Vascular Pathology Practice Questions

Q: Which is associated with vasculitis of medium sized vessels

Polyarteritis nodosa. ***Polyarteritis nodosa*** - **Polyarteritis nodosa (PAN)** is a **necrotizing vasculitis** of **medium-sized or small arteries**, but not arterioles, capillaries, or venules [1]. - It classically affects the **renal and visceral arteries**, sparing the pulmonary circulation, and is associated with **aneurysms** and stenoses. *Temporal arteritis* - This is a form of **large-vessel vasculitis** primarily affecting the **temporal and other cranial arteries** [1]. - It is typically seen in older adults and can cause **headache**, **jaw claudication**, and **blindness**. *Wegener's granulomatosis* - Now known as **Granulomatosis with Polyangiitis (GPA)**, this vasculitis affects **small vessels** and is characterized by a **granulomatous inflammation** of the upper and lower respiratory tracts and kidneys [1]. - It is associated with **PR3-ANCA (c-ANCA)** positivity. *Henoch-Schönlein purpura* - This is an **IgA vasculitis** affecting **small vessels**, typically presenting with **palpable purpura**, arthritis, abdominal pain, and renal involvement (nephritis) [1]. - It is the most common form of vasculitis in children.

Q: In polyarteritis nodosa, aneurysms are seen in all organs EXCEPT:

Lung. ***Lung*** - Polyarteritis nodosa (PAN) typically **spares the pulmonary circulation**, which helps distinguish it from other vasculitides like granulomatosis with polyangiitis (Wegener's) or eosinophilic granulomatosis with polyangiitis (Churg-Strauss) [3]. - Aneurysms are characteristic of PAN and occur in **medium-sized arteries** of various organs but are notably absent in the lungs [1]. *Pancreas* - The pancreas is a common site for vasculitic involvement in PAN, with **microaneurysms** and infarctions frequently observed in its arteries [2]. - Pancreatic involvement can lead to abdominal pain, pancreatitis, and other gastrointestinal symptoms [2]. *Kidney* - The **renal arteries** are frequently affected in PAN, leading to aneurysms, infarctions, and stenosis [1]. - This often results in **hypertension, renal insufficiency**, and hematuria, making kidney involvement a major cause of morbidity and mortality. *Liver* - **Hepatic artery aneurysms** are a recognized feature of PAN, often identified incidentally during imaging studies. - While less common than renal involvement, hepatic vasculitis can lead to abdominal pain and deranged liver function tests. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 517-518. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 687-688. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 519-520.

Q: True about Henoch-Schonlein purpura are the following, EXCEPT:

Is associated with a raised IgE in mesangium. ***Is associated with a raised IgE in mesangium*** - **Henoch-Schonlein Purpura (HSP)** is characterized by **IgA deposition** in the mesangium, not IgE. This IgA deposition is a key pathological feature driving the renal manifestations. - While IgE can be elevated in some allergic conditions, it is not a hallmark of HSP's immune complex deposition in the kidneys. *50% patients can present with GN* - This statement is largely true; **glomerulonephritis (GN)**, ranging from microscopic hematuria to advanced renal failure, is a common complication affecting approximately 30-50% of HSP patients. - The severity of renal involvement is highly variable and can significantly impact the long-term prognosis of the disease. *Can present with abdominal pain* - **Abdominal pain** is a very common gastrointestinal manifestation of HSP, often described as colicky and severe, sometimes accompanied by nausea, vomiting, and gastrointestinal bleeding [1]. - This symptom results from vasculitis affecting the small blood vessels of the gastrointestinal tract, leading to **edema** and **hemorrhage** in the bowel wall. *Primarily a small vessel vasculitis* - HSP is indeed a **leukocytoclastic vasculitis** [2] that predominantly affects **small vessels**, particularly post-capillary venules. - This vasculitis leads to the characteristic palpable purpura [2], as well as the involvement of the gastrointestinal tract, joints, and kidneys. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 518-519. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 279-280.

