StanTon K. Shernan, MD, FAHA, FASE

• Associate Professor of Anesthesia
• Director of Cardiac Anesthesia
• Department of Anesthesiology, Perioperative, and Pain Medicine
• Brigham and Women's Hospital
• Harvard Medical School
• Boston, Massachusetts

Hemolysis Carcinoma Drug reaction Lithiasis Sepsis 60 A 54-year-old First Nations woman has had colicky right upper quadrant pain for the past week cholesterol kit walmart discount 5mg crestor mastercard. Her height is 160 cm (5 feet 3 inches) cholesterol test diy order crestor 5 mg visa, and her weight is 90 kg (body mass index 33) cholesterol counter chart order crestor 5 mg fast delivery. An abdominal ultrasound scan shows calculi within the lumen of the gallbladder xymogen cholesterol order crestor online, and the gallbladder wall appears thickened cholesterol test interference purchase 20mg crestor otc. Which of the following mechanisms is most likely to play the greatest role in development of her disease On physical examination cholesterol levels vary discount crestor 20 mg otc, there is right upper quadrant pain, but no abdominal distention. The loss of hepatic function from destruction of 80% to 90% of the liver results in hyperammonemia from the defective hepatocyte urea cycle, and this leads to hepatic encephalopathy within 2 weeks of the onset of jaundice. An elevated alkaline phosphatase level suggests extrahepatic or intrahepatic biliary obstruction. With the architectural remodeling of cirrhosis, there is portal hypertension and increased loss of hepatic interstitial fluid with protein into the peritoneal cavity. The serum albumin is likely to be low with chronic liver disease because of decreased synthetic capacity. This process takes years, but is potentially reversible to some degree if the injurious stimulus is removed. If sufficient functioning hepatic parenchyma remains, the cirrhosis may be well-compensated. Trail tip: eating polar bear liver, which contains large amounts of vitamin A, may produce vitamin A toxicity. Hyperreflexia, but not diminution of deep tendon reflexes, can occur when hepatic encephalopathy develops from decompensated cirrhosis. Right-sided heart failure, in which the liver may be enlarged because of passive congestion, is associated with distended jugular veins. Liver failure with cirrhosis may lead to hepatic coma, but brain swelling with papilledema is not a major feature. The coagulopathy from decreased liver function may lead to purpuric hemorrhages, but splinter hemorrhages of the nails are most characteristic of embolization from infective endocarditis. The ascites is caused by portal hypertension which results from two major changes: (1) mechanical obstruction to blood flow in the liver due to scarring and compression of sinusoids by regenerating nodules, and (2) splanchnic arterial vasodilation giving rise to hyperdynamic circulation which leads to increased portal venous blood flow. The latter is an important factor in the pathogenesis of portal hypertension and consequent ascites. Portosystemic shunts give rise to esophageal varices that bleed to cause hematemesis. The cause is obscure, but the result is pulmonary arterial vasoconstriction and ventila tion-perfusion (V/Q) mismatches that lead to hypoxemia. Chronic inflammation and steatosis may be seen with cirrhosis, but by themselves do not account for portopulmonary hypertension. In hereditary hemochromatosis, the liver has a dark brown gross appearance caused by extensive iron deposition. In sclerosing cholangitis, there is portal fibrosis, but not much nodular regeneration, so the liver is green and hard and has a finely granular surface. If liver stem cells support hepatocyte regeneration, and ductular reactions are minimal, then cirrhosis may be less progressive, and thin septae suggest some degree of regression. The massive upper gastrointestinal bleeding suggests esophageal varices as a consequence of portal hypertension from cirrhosis. If the patient is currently not drinking alcohol, no fatty change (steatosis) would be present. The architectural changes of cirrhosis persist for decades after cirrhosis develops. Concentric bile duct fibrosis is seen in primary sclerosing cholangitis, which may be idiopathic or may appear in association with inflammatory bowel disease. Budd-Chiari syndrome in hepatic venous thrombosis leads to hepatic enlargement, and it is rare. His final presentation of weight loss and rapid enlargement of the abdomen suggests that a hepatocellular carcinoma has developed, and in most cases is confirmed by an elevated -fetoprotein level. Any mass lesion in the liver is associated with an elevated alkaline phosphatase level. Liver disease that has persisted for 6 months, and histologic evidence of hepatic necrosis with portal inflammation and fibrosis, are features of chronic hepatitis. Choledocholithiasis leads to extrahepatic biliary obstruction and an elevated alkaline phosphatase level, but it is unlikely to produce hepatocellular necrosis. Hepatic congestion with rightsided heart failure produces centrilobular necrosis, but not portal fibrosis. Hemochromatosis can produce portal fibrosis and cirrhosis, but the liver cells show prominent accumulation of golden brown hemosiderin pigment. Sclerosing cholangitis leads to inflammation and obliterative fibrosis of bile ducts. The IgM antibody is replaced within a few months by IgG antibodies, which impart immunity to reinfection. The pattern of histologic change, the degree of transaminase elevation, and the duration of transaminase elevation are poor predictors of chronicity. Development of viral hepatitis requires an immune response against virus-infected cells. During the neonatal period, immune responses are not fully developed; hepatitis does not occur. The high carrier rate is medically significant because it increases the risk of hepatocellular carcinomas 200-fold. In populations with a high carrier rate, coexistent cirrhosis may be absent in 50% of patients. The carrier state is stable in most individuals, the so-called "inactive" carrier state, without elevation in liver enzymes, and some infected persons may eventually clear the virus. There is currently no therapy to aid this viral clearance Vaccination is useful to prevent infection, not clear the virus, although carriers become a reservoir for infection of others. More than 50% of individuals infected with this virus develop chronic hepatitis, and many cases progress to cirrhosis. Most persons have a subclinical infection, but 1 in 7 develops acute hepatitis; death is uncommon, except in pregnant women. Yellow fever is seen in tropical and subtropical regions of Africa and South America and is