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Thread: MCQs: Inflammation

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    MCQs: Inflammation

    Question 1

    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 Complement C3b and IgG

    B Interleukin-1 and tumor necrosis factor

    C Histamine and serotonin

    D Prostaglandin and bradykinin

    E Leukotriene and HPETE
    Answer/ Explanation:
    (D) CORRECT. Aspirin, by inhibiting the cyclooxygenase pathway, can decrease prostaglandin synthesis.

    Question 2

    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 Mast cell

    B Eosinophil

    C Giant cell

    D Neutrophil

    E Plasma cell
    (C) CORRECT. The silicone is a foreign material and produces a foreign body reaction.

    Question 3
    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.

    The most critical factor in determining whether the skin in the region of the burn will regenerate following this is the presence of which of the following factors?

    A Good cardiac output

    B Skin appendages

    C Underlying connective tissue

    D Minimal edema and erythema

    E Granulation tissue
    (B) CORRECT. This is why a full thickness burn is much worse.


    Question 4

    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 Platelet activating factor

    B Prostaglandins

    C Kallikrein

    D Leukotriene

    E Hydrogen peroxide
    (E) CORRECT. This is reduced by myeloperoxidase to a powerful oxidant that kills bacteria. In chronic granulomatous disease, this system is not operative against many bacterial species.

    Question 5

    A clinical study is performed of patients with pharyngeal infections. The most typical clinical course averages 3 days from the time of onset until the patient sees the physician. Most of these patients experienced fever and chills. On physical examination, the most common finding is a pharyngeal purulent exudate.

    Which of the following types of inflammation did these patients most likely have?

    A Granulomatous inflammation

    B Acute inflammation

    C Abscess formation

    D Resolution of inflammation

    E Chronic inflammation
    (B) CORRECT. The short course of days and the purulent exudate are typical features of acute inflammation.

    Question 6

    A 56-year-old man has had increasing dyspnea for 6 years. He has no cough or fever. He was inhaling silica dust for many years in his job. A chest x-ray now shows increased interstitial markings and parenchymal 1 to 3 cm nodules. His pulmonary problems are most likely to be caused by which of the following inflammatory processes?

    A Neutrophilic infiltration with release of leukotrienes

    B Foreign body giant cell formation

    C Plasma cell production of immunoglobulin

    D Histamine release by mast cells

    E Release of growth factors by macrophages


    Question 7

    Premature labor with premature rupture of fetal membranes occurs at 20 weeks gestation in a 20-year-old woman. 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 Immunoglobulin

    B Prostaglandin

    C Complement

    D Fibrinogen

    E Lymphokines
    (B) CORRECT. This mediator of acute inflammation promotes labor through its effects on smooth muscle and blood vessels.

    Question 8

    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 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 Gangrenous necrosis of the foot

    B Hematoma of the thigh

    C Disseminated intravascular coagulation

    D Pulmonary thromboembolism

    E Soft tissue sarcoma
    (D) CORRECT. She has deep and superficial venous thrombosis as a consequence of venous stasis from immobilization. The large deep thrombi can embolize to the lungs and lead to death.

    Question 9

    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 Macrophage

    B Fibroblast

    C Neutrophil

    D Mast cell

    E Platelet
    (A) CORRECT. Epithelioid cells and giant cells are derived from macrophages and are important in the development of granulomatous inflammation.

    Question 10

    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 are most likely to have been caused to undergo diapedesis to reach the organisms as a consequence of release of which of the following chemical mediators?

    A Histamine

    B Prostaglandin

    C Hageman factor

    D Bradykinin

    E Complement C5a
    (E) CORRECT. The C5a component of complement, along with TNF, leukotrienes, and bacterial products is chemotactic for neutrophils.
    Last edited by trimurtulu; 03-11-2009 at 08:13 AM.

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    Question 11

    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 3 days as an initial response to increase myocardial function and promote healing?