Q: Which one of the following does not cause small vessel vasculitis?

Kawasaki disease. ***Kawasaki disease*** - **Kawasaki disease** is a **medium vessel vasculitis** that primarily affects the coronary arteries in children, not small vessels [1]. - It is characterized by fever, rash, lymphadenopathy, and mucocutaneous involvement, with a risk of coronary artery aneurysms [1]. *Churg-Strauss syndrome* - **Churg-Strauss syndrome** (now known as **Eosinophilic Granulomatosis with Polyangiitis** or **EGPA**) is a type of **ANCA-associated vasculitis** that frequently involves small vessels [1]. - It is characterized by asthma, **eosinophilia**, and granulomatous inflammation, often affecting the lungs, skin, and kidneys [1]. *Henoch-Schönlein purpura* - **Henoch-Schönlein purpura** (**IgA vasculitis**) is a common form of **small vessel vasculitis** in children and young adults [1]. - It is characterized by a classic tetrad of palpable **purpura**, **arthralgia**, **abdominal pain**, and **renal disease** [1]. *Microscopic polyangiitis* - **Microscopic polyangiitis** (MPA) is a severe form of **ANCA-associated small vessel vasculitis**. - It typically causes necrotizing glomerulonephritis and pulmonary capillaritis without granuloma formation [2].

Q: Which of the following is NOT a large vessel vasculitis?

PAN. ***PAN*** - **Polyarteritis Nodosa (PAN)** is a **medium-sized vessel vasculitis** that causes necrotizing inflammation of the muscular arteries [4]. - It specifically spares arterioles, capillaries, and venules, distinguishing it from large vessel vasculitides [4]. - PAN typically presents with **systemic symptoms**, **renal involvement**, **peripheral neuropathy**, and **skin manifestations** [1]. *Giant cell arteritis* - **Giant cell arteritis (GCA)**, or temporal arteritis, is a **large vessel vasculitis** affecting the aorta and its major branches, particularly the temporal artery [2]. - It commonly presents in individuals over 50 years old with symptoms like **headache**, **jaw claudication**, and **vision loss** [3]. *Aortitis* - **Aortitis** refers to inflammation of the aorta, which is the body's largest artery, making it by definition a **large vessel vasculitis**. - It can be seen in conditions like **Takayasu arteritis** [3] or **syphilis**, affecting the vessel wall. *Takayasu disease* - **Takayasu arteritis** is a chronic inflammatory condition primarily affecting the **aorta** and its main branches, classifying it as a **large vessel vasculitis** [3]. - It often affects young women and can lead to **stenosis** or **aneurysm formation** in the affected vessels [3]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 687-688. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 516-517. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 688-689. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 517-518.

Q: Which of the following is false about polyarteritis nodosa

Associated with Hepatitis B. ***Bronchial arteries are most common arteries involved*** - This statement is **FALSE** because **polyarteritis nodosa (PAN)** primarily affects **medium-sized muscular arteries**, and the **renal arteries** are the most commonly involved. - While bronchial arteries can be affected, they are not the most common target and involvement of the pulmonary circulation is rare. - PAN characteristically spares the pulmonary vasculature, which helps differentiate it from other systemic vasculitides. *ANCA negative* - **Polyarteritis nodosa (PAN)** is characterized as an **ANCA-negative vasculitis** [1]. - This feature helps differentiate it from other small-to-medium vessel vasculitides that are often ANCA-positive (e.g., GPA, MPA, EGPA) [1]. *Granulomas not seen* - **Granulomas** are a hallmark of certain vasculitides like **Granulomatosis with Polyangiitis (GPA)** but are characteristically **absent in PAN** [2]. - The inflammatory infiltrate in PAN typically consists of neutrophils, eosinophils, and lymphocytes without granuloma formation [2]. *Renal arteries are most commonly involved* - The **renal arteries** are indeed the **most frequently affected** vessels in PAN, leading to **renal ischemia**, hypertension, and potential renal failure. - Involvement of the kidneys is a major cause of morbidity and mortality in PAN. *Associated with Hepatitis B* - This statement is **TRUE** as a significant proportion of **PAN cases (20-30%)** are strongly associated with **Hepatitis B virus (HBV) infection** [1]. - **HBV-associated PAN** is thought to arise from the deposition of immune complexes containing viral antigens in vessel walls [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 687-688. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 517-518.