spread via mosquitoes. Chronic hepatitis is characterized by apoptosis of hepatocytes at the interface between portal tracts and the liver lobule. This eventually leads to cirrhosis with portal bridging fibrosis and nodular regeneration. Concentric bile duct fibrosis occurs in sclerosing cholangitis, which may be idiopathic or, more commonly, is associated with inflammatory bowel disease. Budd-Chiari syndrome in hepatic venous thrombosis leads to hepatic enlargement and necrosis and to ascites. However, though recovery occurs, in the acute phase of the illness beyond incubation, he is highly infective to others. Only 10% of cases progress to chronic hepatitis, and a subset of those go on to cirrhosis. Infection may be asymptomatic for years, but can progress to a chronic phase complicated by recurrent pyogenic cholangitis and jaundice. There is risk for development of cholangiocarcinoma, the second most common primary hepatic malignancy. The extraerythrocytic phase of malaria with plasmodium infection includes the liver. Patients with primary biliary cirrhosis often have antimitochondrial antibody (which also can be seen in autoimmune hepatitis), but the bilirubin concentration and alkaline phosphatase level would be much higher in primary biliary cirrhosis. Metastases are unlikely to obstruct all biliary tract drainage or lead to liver failure severe enough to cause elevations of blood ammonia. Primary biliary cirrhosis is rare, particularly in men, and the alkaline phosphatase level would be much higher. The remaining choices include conditions that are more likely to produce a pattern of chronic hepatic injury. Spider telangiectasias (angiomas) refer to vascular lesions in the skin characterized by a central, pulsating, dilated arteriole from which small vessels radiate. These lesions result from hyperestrogenism (which also contributes to the testicular atrophy). Ascites, splenomegaly, hemorrhoids, and esophageal varices all are related to portal hypertension from cirrhosis and the resultant collateral venous congestion and dilation. The figure shows globular eosinophilic cytoplasmic inclusions called MalloryDenk bodies. These cytokeratin inclusions are characteristic of, but not specific for, alcoholic hepatitis. Centrilobular congestion can lead to centrilobular necrosis without inflammation or Mallory-Denk bodies. Hemosiderin appears granular and brown on H&E staining, but it is blue with Prussian blue stain. In patients with no history of significant ethanol ingestion, a nonalcoholic steatohepatitis may be considered, with obesity, diabetes mellitus, or both as possible causes. Excessive acetaminophen ingestion can cause centrilobular necrosis or diffuse necrosis. Aspirin may be associated with a microvesicular steatosis as Reye syndrome in children. Though there may be hepatocyte loss and inflammation, these are not the most prominent features. In this patient, the disease is decompensating, as evidenced by the elevated blood ammonia level. Risk factors of metabolic syndrome and type 2 diabetes mellitus are driven by obesity. Familial hypercholesterolemia mainly drives atherosclerosis, without liver disease. Chronic viral hepatitis may have an element of steatosis, but not marked, and without vascular disease. The iron accumulation of hemochromatosis may produce cardiomyopathy as well as chronic liver disease without much steatosis. Biliary atresia with marked hyperbilirubinemia becomes apparent in the neonatal period. Hepatic venous thrombosis leads to Budd-Chiari syndrome, which is typically a disease of adults that complicates such conditions as polycythemia or pregnancy. Hepatoblastomas may be congenital, but they are mass lesions unlikely to be associated with such marked increases in liver enzymes. Intrahepatic lithiasis is unlikely to occur in children and is unlikely to produce marked increases in liver enzymes. Neonatal giant cell hepatitis can produce findings of acute hepatitis in neonates, not in children. Because performance is primarily correlated with skill and training, the potential gain from muscle mass is problematic, particularly in view of the deleterious effects, such as hepatic cholestatic hepatitis. Chlorpromazine is more likely to produce a pure cholestasis as an idiosyncratic (unpredictable) reaction. Obstructive jaundice with biliary tract lithiasis results in mostly conjugated hyperbilirubinemia. The total bilirubin concentration may be increased in patients with viral hepatitis or cirrhosis and in individuals taking drugs such as oral contraceptives. Although direct and indirect hyperbilirubinemia may occur in these conditions, conjugated hyperbilirubinemia predominates. The microcytic anemia and the blood in the stool suggest gastrointestinal tract hemorrhage, and a colonic adenocarcinoma should be suspected as the primary site for the hepatic metastases in this case. Antiphospholipid syndrome predisposes to thrombosis with venous obstruction, in which case hepatic enzyme levels should be higher, and the partial thromboplastin time should be prolonged. Ascending cholangitis is typically caused by bacteria such as Escherichia coli or Klebsiella, and patients develop acute symptoms of fever, chills, jaundice, and abdominal pain. Chronic alcoholism is not accompanied by an increase in the alkaline phosphatase level, and there is often a macrocytic anemia. Sclerosing cholangitis would increase the bilirubin concentration and the alkaline phosphatase level. Stress may cause transient unconjugated hyperbilirubinemia to a point that scleral icterus is detectable, when the serum bilirubin reaches about 2 to 2. Acetaminophen in small quantities can be properly detoxified, but ingestion of large quantities can produce hepatocyte necrosis. Choledochal cyst is a rare congenital anomaly producing extrahepatic biliary obstruction with conjugated hyperbilirubinemia. Primary biliary cirrhosis results in conjugated hyperbilirubinemia, as does the rare Dubin-Johnson syndrome. Biliary atresia with obstruction produces more severe jaundice and requires surgical intervention. Neonatal hepatitis can be due to congenital infections that produce more severe jaundice that persists more than 2 weeks. The rare Dubin-Johnson syndrome can occur with autosomal recessive mutation of a gene encoding a canalicular transporter protein 38 E this patient has a history of gallstones and has developed an ascending cholangitis caused by Escherichia coli. Development of cystic lesions in the right lobe of the liver suggests that the patient has developed liver abscesses. Clonorchis sinensis is a liver fluke that is endemic to East Asia, and it is a risk factor for biliary tract cancer.