    A Histamine

    B Immunogloblulin G

    C Complement C3b

    D Leukotriene B4

    E Vascular endothelial growth factor

    (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.

    Question 12

    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 air-fluid level. There are no surrounding infiltrates. Which of the following is the best description for this outcome of her pneumonia?

    A Hypertrophic scar

    B Abscess formation

    C Regeneration

    D Bronchogenic carcinoma

    E Progression to chronic inflammation
    (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 absesses.

    Question 13

    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 inflammatory responses?

    A Neutrophil chemotaxis by leukotriene B4

    B Fever resulting from interleukin-1 release

    C Prostaglandin-mediated vasodilation

    D Pain resulting from bradykinin generation

    E Anticoagulation by Hageman factor inhibition

    (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.

    Question 14

    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 substances on endothelial cells is most instrumental in promoting this inflammatory reaction?

    A Interferon gamma

    B Hageman factor

    C Lysozyme

    D E-selectin

    E Prostacyclin
    (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.

    Question 15

    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 Mycobacterium leprae

    B Pseudomonas aeruginosa

    C Cytomegalovirus

    D Giardia lamblia

    E Treponema pallidum
    (A) CORRECT. Mycobacteria lead to granuloma formation.

    Question 16

    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 which appears to be an area with loss of the epithelial surface. These findings are most typical for which of the following pathologic processes?

    A Abscess

    B Serositis

    C Granuloma

    D Gangrene

    E Ulcer

    (E) CORRECT. The loss of an epithelial surface is ulceration.

    Question 17

    A 17-year-old drive 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 Smooth muscle

    B Endothelium

    C Skeletal muscle

    D Fibroblast

    E Hepatocyte

    (C) 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.

    Question 18

    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 Leukotriene-induced neutrophil aggregation

    B Complement-induced hemolysis

    C Histamine-induced edema

    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.

    Question 19

    A 45-year-old woman has had a chronic, non-productive 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 this inflammation?

    A Interferon gamma

    B Bradykinin

    C Complement C5a

    D Histamine

    E Prostaglandin E2
    (A) CORRECT. This is a non-caseating granuloma typical for sarcoidosis. Granulomas are a form of type IV hypersensitivity. There are cytokines such as interferon gamma produced by lymphocytes that stimulate macrophages to develop a granulomatous response.

    Question 20

    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 this patient?

    A Increased white blood cell count

    B Elevated sedimentation rate

    C Decreased serum complement

    D Increased serum creatine kinase

    E Decreased platelet count

    (D) CORRECT. CK is an enzyme released from the damaged muscle.


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    Question 21

    A 15-year-old girl has had episodes of sneezing with watery eyes and runny nose for the past 2 weeks. On physical examination she has red, swollen nasal mucosal surfaces. She has had similar episodes each Spring and Summer when the amount of ragweed pollen in the air is high.

    Her symptoms are most likely to be mediated by the release of which of the following chemical mediators?

    A Complement C3b

    B Platelet activating factor (PAF)

    C Tumor necrosis factor (TNF)

    D Histamine

    E Immunoglobulin G

    (D) CORRECT. Histamine, mainly released from mast cells in perivascular locations, leads to vasodilation and fluid exudation. That is why people with allergies take antihistamines.

    Question 22

    A 45-year-old man has been working hard all day long carrying loads of bricks to build a wall. He is most likely to use a non-steroidal anti-inflammatory drug such as ibuprofen in order to try and diminish which of the following processes in his arms?

    A Thrombosis

    B Pain

    C Liquefactive necrosis

    D Fibrinolysis

    E Scar formation

    (B) CORRECT. Aspirin, indomethacin, and NSAIDS block the cyclo-oxygenase arm of the arachidonic acid pathway, which generates the prostaglandins that play a role in development of pain as a consequence of the inflammatory process.