Q: A teenager has a progressively increasing soft reddish swelling on his chest. Its histological appearance is given below. Which of the following is the likely diagnosis?

Hemangioma. ***Hemangioma*** - The image displays numerous **blood-filled vascular channels** lined by endothelial cells, which is characteristic of a hemangioma [1]. - The clinical presentation of a **soft, reddish swelling** aligns with the typical appearance of a hemangioma, which is a benign proliferation of blood vessels [1]. *Fibroadenoma* - Fibroadenomas are benign tumors composed of both **glandular and stromal tissue**, primarily found in the breast. - Histologically, they show **proliferating ducts and surrounding connective tissue**, not blood-filled spaces. *Fibroma* - A fibroma is a benign tumor of **fibrous connective tissue**, characterized by abundant collagen. - Histologically, it would consist of **spindle-shaped cells and collagen fibers**, lacking the vascular spaces seen in the image. *Lipoma* - A lipoma is a benign tumor composed of **mature fat cells** (adipocytes). - Histologically, it would show a collection of **uniform fat cells** with small nuclei, which is distinctly different from the image provided. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 481-482, 523-525.

Q: Most characteristic finding in granulomatosis with polyangiitis?

Geographic necrosis. ***Geographic necrosis*** - This describes the **characteristic pattern of necrosis** seen within the granulomatous inflammation in granulomatosis with polyangiitis (GPA) [3]. - The necrosis is **basophilic, serpiginous, and irregularly shaped** (geographic pattern), surrounded by palisading histiocytes and multinucleated giant cells. - This is seen in the classic **necrotizing granulomatous inflammation** that defines GPA, particularly in the **respiratory tract** (nasal, sinus, lung) and occasionally kidneys [3]. - Geographic necrosis is the most specific histological pattern among these options for identifying GPA. *Fibrinoid necrosis* - This occurs in the walls of **small and medium-sized vessels** as part of the necrotizing vasculitis in GPA. - While important in GPA pathogenesis, fibrinoid necrosis is **not specific** to GPA—it occurs in many forms of vasculitis (polyarteritis nodosa, microscopic polyangiitis, etc.) [1], [2]. - The geographic necrosis within granulomas is more diagnostically characteristic. *Caseous necrosis* - This type of necrosis is classically associated with **tuberculosis** and some fungal infections. - It has a "cheese-like" appearance, which is distinct from the basophilic geographic pattern seen in GPA. *Coagulative necrosis* - This is a common form of necrosis associated with **ischemia** (e.g., myocardial infarction). - It preserves the architectural outline of tissue, which is not characteristic of GPA. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 518-519. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 517-518. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 519-520.

Q: A 70-year-old woman with a history of hypertension presents with a pulsatile abdominal mass. A CT scan shows an aortic aneurysm. Which histologic finding is most likely to be present in this patient?

Medial necrosis. ***Medial necrosis*** - Aortic aneurysms are often associated with **medial necrosis**, a degeneration of the medial layer of the aortic wall [1]. - This finding is especially common in **syndromes** like Marfan syndrome and is critical in the pathophysiology of aneurysms. *Foamy histiocytes* - Typically associated with **atheromatous plaques** and lipid-laden lesions, not directly related to **aortic aneurysms**. - While foam cells can be seen in atherosclerosis, they do not indicate the structural changes in the aortic wall characteristic of aneurysms. *Hyaline arteriolosclerosis* - Characterized by **hyaline changes** in small arterioles, mainly related to systemic hypertension and renal complications. - This histological finding is not specific or commonly linked to **aortic aneurysms**, making it irrelevant in this context. *Lipid-laden macrophages* - Found predominantly in areas of **atherosclerosis**, indicating lipid accumulation; however, this is not a primary feature of **aortic aneurysms**. - Their presence does indicate atherosclerotic disease but does not reflect the pathological changes in an aortic aneurysm. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 267-268.