Desquamative interstitial pneumonitis Hypersensitivity pneumonitis Idiopathic interstitial fibrosis Nonatopic bronchial asthma Nonspecific interstitial pneumonia 24 A 68-year-old man has had worsening dyspnea with a nonproductive cough for the past 9 months cholesterol food sources crestor 10 mg free shipping. A transbronchial biopsy is obtained and the microscopic findings with trichrome stain are shown in the figure cholesterol how to lower buy generic crestor 10 mg online. Despite glucocorticoid therapy is cholesterol in shrimp good or bad purchase discount crestor line, his condition does not improve cholesterol levels good cheap crestor amex, and he dies 2 years later cholesterol levels charts buy crestor no prescription. Goodpasture syndrome Hypersensitivity pneumonitis Idiopathic pulmonary fibrosis Sarcoidosis Systemic sclerosis 27 A 54-year-old woman has had a mild fever with cough for a week cholesterol zvyseny buy 10 mg crestor with mastercard. She then begins to have increasing fever, cough, shortness of breath, and malaise. A transbronchial biopsy specimen shows polypoid plugs of loose fibrous tissue and granulation tissue filling bronchioles, along with a surrounding interstitial infiltrate of mononuclear cells. Increased exposure to which of the following pollutants is most likely to produce these findings Carbon monoxide Ozone Silica Tobacco smoke Wood dust the Lung 231 31 A radiographic study of inhalational lung diseases is conducted. One pattern of involvement is seen in persons whose total lung capacity, diffusing capacity, and compliance is decreased. This pattern consists of numerous bilateral nodular opacifications on chest radiographs. Polarizable needlelike crystals are seen on microscopic examination of these nodules. Cigarette smoke Mold spores Silica dust Sulfur dioxide Wood particles 29 A study of persons with a history of mining occupational exposure to inhaled dusts is performed. Though found in urban air in small amounts, this dust consists of 1- to 5-micron particles that are inert and insoluble. Fibrosis occurs only with large amounts of dust accumulation, mainly in upper lobes, with nodular opacities larger than 1 cm seen on chest radiographs. Asbestos Beryllium Carbon Iron Sulfur dioxide 32 A 36-year-old woman has had a low-grade fever and worsening nonproductive cough and dyspnea for the past 2 years. On physical examination, he is afebrile, with a pulse of 70/min, respirations 30/min, and blood pressure 120/75 mm Hg. A transbronchial biopsy is performed; the figure shows the microscopic appearance with Prussian blue stain. Anthracosis Asbestosis Berylliosis Calcinosis Silicosis 1-Antitrypsin deficiency Chronic bronchitis Diffuse alveolar damage Goodpasture syndrome Nonatopic asthma Sarcoidosis 33 A 65-year-old man worked in a shipyard for 10 years, and then he worked for 5 years for a company that installed fire retardant insulation. He experienced increasing dyspnea for 11 years with progressive respiratory failure and hypoxemia. Which of the following findings is most likely to be seen on a chest radiograph in this patient A transbronchial biopsy is performed and microscopic examination shows numerous alveolar macrophages, plump epithelial cells, mild interstitial fibrosis, and loss of respiratory bronchioles. Type I hypersensitivity Cigarette smoking Ciliary dyskinesia Inhalation of mold spores Cell-mediated response to silica dust 34 A 61-year-old woman has noted increasing dyspnea and a nonproductive cough for 5 months. A chest radiograph shows prominent hilar lymphadenopathy with reticulonodular infiltrates bilaterally. A transbronchial biopsy is performed, and the microscopic findings include interstitial fibrosis and small, noncaseating granulomas. The medical history indicates that she smoked cigarettes for 10 years, but stopped 5 years ago. T cell-mediated response to unknown antigen Antibody-mediated diffuse alveolar damage Deposition of immune complexes Infection with atypical mycobacteria Smoke inhalation with loss of bronchioles 35 A 64-year-old alfalfa farmer has a 15-year history of increasing dyspnea. A transbronchial lung biopsy specimen shows interstitial infiltrates of lymphocytes and plasma cells, minimal interstitial fibrosis, and small granulomas. A Autoantibodies against alveolar basement membranes B Chronic inhalation of silica particles C Hypersensitivity to spores of actinomycetes D Infection with Mycobacterium tuberculosis E Prolonged exposure to inorganic dusts 36 A 25-year-old man experiences acute onset of fever, cough, dyspnea, headache, and malaise a day after moving into a new apartment. Which of the following pathogenic mechanisms is most likely to produce these findings A Antigen-antibody complex-mediated injury B Antibody-mediated injury to basement membrane C Formation of mycolic acid as a result of tubercular infection D Generation of prostaglandins by basophil recruitment E Release of histamine from mast cells F Toxic injury to type I pneumocytes caused by inhaled dust 38 A 33-year-old woman has had increasing dyspnea with cough for the past 10 days. Over the past 2 days, her cough has become productive of chunks of gelatinous sputum. A transbronchial biopsy is performed and the microscopic appearance with H&E staining is shown in the figure. Antibody directed against which of the following substances is most likely to cause her illness He is afebrile, his pulse is 70/min, his respirations are 27/min and shallow, and his blood pressure is 130/85 mm Hg. Which of the following clinical disorders is most likely to precede the appearance of the lesion shown Her condition improved, and she was able to get up and move about with assistance. A few minutes after walking to the bathroom, she experienced sudden onset of severe dyspnea with chest pain and diaphoresis. Which of the following is the most likely mechanism for sudden death in this patient Bronchoconstriction Compression atelectasis Hemorrhagic infarction Interstitial edema Acute cor pulmonale 40 A clinical study is performed that includes patients who are hospitalized for more than 2 weeks and who were bedridden for more than 90% of that time. These patients undergo Doppler venous ultrasound examination of the lower extremities, blood gas testing, and radiographic pulmonary ventilation and perfusion scanning. A cohort of patients is found who have abnormal ultrasound results suggestive of thrombosis, blood gas parameters with a slightly lower Po2, and small pulmonary perfusion defects. Which of the following symptoms and signs are most likely to be seen in this cohort of patients Dyspnea Hemoptysis Palpitations Pleuritic pain Orthopnea No symptoms 42 A 45-year-old man has had progressive dyspnea on exertion with fatigue for the past 2 years. On auscultation of his chest he has a prominent pulmonary component of S2, a systolic murmur of tricuspid insufficiency, and bruits over peripheral lung fields. Which of the following is the most likely disease process causing his pulmonary disease Atherosclerosis Pneumonitis Sarcoidosis Thromboembolism Vasculitis 43 A 75-year-old woman has had worsening lower leg edema and dyspnea for the past 5 years. Anesthesia is most likely to produce this effect via which of the following mechanisms Decreased ciliary function Diminished macrophage activity Hypogammaglobulinemia Neutropenia Squamous metaplasia Tracheal erosions 44 A 25-year-old woman has had progressive dyspnea and fatigue for the past 2 years. On physical examination, she has pedal edema, jugular venous distention, and hepatomegaly. Cardiac catheterization is performed, and the pulmonary arterial pressure is increased, without gradients across the pulmonic valve, and no shunts are noted. A transbronchial biopsy is performed, and microscopic examination shows plexiform lesions. A transbronchial lung biopsy on microscopic examination shows focal necrosis of alveolar walls associated with prominent intra-alveolar hemorrhage. Which of the following antibodies is most likely involved in the pathogenesis of his condition A transbronchial lung biopsy is performed, and microscopic examination shows necrotizing granulomatous capillaritis, a poorly formed granuloma, and intra-alveolar hemorrhage. The study group is found to have a higher incidence of pulmonary infections in the 2 weeks following their surgical procedure than patients who were not intubated and did not 49 A 71-year-old woman has smoked a pack of cigarettes per day for 50 years. Over the past 3 days she has become febrile, with a productive cough, and severe dyspnea. A chest radiograph shows a 3-cm round lesion with an air-fluid