    Question 23

    Within minutes following a bee sting, a 37-year-old man develops marked respiratory stridor with dyspnea and wheezing. He also develops swelling and erythema seen in his arms and legs. An injection of epinephrine helps to reverse these events and he recovers within minutes.

    Which of the following chemical mediators is most important in the pathogenesis of this man's condition?

    A Bradykinin

    B Complement C5a

    C Nitric oxide

    D Tumor necrosis factor

    E Histamine
    [HIDE](E) CORRECT. This is systemic anaphylaxis, a type I hypersensitivity reaction in which the antigen contacts preformed antibody attached to mast cells, leading to mast cell degranulation and production of symptoms, typically within minutes.[/HIDE]

    Question 24

    A 72-year-old woman did not get a "flu" shot in the fall as recommended for older persons. In the wintertime, she became ill, as many people in her community did, with a respiratory illness that lasted for several weeks. During this illness, she had a fever with a non-productive cough, mild chest pain, myalgias, and headache.

    What was her chest radiograph most likely to have shown during this illness?

    A 6 cm left hilar mass

    B Bilateral interstitial infiltrates

    C Marked hilar lymphadenopathy

    D Left upper lobe consolidation

    E Extensive pleural thickening with pleural effusions

    [HIDE](B) CORRECT. Viral illnesses, including those caused by common viral respiratory pathogens such as influenza, produce chronic inflammation that is interstitial in the lungs. The lack of an alveolar filling process results in the lack of a productive cough.[/HIDE]

    Question 25

    In an experiment, Enterobacter cloacae organisms are added to a solution containing leukocytes. Engulfment and phagocytosis of the microbes is observed to occur. Next a substance is added which enhances engulfment.

    Which of the following substances is most likely to produce this effect?

    A Complement C3b

    B Glutathione peroxidase

    C Immunoglobulin M

    D P-selectin

    E NADPH oxidase

    [HIDE](A) CORRECT. The C3b fragment serves as an effective opsonin.[/HIDE]

    Question 26

    A 43-year-old woman has had nausea with vomiting persisting for the past 5 weeks. On physical examination there are no abnormal findings. She undergoes an upper GI endoscopy and gastric biopsies are obtained. The microscopic appearance of these biopsies shows mucosal infiltration by lymphocytes, macrophages, and plasma cells.

    Which of the following conditions is this woman most likely to have?

    A Staphylococcus aureus septicemia

    B Ingestion of chili peppers

    C Diabetes mellitus

    D Tuberculosis

    E Infection with Helicobacter pylori

    [HIDE](E) CORRECT. This is a chronic inflammatory process, based upon the inflammatory cell components.[/HIDE]

    Question 27

    In an experiment, lymphatic channels are observed in normal soft tissue preparations. Staphylococcus aureus organisms are innoculated into the tissues and the immunologic response observed over the next 24 hours.

    Which of the following functions is most likely to be served by these lymphatics to produce a specific immune response to these organisms?

    A Carry lymphocytes to peripheral tissue sites

    B Remove extravascular tissue fluid

    C Transport antigen presenting cells

    D Serve as a route for dissemination of infection

    E Provide an emigration point for neutrophils
    [HIDE](C) CORRECT. Antigen presenting cells such as dendritic cells and macrophages which have trapped antigen can be transported to lymph nodes where they encounter specific clones of memory cells capable of responding to those specific antigens, and this typically happens within a day. [/HIDE]

    Question 28

    In an experiment, surgical wound sites are observed following suturing. An ingrowth of new capillaries is observed to occur within the first week. A substance elaborated by macrophages is found at the wound site to stimulate this capillary proliferation.

    Which of the following substances is most likely to have this function?

    A Platelet-derived growth factor

    B Phospholipase C-gamma

    C Fibronectin

    D Fibroblast growth factor

    E Epidermal growth factor
    (D) CORRECT. FGF can stimulate all aspects of angiogenesis.