Q: A red soft to firm swelling on the sternum shows proliferation of endothelial cells forming vascular channels on biopsy. What is the most likely diagnosis?

Hemangioma. ***Hemangioma*** - The soft to firm swelling and histological findings indicative of vascular spaces are characteristic of a **hemangioma**, often presenting as a benign vascular tumor [1][2]. - Commonly found in the **sternum**, it may show red or bluish discoloration and typically undergoes a **biopsy** revealing endothelial cell proliferation [2]. *Osteochondroma* - This is a **benign bone tumor** that arises from the growth plate but typically presents as a hard, bony mass rather than a soft swelling. - Histologically, it shows **cartilaginous cap** and is associated with bone rather than vascular structures. *Osteoid osteoma* - Usually presents as a **painful, small bone lesion** often found in the long bones, generally not in the sternum and characterized by a **nidus** of osteoid. - The biopsy would show a **central nidus** with osteoid and woven bone, not consistent with soft swellings. *Paget disease* - This chronic bone disorder involves excessive bone remodeling, leading to enlarged and deformed bones rather than a discrete swelling. - Histologically, it would show **disorganized bone** formation and is not associated with soft or firm masses like hemangiomas. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 481-482. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 523-524.

Question 1

Which is associated with vasculitis of medium sized vessels

Accepted Answer

Polyarteritis nodosa

Answer

Wegener's granulomatosis

Answer

Temporal arteritis

Answer

Henoch-Schönlein purpura

Question 2

In polyarteritis nodosa, aneurysms are seen in all organs EXCEPT:

Accepted Answer

Lung

Answer

Pancreas

Answer

Kidney

Answer

Liver

Question 3

True about Henoch-Schonlein purpura are the following, EXCEPT:

Accepted Answer

Is associated with a raised IgE in mesangium

Answer

50% patients can present with GN

Answer

Can present with abdominal pain

Answer

Primarily a small vessel vasculitis

Question 4

Which one of the following does not cause small vessel vasculitis?

Accepted Answer

Kawasaki disease

Answer

Churg - strauss syndrome

Answer

Henoch - Schonlein purpura

Answer

Microscopic polyangiitis

Question 5

Which of the following is NOT a large vessel vasculitis?

Accepted Answer

PAN

Answer

Giant cell arteritis

Answer

Aortitis

Answer

Takayasu disease

Question 6

Which of the following is false about polyarteritis nodosa

Accepted Answer

Associated with Hepatitis B

Answer

Granulomas not seen

Answer

ANCA negative

Answer

Renal arteries are most commonly involved.

Question 7

A teenager has a progressively increasing soft reddish swelling on his chest. Its histological appearance is given below. Which of the following is the likely diagnosis?

Accepted Answer

Hemangioma

Answer

Fibroadenoma

Answer

Fibroma

Answer

Lipoma

Question 8

Most characteristic finding in granulomatosis with polyangiitis?

Accepted Answer

Geographic necrosis

Answer

Caseous necrosis

Answer

Fibrinoid necrosis

Answer

Coagulative necrosis

Question 9

A 70-year-old woman with a history of hypertension presents with a pulsatile abdominal mass. A CT scan shows an aortic aneurysm. Which histologic finding is most likely to be present in this patient?

Accepted Answer

Medial necrosis

Answer

Lipid-laden macrophages

Answer

Foamy histiocytes

Answer

Hyaline arteriolosclerosis

Question 10

A red soft to firm swelling on the sternum shows proliferation of endothelial cells forming vascular channels on biopsy. What is the most likely diagnosis?

Accepted Answer

Hemangioma

Answer

Osteochondroma

Answer

Osteoid osteoma

Answer

Paget disease

Vascular Pathology — MCQs

Vascular Pathology — MCQs

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