level in the right lower lobe. Which pair of the following organisms is most likely to be detected in his sputum Cryptococcus neoformans and Candida albicans Cytomegalovirus and Pneumocystis jiroveci Mycobacterium tuberculosis and Aspergillus fumigatus Nocardia asteroides and Actinomyces israelii Staphylococcus aureus and Bacteroides fragilis the Lung 235 54 A 4-year-old healthy girl from Utrecht in the Netherlands has had a fever with dyspnea, tachypnea, nonproductive cough, myalgias, and rhinorrhea for 3 days. Group A Streptococcus Bordetella pertussis Candida albicans Cytomegalovirus Haemophilus influenzae Human metapneumovirus 51 A 20-year-old man has had a mild fever with nonproductive cough, headache, and myalgias for the past week. Legionella pneumophila Mycobacterium fortuitum Mycoplasma pneumoniae Nocardia asteroides Respiratory syncytial virus 55 A 3-year-old boy has had a cough, headache, and slight fever for 5 days. On auscultation, there are inspiratory crackles, but no dullness to percussion or tympany. Hilar lymphadenopathy Hyperinflation Interstitial infiltrates Lobar consolidation Pleural effusions Upper lobe cavitation 52 A 26-year-old woman from East Asia developed a fever with chills over the past 4 days. Yesterday, she had increasing shortness of breath and a nonproductive cough, headache, and myalgias. Over the next 2 days, she has increasing respiratory distress requiring intubation and mechanical ventilation. Bronchoalveolar lavage specimens examined microscopically show macrophages filled with acid-fast infectious organisms. Aspergillus niger Candida albicans Legionella pneumophila Mycobacterium avium-complex Nocardia asteroides Pseudomonas aeruginosa 53 An epidemiologic study shows that a highly pathogenic strain of influenza A virus with the antigenic type H5N1 that normally causes disease in birds has been increasingly found to cause influenza in humans. Unlike other strains of influenza A virus, this H5N1 virus is associated with a 60% mortality rate. The enhanced pathogenicity of this avian flu virus is primarily due to mutation in its genome that enables it to do which of the following A chest radiograph shows a solitary, 3-cm left upper lobe mass without calcifications. Mycobacterium tuberculosis infection Necrotizing granulomatous vasculitis Poorly differentiated adenocarcinoma Staphylococcus aureus abscess Thromboembolism with infarction 59 A previously healthy, 20-year-old woman has had a low-grade fever for the past 2 weeks. The gross appearance of the lung shown in the figure is representative of her disease. Which of the following laboratory studies is most likely to report a positive result He recently developed a low-grade fever and cough with mucoid sputum production, and after 1 week, he noticed blood-streaked sputum. Which of the following findings in his sputum sample is most likely to be present Acid-fast bacilli Branching septate hyphae Charcot-Leyden crystals Foreign body giant cells Gram-negative bacilli Small dark neoplastic cells 60 A 46-year-old man from northern Mexico has had fever, nonproductive cough, and weight loss for 2 months. Bronchoalveolar lavage is performed and microscopic examination of the fluid shows organisms averaging 50 microns in diameter with thick walls and filled with endospores. A transbronchial biopsy is obtained and the microscopic appearance is shown in the figure. Candida albicans Influenza A Legionella pneumophila Mycobacterium tuberculosis Mycoplasma pneumoniae Nocardia asteroides Candida albicans Cryptococcus neoformans Cytomegalovirus Klebsiella pneumoniae Pneumocystis jiroveci 62 A 56-year-old man is undergoing chemotherapy for leukemia. He has developed fever, nonproductive cough, dyspnea, pleuritic chest pain, and hemoptysis over the past week. Bronchoalveolar lavage is performed, and microscopic examination of the fluid shows narrow branching septate hyphae. Aspergillus fumigatus Candida albicans Cryptococcus neoformans Moraxella catarrhalis Mucor circinelloides 64 A 43-year-old woman has had malaise and an 8-kg weight loss over the past 3 years. She has had fever and a nonproductive cough with increasing dyspnea for the past 3 days. There is dullness to percussion over the lungs and diffuse crackles on auscultation. Bronchoalveolar lavage is done, and the fluid is stained with Gomori methenamine silver, with high-power microscopic appearance shown in the figure. Which of the following underlying conditions is most likely present in this woman A chest radiograph shows no hilar adenopathy, but there is cavitation within a 3-cm lesion near the right hilum. Adenocarcinoma in situ Kaposi sarcoma Large cell anaplastic carcinoma Metastatic renal cell carcinoma Non-Hodgkin lymphoma Small cell anaplastic carcinoma Squamous cell carcinoma 68 A 60-year-old woman has had a chronic nonproductive cough for 4 months along with loss of appetite and a 6-kg weight loss. A fine-needle aspiration biopsy is performed, and she undergoes a right lower lobectomy. Adenocarcinoma Bronchial carcinoid Hamartoma Large cell carcinoma Small cell anaplastic carcinoma Squamous cell carcinoma 66 A 79-year-old woman has had increasing malaise and a 5-kg weight loss over the past 5 months. Adenocarcinoma Granulomatous inflammation Necrotizing vasculitis Organizing abscess Silica crystals 67 A 45-year-old woman, a nonsmoker, has had a chronic nonproductive cough for 6 months along with 8-kg weight loss. The microscopic examination of the lesion shows glands invading the surrounding lung. Which of the following molecular test findings is 69 A 50-year-old man has developed truncal obesity, back pain, and skin that bruises easily over the past 5 months. A chest radiograph shows an ill-defined, 4-cm mass involving the left hilum of the lung. Cytologic examination of bronchial washings from bronchoscopy shows round epithelial cells that have the appearance of lymphocytes but are larger. The patient is told that, although his disease is apparently localized to one side of the chest cavity, surgical treatment is unlikely to be curative. The findings on physical examination include unilateral enophthalmos, miosis, anhidrosis, and ptosis on the right side of her face. A chest radiograph shows right upper lobe opacification and bony destruction of the right first rib. Bronchopneumonia Bronchiectasis Bronchogenic carcinoma Sarcoidosis Tuberculosis 70 A 57-year-old woman has had a cough and pleuritic chest pain for the past 3 weeks. A chest radiograph shows an ill-defined area of opacification in the left lower lobe. After 1 month of antibiotic therapy, her condition has not improved, and the lesion is still visible radiographically. Adenocarcinoma in situ Large cell anaplastic carcinoma Malignant mesothelioma Metastatic breast carcinoma Squamous cell carcinoma 73 A 43-year-old woman has never smoked and works as a file clerk at a university that designates all work areas as nonsmoking. A routine chest radiograph shows a 3-cm, sharply demarcated mass in the left upper lobe of the lung. Fineneedle aspiration of the mass is attempted, but the pathologist performing the procedure remarks, "This is like trying to biopsy a ping-pong ball. Adenocarcinoma Hamartoma Large cell carcinoma Mesothelioma Non-Hodgkin lymphoma Squamous cell carcinoma 71 A 59-year-old man who has smoked one pack of cigarettes per day for the past 43 years has developed a severe cough with hemoptysis over the past month. Bilateral upper lobe cavitation Diaphragmatic pleural calcified plaques Extensive areas of infiltrates Invasive perihilar mass Pneumothorax Subpleural nodule with hilar adenopathy Upper lung nodule with air-fluid level 74 A 40-year-old man has had an increasing cough with hemoptysis for 2 weeks. His condition improves with antibiotic therapy; however, the cough and hemoptysis persist for 2 more weeks. Bronchoscopic examination shows a tan, circumscribed obstructive mass filling a right upper lobe bronchus. Adenocarcinoma Carcinoid tumor Hamartoma Kaposi sarcoma Large cell carcinoma 75 A 24-year-old man has had increasing dyspnea for the past 10 weeks. There is dullness to percussion over the lungs posteriorly and decreased breath sounds. A chest radiograph shows large bilateral pleural effusions and widening of the mediastinum. Thoracentesis is performed on the left side and yields 500 mL of milky white fluid. Laboratory studies of the fluid show a high protein content; microscopy shows many lymphocytes and fat globules. Asbestos Bird dust Coal dust Cotton fibers Ozone Silica 76 A 68-year-old man has had increasing dyspnea with cough productive of frothy sputum for the past 5 months.