    Question 29

    A 55-year-old man with a history of ischemic heart disease has worsening congestive heart failure. He has noted increasing dyspnea and orthopnea for the past 2 months. On physical examination there is dullness to percussion at lung bases. A chest x-ray shows bilateral pleural effusions. A left thoracentesis is performed, and 500 mL of fluid is obtained.

    Which of the following characteristics of this fluid would most likely indicate that it is a transudate?

    A Cloudy appearance

    B High protein content

    C <3 lymphocytes/microliter

    D The presence of fibrin

    E Large size of the effusion

    [HIDE](C) CORRECT. A transudate has few cells or protein and has a clear appearance.[/HIDE]

    Question 30

    In a clinical study, patients undergoing laparoscopic cholecystectomy are followed to document the post-surgical wound healing process. The small incisions are closed with sutures. Over the 4 weeks following surgery, the wounds are observed to regain tensile strength and there is re-epithelialization.

    Of the following substances, which is most likely found to function intracellularly in cells involved in this wound healing process?

    A Fibronectin

    B Laminin

    C Tyrosine kinase

    D Hyaluronic acid

    E Collagen
    [HIDE](C) CORRECT. Cell surface growth factor receptors recruit intracellular protein kinases that begin a sequence of events leading to cell division and growth.[/HIDE]


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    Question 31

    A bee sting is suffered by a 28-year-old man, and his wife searches frantically for the medical kit with the injectable epinephrine.

    Which of the following immunologic mechanisms are they trying to prevent?

    A Local immune complex formation

    B Interleukin release from macrophages

    C Binding of anti-receptor antibody

    D Systemic anaphylaxis

    E Complement activation

    [HIDE](D) CORRECT. Exposure to the allergens of a bee sting is a cause for systemic anaphylaxis for some people..[/HIDE]

    Questions 32

    A 35-year-old man has decreasing mobility of his spine, and he becomes more "hunched over" during the past 5 years. He has hip pain bilaterally. On physical examination he has loss of lumbar lordosis and diminished range of motion at the hips. A radiograph of the pelvis shows ankylosis with sacroiliitis of the sacroiliac joints bilaterally. No other joints appear to be affected. His antinuclear antibody test is negative. He has no other significant medical problems.

    Which of the following laboratory test findings is most likely to be present in this man?

    A HLA B27

    B ANA positive at 1:256

    C Elevated rheumatoid factor

    D Markedly decreased serum complement

    E Monoclonal gamma spike
    [HIDE](A) CORRECT. However, not every person with HLA B27 present will develop ankylosing spondylitis, one of the spondyloarthropathies.[/HIDE]

    Question 33

    A 45-year-old man has been plagued by mild chronic diarrhea and increased numbers of minor respiratory tract infections for most of his life. Following a motor vehicle accident with multiple lacerations to the lower leg, he has a significant blood loss requiring transfusion of blood products. During the transfusion, he is noted to have an anaphylactic transfusion reaction.

    Which of the following diseases is he most likely to have?

    A Selective IgA deficiency

    B Amyloidosis

    C Systemic lupus erythematosus

    D Niemann-Pick disease

    E Graft versus host disease

    [HIDE](A) CORRECT. Such persons can live a normal life, but they can have antibodies to IgA, which set off an anaphylactic reaction when they encounter IgA in the serum in transfused blood products.[/HIDE]

    Question 34

    A 55-year-old woman has had increasing difficulty with swallowing over the past year. On physical examination her blood pressure is 210/110 mm Hg. Laboratory testing reveals a positive antinuclear antibody test with a nucleolar pattern on immunofluorescence. Her serum complement levels are normal.

    Which of the following lesions is most likely to be seen in her kidneys with renal biopsy?

    A Renal cell carcinoma

    B Nodular glomerulosclerosis

    C Acute glomerulonephritis

    D Hyperplastic arteriolosclerosis

    E Polycystic change
    [HIDE](D) CORRECT. These findings are typical for diffuse scleroderma, and malignant hypertension may result.[/HIDE]

    Question 35

    A positive tuberculin skin test, with a firm 15 mm diameter dark red firm area of induration on the forearm, appears 60 hours following injection of the PPD.

