this renal
  disease be associated?
• Renal vein thrombosis
• Carcinoma of the colon
• Hodgkin lymphoma
• Hypocomplementemia

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Ans. C Hodgkin lymphoma

• This is an example of minimal change disease.
  It is characterized by diffuse effacement of the
  foot processes of the in glomeruli. By light
  microscopy, like in this case, the glomeruli are
  normal.
• MCD can be associated with Hodgkin lymphoma, and
  left frequently other lymphoma and leukemias.

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Question 75
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Question 75

• This high power photograph depicts a portion of a
  breast structure. It is
• Normal lobule
• Sclerosing adenosis
• Fibroadenoma
• Atypical lobular hyperplasia

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Ans. A
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Aarons helpful hints for the boards 3

• The boards love to show you a high power image of
  something normal, and try to get you to call it
  malignant

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Aarons helpful hints for the boards 4

• The boards love electron microscopy

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Question 121
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Question 121

• These ultrastructural findings are diagnostic of
• Angiosarcoma
• Leiomyoma
• Eosinophilic granuloma
• Squamous carcinoma
• Ewing sarcoma

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Ans C

• These are the rodlike pentalaminar structures of
  Birbeck granules with a dilated terminal end
  (tennis racket shape).
• Birbeck granules are characteristic of Langerhans
  cell histiocytosis which is also known as
  eosinophilic granuloma.

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Question 122
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Question 122

• These ultrastructural findings, a soft tissue
  mass on the lower extremity of a 22 year old
  woman are diagnostic of
• Clear cell sarcoma
• MFH
• Giant cell tumor of tendon sheath
• Alveolar soft part sarcoma
• Embryonal rhabdomyosarcoma

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Ans D

• These rhomboid shaped crystals are characteristic
  of alveolar soft part sarcoma.
• ASPS has a classic presentation of a mass in the
  lower extremity of a female adolescent or young
  female adult.

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Question 123
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Question 123

• This is an ultrastructural feature of
• Clear cell sarcoma
• Neurofibroma
• Malignant schwannoma
• Angiosarcoma
• Ewing sarcoma

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Ans A

• Clear cell sarcoma is a tumor which produces
  melanin and occurs mostly in young female adults.
  Fibrous tissue divide the tumor into nests. The
  tumor cells are pale staining and found in short
  fascicles. By, IHC this tumor is positive for
  S100, hmb-45, melanA and mircophtalmia
  transcription factor.
• By EM, melanosomes are often seen, as in this
  case.

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Aarons helpful hints for the boards 5

• The boards like to test you on administrative
  stuff that you dont know and dont need to know

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i.e.

• Clia 88
• The Family Leave Protection Act
• Indirect and direct costs
• Positive predictive value equations

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Aarons helpful hints for the boards 6

• The boards contain both extremely difficult and
  extremely hard questions

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Question 84
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Question 84

• In this Masson trichrome stain. The blue
  staining strands represent
• Mallory bodies
• Sinusoidal collagen
• Amyloid
• Hyperplastic kupffer cells
• None of the above.

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Ans B
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Aarons helpful hints for the boards 7

• The boards like to test you on reactive conditions

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Question 23
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Question 23

• This lesion is most likely o be seen in an
  endomyocardial biopsy from a patient with
• SLE
• AIDS
• A transplanted heart
• Chagas disease
• MacCallums plague

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Answer C

• Quilty lesions are endocardial inflammatory
  infiltrates associated with heart transplantation
  coupled with cyclosporine A. Quilty A lesions are
  confined to the endocardium and are composed
  primarily of small lymphocytes, with small
  capillaries, macrophages, and plasma cells.
  Quilty B lesions are similar, but they extend
  into the underlying subendocardium and
  interstitium, surrounding cardiomyocytes that may
  or may not show focal myocyte necrosis. Quilty
  lesions (A or B) do not appear to be clinically
  relevant.
• In Chagas disease, you would see acute
  inflammation and the amastigotes. In SLE, you
  would see vegetations on the valves with necrosis

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Aarons helpful hints for the boards 8

• The boards love heme

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Question 33
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Question 33

• Which blood cell parameter would most likely be
  accurate if this specimen is run on an automated
  cell counter?
• Hematocrit
• Hemoblobin
• Red blood cell count
• Mean cell volume
• Red cell distribution width

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Answer B

• This picture is showing red blood cell
  agglutination as seen in cold agglutinin disease.
  The RBC count is artificially lowered and the
  mean corpuscular volume falsely elevated. The
  reticulocyte count is also elevated. Hematocrit
  measures the volume of red blood cells as a
  percentage of the total blood volume.

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Question 34
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Question 34

• This RBC morphology may be associated with..
• Rh null disease
• Bombay blood group
• Kell negative cells
• Sickle cell disease
• S-C disease

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Answer E

• In Hb S-C disease. You can see sickle cells and
  target cells and Hb C crystals.

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Question 35
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Question 35

• The most likely diagnosis is
• Plasmodium vivax
• Plasmodium malaria
• Plasmodium falciparum
• Histoplasma capsulatum
• Toxoplasma gondii

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Answer C

• Multiple trophozoites of P. falciparum are often
  seen in a single red blood cells at the margins.
  Multiple parasites are rarely seen in P. ovale or
  P. malariae.

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Question 37
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Question 37

• Which would you expect to find?
• t(821)(q22q22)
• t(1517)(q22q11)
• t(922)(q34q11)
• t(814)(q24q11)
• t(119)(q23p13)

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Answer B

• --This is an example of acute promyelocytic
• leukemia with the cytogenetic translocation,
• t(1517)(q22q11)
• --t(821)(q22q22) is found in AML FAB M2.
• --t(922)(q34q11) is found in CML.
• --t(814)(q24q11) is found in Burkitt lymphoma.
• --t(119)(q23p13) is seen in acute lymphocytic
  leukemia.

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Question 38
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Question 38

• The most likely diagnosis is
• A. Prolymphocytic leukemia
• B. Follicular lymphoma
• C. Chronic lymphocytic leukemia
• D. Mantle cell lymphoma.
• E. Acute lymphocytic leukemiaL1.

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Answer C

• This is a bad example of CLL/CLL. Many of the
  lymphocytes are small and round in shape. Smudge
  cells are also present.
• In follicular lymphoma, we would expect to see
  cleaved lymphocytes, so called butt cells. ALL
  shows blastic cells with immature nuclei. Mantle
  cells are more irregularly shaped. In
  prolymphocytic leukemia the lymphocytes are
  larger and have nucleoli.

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The last of Aarons helpful hints

• The boards often have aweful picture like the
  last slide, but you still have to answer the
  question

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Questions?

• Questions?