Which of the following treatment strategies is most appropriate for his gastric lesions Antibiotics Chemotherapy Corticosteroids Multivitamins Total gastrectomy Vagotomy Gastrointestinal Tract 267 specimen shows a monomorphous infiltrate of lymphoid cells microscopically normal cholesterol ratio uk buy cheap crestor 10mg on-line. Autoimmune gastritis Chronic gastritis Crohn disease Diffuse large B-cell lymphoma Gastrointestinal stromal tumor Mucosa-associated lymphoid tissue tumor 26 A 49-year-old woman has a history of peptic ulcer disease for which she has been treated with proton pump inhibitors cholesterol test hdl ldl buy discount crestor 20mg line. Biopsies are taken and microscopically show the lesions to consist of irregular glands that are cystically dilated and lined by flattened parietal and chief cells cholesterol japan cheap crestor 10 mg visa. Fundic gland polyps Gastric adenomas Hyperplastic polyps Hypertrophic gastropathy 27 A 53-year-old woman has had nausea cholesterol urine test buy crestor 10mg with mastercard, vomiting cholesterol definition english discount crestor uk, and midepigastric pain for 5 months cholesterol and vitamin d cheap 5mg crestor with visa. Which of the following neoplasms is most likely to be seen in a biopsy specimen of this mass Adenocarcinoma Leiomyosarcoma Neuroendocrine carcinoma Non-Hodgkin lymphoma Squamous cell carcinoma 30 A 26-year-old man is brought to the emergency department after sustaining abdominal gunshot injuries. At laparotomy, while repairing the small intestine, the surgeon notices a 1-cm mass at the tip of the appendix. The yellow-tan submucosal mass is removed, and the microscopic appearance of the mass is shown in the figure. Immunohistochemical staining is positive for chromogranin and synaptophysin but negative for Ki-67. Lipoblast Ganglion cell Goblet cell Neuroendocrine cell Smooth muscle cell 28 A 67-year-old woman has experienced severe nausea, vomiting, early satiety, and a 9-kg weight loss over the past 4 months. Upper gastrointestinal endoscopy shows that the entire gastric mucosa is eroded and has an erythematous, cobblestone appearance. Which of the following is most likely to be found on histologic examination of a gastric biopsy specimen Chronic atrophic gastritis Primary gastric lymphoma Gastrointestinal stromal tumor Granulomatous inflammation Signet ring cell adenocarcinoma 29 A 52-year-old man has had a 4-kg weight loss and nausea for the past 6 months. Upper gastrointestinal endoscopy shows a 6-cm area of irregular, pale fundic mucosa and loss of the rugal folds. A biopsy 31 A 55-year-old man experiences episodes of diaphoresis, dyspnea, and diarrhea for 10 months. On physical examination he has midabdominal discomfort with deep palpation, and bowel sounds are reduced. Camera endoscopy is performed, and on review of the images, there is a midjejunal mass that partially obstructs the lumen. At laparotomy a 5-cm submucosal jejunal mass is resected, and on microscopy it is composed of nests and trabeculae of round cells with pink, granular cytoplasm. The cells of this mass are most likely related to which of the following embryologic derivatives On physical examination, his abdomen is diffusely tender, and bowel sounds are absent. Appendicitis Cholecystitis Pancreatitis Intestinal infarction Pseudomembranous colitis 32 A 61-year-old man with increasing fatigue, early satiety, and nausea for 5 months vomited dark granular material yesterday. Biopsies are taken and microscopically the mass is composed of spindle cells that are positive for c-Kit with immunohistochemical staining. Gastrectomy is performed, and the 10-cm circumscribed mass arises from the gastric wall. Which of the following therapies is most likely to be a useful adjunct in treatment of his disease Amoxicillin Azathioprine Cyclophosphamide Imatinib Prednisone Radiation 33 A 57-year-old man from Innsbruck, Austria, goes to the emergency department because of increasing abdominal pain with distention that developed over the past 24 hours. The abdomen is tympanitic, without a fluid wave, and bowel sounds are nearly absent. There is a well-healed, 5-cm transverse scar in the right lower quadrant of the abdomen. An abdominal plain film shows dilated loops of small bowel with air-fluid levels, but there is no free air. At laparotomy, the surgeon notices a 20-cm portion of reddish black ileum that changes abruptly to pink-appearing bowel on distal and proximal margins. Adenocarcinoma of the ileum Adhesions Crohn disease Indirect inguinal hernia Intussusception Tuberculosis Volvulus 36 A 71-year-old woman with a history of rheumatic heart disease is hospitalized with severe congestive heart failure. The abdomen is distended and tympanitic, without a fluid wave, and bowel sounds are absent. Colonoscopy shows patchy areas of mucosal erythema with some overlying tan exudate in the ascending and descending colon. Ischemic colitis Mesenteric vasculitis Shigellosis Ulcerative colitis Volvulus 34 An 11-month-old, previously healthy infant has not produced a stool for 1 day. An abdominal plain film radiograph shows no free air, but there are distended loops of small bowel with air-fluid levels. Duodenal atresia Hirschsprung disease Intussusception Meckel diverticulum Pyloric stenosis 37 A 60-year-old man has had increasing fatigue for the past 8 months. On digital rectal examination, no masses are palpable, but a stool sample is positive for occult blood. Auscultation of the abdomen shows active bowel sounds, and on palpation there are no masses or areas of tenderness. Angiography shows a 1-cm focus of dilated and tortuous vascular channels in the mucosa and submucosa of the cecum. Angiodysplasia Collagenous colitis Diverticulosis Internal hemorrhoids Mesenteric vein thrombosis 38 A 21-year-old man has had increasingly voluminous, bulky, foul-smelling stools and a 7-kg weight loss for the past year. On physical examination, there are no palpable abdominal masses, and bowel sounds are present. Which of the following laboratory findings is most likely to be present on examination of his stool A stool sample is negative for occult blood, ova, and parasites, and a stool culture yields no pathogens. An upper gastrointestinal endoscopy is performed and a biopsy specimen from the upper part of the small bowel shows severe diffuse blunting of villi and a chronic inflammatory infiltrate in the lamina propria. Which of the following serologic tests is most likely to be positive in this patient Various meats, salads, breads, and desserts that were brought in earlier that morning are served. By midafternoon, the single office restroom is being used by many employees who have vomiting and acute, explosive diarrhea accompanied by abdominal cramping. Which of the following infectious agents is most likely responsible for this turn of events Bacillus cereus Clostridium difficile Escherichia coli Salmonella enterica Staphylococcus aureus Vibrio parahaemolyticus 40 A 41-year-old woman has had diarrhea and fatigue with a 3-kg weight loss over the past 6 months. On physical examination, she is afebrile and has mild muscle wasting, but her motor strength is normal. A biopsy specimen from the upper jejunum is obtained, and microscopic findings are reviewed. Which of the following microscopic features is most likely to be seen in the biopsy specimen Crypt abscesses and mucosal ulceration Foamy macrophages within the lamina propria Lymphatic obstruction Noncaseating granulomas Villous blunting and flattening 44 A healthy 21-year-old woman develops a profuse, watery diarrhea 1 day after a meal of raw oysters. Cryptosporidium parvum Entamoeba histolytica Staphylococcus aureus Vibrio parahaemolyticus Yersinia enterocolitica 41 An epidemiologic study of children with failure to thrive is undertaken in Guatemala. Some of these children with ages 1 to 3 years have repeated bouts of diarrhea, but do not improve with dietary supplements. Jejunal