    This finding is most likely to be a consequence of which of the following types of hypersensitivity reaction?

    A Type I hypersensitivity

    B Type II hypersensitivity

    C Type III hypersensitivity

    D Type IV hypersensitivity

    E Complement activation

    [HIDE](D) CORRECT. This test relies on intact cell-mediated immune response.[/HIDE]

    Question 36

    A study of immunofluorescence patterns in skin biopsies is performed. The immunofluorescence pattern in the skin, with antibody to IgG, which shows a band of immunofluorescence at the dermal-epidermal junction, is most likely to be based upon which of the following pathologic mechanisms?

    A Increased numbers of CD4 lymphocytes infiltrating the dermis

    B Degranulation of mast cells

    C Trapping of antigen-antibody complexes

    D Macrophages are releasing cytokines

    E Neutrophils are emigrating from capillaries

    [HIDE](C) CORRECT. This pattern is typical for a type III hypersensitivity reaction. Antigen-antibody complexes tend to be trapped along basement membranes.[/HIDE]

    Question 37

    A 15-year-old boy underwent bone marrow transplantation for aplastic anemia, with marrow donated from a sibling, with a 5 out of 6 antigen match. He later developed a fine, scaling skin rash as well as a watery diarrhea.

    Which of the following laboratory test findings is most likely to accompany this patient's disease?

    A Hyperamylasemia

    B Hyperbilirubinemia

    C Hypocomplementemia

    D Neutrophilia

    E Elevated creatine kinase

    [HIDE](B) CORRECT. There is cholestasis in the liver as a consequence of graft versus host disease (GVHD).[/HIDE]

    Question 38

    A 50-year-old man with end stage renal disease from long-standing diabetes mellitus receives a cadaveric renal transplant. A month later, he has increasing malaise. His urine output decreases. Laboratory studies show a rising serum urea nitrogen and creatinine. The allograft is biopsied and seen microscopically to be undergoing destruction by cells which are recognizing graft cells expressing class I HLA antigens.

    Which of the following cells is most likely to mediate this response?

    A CD4 lymphocytes

    B NK cells

    C CD8 lymphocytes

    D Macrophages

    E Plasma cells
    [HIDE](C) CORRECT. These are cytotoxic lymphocytes that participate in acute cellular rejection of solid organ transplants.[/HIDE]

    Question 39

    Persons infected with HIV are shown to have a period of clinical latency of infection lasting years. During this time their risk for infection by opportunistic pathogens is not increased. However, a reservoir of virus remains within their lymphoid tissues.

    Which of the following cells is most important to maintain this reservoir of HIV?

    A CD8 lymphocyte

    B High endothelial venule cell

    C Macrophage

    D Memory B cell

    E NK cell

    F Plasma cell

    [HIDE](C) CORRECT. Macrophages can become infected with HIV but can survive and serve as a reservoir for spread to other cells. Follicular dendritic cells can also capture HIV and spread it to other cells.[/HIDE]

    Question 40

    A 21-year-old man with serum IgA of 22 mg/dL, IgG of 175 mg/dL, and IgM of 40 mg/dL has had a high fever with cough productive of yellowish sputum for the past two days. Auscultation of the chest reveals a few crackles in both lung bases. A chest radiograph reveals bilateral patchy pulmonary infiltrates.

    Which of the following inflammatory cell types will most likely be seen in greatly increased numbers in his sputum specimen?