biopsies show blunted, atrophic villi with crypt elongation and chronic inflammatory infiltrates. What is the most likely factor contributing to recurrent diarrhea in these children Microscopic examination of the stool shows numerous leukocytes and gram-negative curved rods. Bacillus cereus Campylobacter jejuni Clostridium perfringens Giardia lamblia Rotavirus 42 A 40-year-old man has episodic abdominal bloating, flatulence, and explosive diarrhea. Laboratory studies show no increase in stool fat and no occult blood, ova, or parasites in the stool. Autoimmune gastritis Celiac disease Cholelithiasis Cystic fibrosis Disaccharidase deficiency 46 A 36-year-old man experiences cramping abdominal pain with fever and watery diarrhea 2 days after eating a chicken salad sandwich. Physical examination shows mild diffuse abdominal pain on palpation, but there are no masses. Which of the following infectious agents is the most likely cause for their illness Cytomegalovirus Clostridium botulinum Norovirus Staphylococcus aureus Strongyloides stercoralis Vibrio cholerae 47 In an epidemiologic study of infections of the gastrointestinal tract, cases of patients living in Haiti from whom definitive cultures were obtained are analyzed for clinical and pathologic findings that may be useful for diagnosis. A group of patients is identified who initially had abdominal pain and diarrhea during week 1 of their illness. Campylobacter jejuni Clostridium perfringens Mycobacterium bovis Salmonella typhi Shigella sonnei Yersinia enterocolitica 50 A 5-month-old, previously healthy infant girl in Bangladesh develops a watery diarrhea that lasts for 1 week. The infant has a mild fever during the illness, but has no abdominal pain or swelling. Campylobacter jejuni Cryptosporidium parvum Escherichia coli Listeria monocytogenes Norwalk virus Rotavirus Shigella flexneri 48 A 65-year-old woman is being treated in the hospital for pneumonia complicated by septicemia. She has required multiple antibiotics and was intubated and mechanically ventilated earlier in the course. Bowel sounds are absent, and an abdominal radiograph shows dilated loops of small bowel suggestive of ileus. She has a low volume of bloody stool that is positive for Clostridium difficile toxin. Gas gangrene with myonecrosis Inflammatory bowel disease Ischemic bowel disease Pseudomembranous enterocolitis Toxic megacolon 51 A study of children living in rural Malawi in Africa reveals a high prevalence of iron deficiency anemia. Pruritus of the skin of their feet as well as cough are additional findings in many of these children. Which of the following parasitic infestations is the most likely cause for these findings Ancylostoma duodenale Ascaris lumbricoides Cryptosporidium parvum Enterobius vermicularis Schistosoma mansoni 52 A 31-year-old woman had increasingly severe diarrhea 1 week after returning from a trip to Central America. The diarrheal illness subsided within 4 weeks, but now she has become febrile and has pain in the right upper quadrant of the abdomen. An abdominal ultrasound scan shows a 10-cm, irregular, partly cystic mass in the right hepatic lobe. On physical examination, his abdomen is diffusely tender and distended, and bowel sounds are absent. He undergoes surgery, and a 27-cm segment of terminal ileum with a firm, erythematous serosal surface is removed. The microscopic appearance of a section through the excised ileum is shown in the figure. Which of the following additional complications is the patient most likely to develop as a result of this disease process Adenocarcinoma Enterocutaneous fistula Intussusception Liver abscess Mesenteric artery thrombosis 55 A 49-year-old woman has had abdominal cramps and diarrhea with six stools per day for the past month. She has a history of similar episodes of self-limited pain and diarrhea, which have occurred multiple times during the past 20 years. Findings on physical examination are unremarkable, but a stool sample is positive for occult blood. Colonoscopy shows diffuse and uninterrupted mucosal inflammation and superficial ulceration extending from the rectum to the ascending colon. Adenocarcinoma Diverticulitis Fat malabsorption Perirectal fistula formation Primary biliary cirrhosis Pseudomembranous colitis 54 A 30-year-old woman has a 5-year history of recurrent episodes marked by days of abdominal bloating with alternating constipation and diarrhea. She notes hard stools of narrow caliber, low volume mucous diarrhea, and pain in the left lower quadrant. Laboratory studies including stool for ova and parasites, bacterial pathogens, and fat show no abnormalities. On physical examination, he is afebrile; there is mild lower abdominal tenderness but no masses, and bowel sounds are present. Colonoscopy shows many areas of mucosal edema and ulceration and some areas that appear normal. Microscopic examination of a biopsy specimen from an ulcerated area shows a patchy acute and chronic inflammatory infiltrate, crypt abscesses, and noncaseating granulomas. Amebiasis Crohn disease Sarcoidosis Shigellosis Ulcerative colitis 56 A 35-year-old woman has had increasing lower back pain for 5 years. During the past year she also has had arthritic pain involving the knees, hips, and wrists. On colonoscopy there is friable mucosa from the rectum to the ascending colon, and a perianal fistula is noted. Biopsies are taken and on microscopic examination show acute and chronic mucosal inflammation with focal erosion. Which of the following ongoing testing procedures is most useful for long-term follow-up of this woman Angiodysplasia Crohn disease Diverticulitis Ischemic enteritis Ulcerative colitis 60 A 65-year-old woman has a routine health maintenance examination. Adenocarcinoma Bowel obstruction Pericolic abscess Malabsorption Toxic megacolon 61 the mother of a 4-year-old child notes blood when laundering his underwear. It is excised and microscopically shows cystically dilated crypts filled with mucin and inflammatory debris, but no dysplasia. The polyp is removed; its histologic appearance is shown in the figure at low (A) and high (B) magnifications. Low risk for development of carcinoma Inheritance of an abnormal tumor suppressor gene Presence of similar lesions in the small intestine History of iron deficiency anemia Risk for development of endometrial carcinoma 63 A 70-year-old man has a routine health maintenance examination. On physical examination, there are no remarkable findings, but a stool sample is positive for occult blood. A colonoscopy is performed and shows a 5-cm sessile mass in the upper portion of the descending colon at 50 cm from the anal verge. The histologic appearance at low power of a biopsy specimen of the lesion is shown in the figure. Five years later, he has constipation, microcytic anemia, and a 5-kg weight loss over 6 months. The figure shows the gross appearance of the mucosal surface of the colectomy specimen. Which of the following molecular biological events is thought to be most critical in the development of such lesions On physical examination, there is an abdominal fluid wave, and bowel sounds are present. Cytologic examination of the fluid shows malignant cells consistent with adenocarcinoma. Her medical history indicates that she has had no major medical illnesses and no surgical procedures. Her sister was diagnosed with endometrial cancer and her brother had carcinoma of the stomach. On physical exam, there are no abnormal findings except for stool positive for occult blood. Colonoscopy is performed for the first time in this man, followed by colonic resection with the gross appearance shown in the figure. Angiodysplasia Hemorrhoids Intussusception Ischemic colitis Volvulus Gastrointestinal Tract 275 70 A 53-year-old woman has increasing abdominal girth for the past 2 years. Paracentesis is performed and cytologic examination of the fluid obtained shows well-differentiated columnar cells with minimal nuclear atypia.

Acute bacterial prostatitis Chronic abacterial prostatitis Prostatic adenocarcinoma Prostatic hyperplasia Syphilitic prostatitis 36 A 71-year-old cholesterol medication pain buy generic crestor 20 mg online, previously healthy man comes to his physician for a routine health examination cholesterol yahoo purchase crestor 5 mg without a prescription. Which of the following histologic findings is most likely to be found in a subsequent biopsy specimen of his prostate Acute prostatitis Adenocarcinoma Chronic abacterial prostatitis Nodular hyperplasia Prostatic intraepithelial neoplasia 33 A 65-year-old man has had multiple cholesterol lowering diet patient information purchase crestor 20 mg without prescription, recurrent urinary tract infections for the past year cholesterol in dry shrimp buy crestor 20 mg low price. Escherichia coli and streptococcal organisms have been cultured from his urine during these episodes cholesterol foods help lower order crestor in india, with bacterial counts of more than 105/mL cholesterol ranges normal purchase 5mg crestor fast delivery. He has difficulty with urination, including starting and stopping the urinary stream. Which of the following is the most likely condition predisposing him to recurrent infections Epispadias Nodular prostatic hyperplasia Phimosis Posterior urethral valves Prostatic adenocarcinoma Vesicoureteral reflux 37 An 85-year-old man has experienced urinary hesitancy and nocturia for the past year. The blood urea nitrogen concentration is 44 mg/dL, and the serum creatinine level is 3. Microscopic examination shows that more than 90% of the tissue has a pattern of cords and sheets of cells with hyperchromatic pleomorphic nuclei, prominent nuclei, and scant cytoplasm. The study will determine whether symptoms of prostate disease are ameliorated in the individuals who take these drugs. Which of the following diseases of the prostate is most likely to benefit from one or both of these drugs A urologist obtains transrectal biopsy specimens, and microscopic examination shows multifocal areas of glandular hyperplasia and the appearance shown in the figure. Which of the following statements applies best to this clinical and pathologic scenario A Associated with increased risk for invasive cancer B Chronic inflammation from urinary tract obstruction C Normal microscopic finding of the peripheral zone D Related to an inherited tumor suppressor gene mutation E Responsive to 5-reductase inhibitor therapy 39 A 45-year-old man comes to the physician for a routine health maintenance examination. Prostate biopsies are performed and the high power microscopic appearance of a biopsy specimen is shown in the figure. All or part of one or both ureters may be duplicated, but this is usually an incidental finding; granulomatous inflammation in the urinary tract is uncommon. Urachal remnants (embryologic allantois) may predispose to infection but not hydronephrosis; adenocarcinoma may arise in a urachal cyst. Interstitial cystitis is a complication of recurrent bladder infection, most often in women, and characterized by chronic pain. Malakoplakia is a rare response to bacterial infection in which collections of macrophages filled with degraded bacterial products elicit formation of intracellular laminated, calcified concretions called Michaelis-Gutmann bodies. Diverticula may develop in the setting of obstruction and bladder wall 3 C Bilateral hydronephrosis, without hydroureter or bladder dilation, suggests that the problem involves both ureters. Nephrolithiasis could cause ureteropelvic junction obstruction, but bilaterality would be uncommon. Polypoid cystitis results from inflammation but may mimic a tumor mass, and could obstruct one or both ureteral orifices with hydroureter. Renal cell carcinoma is likely to be unilateral, but may cause only focal obstruction. Urothelial carcinomas may be multifocal, but are unlikely to obstruct both ureters simultaneously. Obesity increases the risk for malignancy, but correlation with a specific malignancy is difficult to draw. Schistosomiasis can lead to squamous metaplasia and increased risk for squamous carcinoma of the bladder. Congenital diverticula result from either focal failure in formation of bladder musculature or bladder outlet obstruction, and there is no fistulous tract. Exstrophy refers to failure in development of the lower abdominal wall, leaving an open defect to the bladder. Abnormal reflux of bladder contents into the ureter defines vesicoureteral reflux, which may be due to congenital abnormalities of bladder development, but there is no fistulous tract. A vitelline duct remnant may account for a Meckel diverticulum, or rarely a fistulous tract from small intestine to umbilicus. After absorption, aromatic amines are hydroxylated into an active form, which is detoxified by conjugation with glucuronic acid and then excreted. Urinary glucuronidase splits the nontoxic conjugated form into the active carcinogenic form. Adenocarcinoma is a complication of the congenital condition known as exstrophy of the bladder. Rhabdomyosarcoma of the pelvis is typically a pediatric neoplasm, and not associated with chemical exposures. Renal cell carcinomas also may manifest as painless hematuria, but exposure to aniline dyes is not a risk factor. Squamous cell carcinoma is the most common malignancy of the urethra, but it is rare and has no relation to carcinogens. Malakoplakia is a reaction to chronic bacterial infections, usually Escherichia coli and Proteus species, and often in the setting of immunosuppression. Chemical carcinogens such as aniline dyes increase the risk for developing urothelial carcinoma, but do not dictate therapy. In an older man, this type of obstruction is most often caused by prostatic enlargement caused by hyperplasia or carcinoma. Autoimmune conditions may be associated with interstitial cystitis, but cystitis does not cause bladder neck obstruction. Polycythemia can be the result of a paraneoplastic syndrome, but urothelial malignancies are unlikely to produce this finding; renal cell carcinoma is a more likely cause. Bladder outlet obstruction can increase the risk of infection, typically with bacterial organisms such as Escherichia coli, not Mycobacterium tuberculosis. It is not an infectious process, so multinucleated cells (herpes simplex virus) or plasma cell infiltrates (syphilis) are unlikely. The embryologic allantois extends from the developing bladder and may persist as a urachal remnant forming a diverticulum, cyst, or fistula to the umbilicus, and there 11 E Carcinoma of the urethra is uncommon. A clear cell carcinoma occurs on the cervix and may be related to in utero exposure to diethylstilbestrol. An embryonal rhabdomyosarcoma (sarcoma botryoides) is a rare tumor that occurs in children. Phimosis is a nonretractile prepuce, and paraphimosis refers to forcible retraction of the prepuce that produces pain and urinary obstruction. Condyloma lata may appear in association with secondary syphilis, but are flat and typically do not