    A Macrophages

    B Neutrophils

    C Mast cells

    D Small lymphocytes

    E Langhans giant cells
    [HIDE](B) CORRECT. The signs and symptoms are suggestive of an acute bacterial pneumonia. The decreased serum immunoglobulins at his age suggest common variable immunodeficiency, which puts him at risk for bacterial infections. Such infections promote an acute inflammatory response dominated by neutrophils, which gives the sputum the yellowish, purulent appearance. [/HIDE]

    Question 41

    A 31-year-old man incurs an injury in an industrial accident, with a steel H-beam striking the right side of his face, crushing the zygomatic arch and damaging the globe of the right eye. He undergoes plastic repair of bone and soft tissues and an attempt is made to salvage the eye. A month later, he has decreased visual acuity in both eyes, with choroidal thickening seen on funduscopic examination. The right eye is enucleated and shows prominent CD4 lymphocyte and macrophage infiltration of the uvea.

    By which of the following immunologic mechanisms has this condition most likely developed?

    A Breakdown of T-cell anergy

    B Polyclonal lymphocyte activation

    C Release of sequestered antigens

    D Cross-reactivity with myocardial antigens

    E Failure of T-cell mediated suppression
    [HIDE](C) CORRECT. Sympathetic ophthalmia, with released of antigens that incite a granulomatous response, even in the opposite eye, can occur by this mechanism.[/HIDE]

    Question 42

    A neonate born at term developed tetany soon after birth. On physical examination the infant has a heart murmur. Laboratory studies show a serum calcium of 6.3 mg/dL. Echocardiography reveals a membranous intraventricular septal defect. Within the next year, this infant has bouts of Pneumocystis carinii (jiroveci) pneumonia, Aspergillus fumigatus pneumonia, and parainfluenza virus and herpes simplex virus upper respiratory infections.

    Which of the following abnormalities most likely explains the development of this infant's findings?

    A A deficiency of adenosine deaminase

    B 22q- chromosome deletion

    C Reduction in CD4 lymphocytes

    D Defect in NADPH oxidase

    E Failure of maturation of B cells into plasma cells
    [HIDE](B) CORRECT. This pattern of infection implies a problem with cell-mediated immunity, and the hypocalcemia suggests DiGeorge syndrome with thymic hypoplasia. The thymus, parathyroids, aorta, and heart can be involved. T-cell function is deficient, resulting in recurrent and multiple fungal, viral, and protozoal infections.[/HIDE]

    Question 43

    A 45-year-old woman has experienced progressive, increasing muscular weakness, particularly toward the end of the day, over the past 2 months. She does not have arthralgias or myalgias. On physical examination her motor strength goes from 5/5 to 4/5 with repetitive movement of extremities. A chest CT scan reveals an anterior mediastinal mass. Laboratory studies show that her antinuclear antibody test is negative.

    By which of the following immunologic mechanisms is her disease most likely produced?

    A Local immune complex formation

    B Interleukin release from macrophages

    C Binding of anti-receptor antibody

    D Mast cell degranulation

    E Cross-reactivity with tissue antigens

    [HIDE](C) CORRECT. Myasthenia gravis is an example of an anti-receptor disease of an autoimmune nature (type II hypersensitivity). Antibody is directed against acetylcholine receptors. Many myasthenia gravis patients have a thymoma or thymic hyperplasia.[/HIDE]

    Question 44

    A 45-year-old woman has noted episodes of pain with swelling and warmth of her hands and feet for the past 3 weeks. During these episodes, lasting hours to days, it is difficult for her to walk or to prepare meals. On physical examination she has painful 1 cm subcutaneous nodules on the extensor surfaces of her elbows. Over the next 6 years, her hands become deformed so that it is difficult to perform tasks as simple as opening a door or buttoning her blouse.

    Which of the following laboratory test findings is she most likely to have?

    A HLA B27

    B ANA positive at 1:256

    C Elevated rheumatoid factor

    D Markedly decreased serum complement

    E Hypogammaglobulinemia
    [HIDE](C) CORRECT. Her joint deformities occurred as a complication of rheumatoid arthritis. Rheumatoid nodules typically form in subcutaneous locations on extensor surfaces, though they may involve visceral organs such as lung less commonly.[/HIDE]

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