ulcerate. The inguinal hernia and the cryptorchidism are abnormalities that may accompany this condition. Epispadias is a congenital condition in which the urethra opens abnormally on the dorsal aspect of the penis. Bowen disease, which is squamous cell carcinoma in situ of the penis, occurs in adults. It can be congenital, but more likely is the result of inflammation of the foreskin of the penis. Prior phimosis and human papillomavirus infection, more likely in uncircumcised men, are risk factors. Urothelium extends to the urethral orifice and development of urothelial carcinoma is theoretically possible at this site, but is far less common than squamous carcinomas. Forcible retraction may result in vascular compromise, with further inflammation and swelling (paraphimosis). Bowenoid papulosis is a premalignant lesion of the penile shaft resulting from viral infection. Epispadias is a congenital condition in which the penile urethra opens onto the dorsal surface of the penis. Candidiasis is most likely to produce shallow ulcerations that are intensely pruritic. Similar to carcinoma in situ elsewhere, it has a natural history of progression to invasive cancer if untreated. Poor hygiene and infection with human papillomavirus (particularly types 16 and 18) are factors that favor development of dysplasias and cancer of the genital epithelia. Syphilis is a sexually transmitted disease that produces a hard chancre, which heals in a matter of weeks. Scabies mites are more likely to be found in linear burrows in epidermis scraped from the extremities. Neoplasms with atypical cells may ulcerate, but such lesions are unlikely to be shallow or multiple without a mass lesion present. Intranuclear inclusions suggest a viral infection; however, diabetes is not a risk factor for genital viral infections. Unilateral cryptorchidism may lead to infertility, because it may be associated with atrophy of the contralateral descended testis. Isolated cryptorchidism is a developmental defect that is usually sporadic and is not inherited in the germline. Mumps infection tends to produce patchy bilateral testicular atrophy, usually without infertility. Candidiasis can be associated with inflammation, such as balanoposthitis, but not condylomata. Recurrent gonococcal infection indicates that the patient is sexually active and at risk for additional infections, but is not the cause for the condylomata. Gonococcal infection causes suppurative lesions in which there may be liquefactive necrosis and a neutrophilic exudate or mixed inflammatory 19 A this is acute epididymitis/orchitis, and most of these infections are secondary to ascending infections from the urinary tract. Mumps orchitis is likely to be bilateral, and not associated with urinary tract infection. Tuberculosis can produce testicular infection, but the time course is likely to be weeks to months, and with preceding respiratory disease. Syphilis can lead to orchitis, but is unlikely to be preceded by urinary tract infection. The orchitis in children is usually not severe, and its involvement of the testis is patchy or unilateral so that infertility is not a common outcome. Cryptorchidism results from failure of the testis to descend into the scrotum normally; the abnormally positioned testis becomes atrophic throughout. A hydrocele is a fluid collection outside the body of the testis that does not interfere with spermatogenesis. Klinefelter syndrome and estrogen therapy can cause tubular atrophy, although it is generalized in both cases. Radiation as well as many chemotherapeutic agents are particularly harmful to rapidly and continuously proliferating testicular germ cells, but the effect would be diffuse within the testicular parenchyma. Radiotherapy is typically targeted to malignancies to prevent damage to normal surrounding tissues. Patients who wish to father children may want to store sperm in a sperm bank before undergoing radiation or chemotherapy. The prognosis is good in most cases, even with metastases, because seminomas are radiosensitive. Fragile X syndrome is associated with bilaterally enlarged testes and mental retardation. Klinefelter syndrome is associated with bilaterally decreased testicular size and reduced fertility. An abnormally positioned or anchored testis in the scrotum is a risk factor for this condition. Testicular carcinomas do not obstruct the blood flow, and are not likely to produce an acute event. Parasitic infestation, typically filariasis, obstructs the flow of lymph, leading to gradual enlargement of the scrotum with thickening of the overlying skin. Tuberculosis can spread from the lung through the bloodstream, producing miliary tuberculosis, seen as multiple pale, millet-sized lesions, most often involving the epididymis. A previous vasectomy may lead to a small leakage of fluid and sperm, producing a localized sperm granuloma. Some patients have gynecomastia caused by androgenic or estrogenic hormone production (or both) by the tumor. Most patients are young to middle-aged men; sexual precocity may occur in the few boys who have such tumors. Choriocarcinomas are grossly soft and hemorrhagic masses that have large bizarre syncytiotrophoblast and cytotrophoblast cells and are aggressive. Embryonal carcinomas are large, aggressive tumors that have a variegated gross appearance and primitive cells with large, hyperchromatic nuclei. Gonadoblastomas are rare testicular tumors that arise in the setting of gonadal dysgenesis. A pure seminoma can be uniformly brown on cut surface, but often has a lymphoid stroma, and is not likely to secrete androgens or estrogens. Yolk sac tumors have cells that organize into primitive endodermal sinuses (SchillerDuval bodies). The infection typically starts in the epididymis and spreads to the body of the testis. Chancroid caused by Haemophilus ducreyi leads to ulcerated nodules of the external genitalia. Mumps produces patchy orchitis with minimal inflammation, which heals with patchy fibrosis. Syphilis involves the body of the testis, and there can be gummatous inflammation with neutrophils, necrosis, and some mononuclear cells. The most common form of testicular neoplasm combines multiple elements; the term teratocarcinoma is sometimes used to describe tumors with elements of teratoma, embryonal carcinoma, and yolk sac tumor. It is unusual for a tumor to metastasize to the testis; this patient is of an age at which a primary cancer of the testis should be considered when a testicular mass is present. On examining more histologic sections from the mass, the pathologist would find the malignant elements. Pure yolk sac tumors are rare in adults, but yolk sac components are common in mixed nonseminomatous tumors. Cytotrophoblasts do not produce a serum marker, but they may be present in a choriocarcinoma along with syncytiotrophoblasts, which do produce human chorionic gonadotropin. Embryonal carcinoma cells are common in nonseminomatous tumors, however, and are often mixed with other cell types.

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