Vascular Pathology — MCQs

A 45-year-old male having a long history of cigarette smoking presented with gangrene of the left foot, which was treated with an amputation. Representative sections from the specimen revealed the presence of arterial thrombus with neutrophilic infiltrate in the arterial wall, as well as inflammation extending into the adjacent veins and nerves. What is the most probable diagnosis?

Vascular Pathology Indian Medical PG Practice Questions and MCQs

Question 301: Which of the following organs typically develops red infarcts due to dual blood supply?

A. Kidney
B. Lung (Correct Answer)
C. Spleen
D. Heart

Explanation: ***Lung*** - Red infarcts, characterized by their **hemorrhagic appearance**, often occur in organs like the lung due to their **dual blood supply** (bronchial and pulmonary arteries) and the presence of **venous obstruction** [1]. - This type of infarct is formed due to the inability to drain the blood appropriately, leading to **blood pooling** in infarcted areas [1]. *Spleen* - The spleen typically undergoes **white infarcts** due to its **end-arterial blood supply**, meaning it has only one arterial source, leading to necrosis without significant hemorrhage [1]. - Infarction in the spleen often presents as **firm and pale**, contrasting with the red nature of lung infarcts [1]. *Kidney* - The kidney also exhibits **white infarcts** due to its **segmental arteries**, resulting in necrosis without hemorrhage when blood flow is disrupted [1]. - The kidney infarcts result in **pale areas of necrosis**, again different from the vascular characteristics of lung infarcts [1]. *Heart* - Heart infarcts typically manifest as **transmural or subendocardial infarctions** which can lead to ischemic heart disease but do not classically present as red infarcts [1]. - They are usually **pale** in appearance initially due to interrupted blood supply from the coronary arteries, lacking the characteristics of red lung infarcts [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, p. 140.

Question 302: In a kidney specimen, fibrinoid necrosis and an onion peel appearance are observed. The most probable pathology is:

A. Glomerulosclerosis
B. Hyperplastic arteriolosclerosis (Correct Answer)
C. Fibrillary glomerulonephritis
D. Hyaline degeneration

Explanation: ***Hyperplastic arteriolosclerosis*** [1][2] - Characterized by **fibrinoid necrosis** of the vessel walls and an **onion peel appearance** indicating concentric lamination [1][2]. - Commonly associated with **malignant hypertension** [2][3], leading to significant renal damage. *Hyaline degeneration* - Typically features **homogeneous glassy appearance** but does not involve **onion peel appearance**. - More often a response to **chronic injury** rather than the acute vascular changes seen here. *Fibrillary glomerulonephritis* - Involves deposition of **fibrillary structures** in the glomeruli, not in the arterioles. - Lacks the characteristic **fibrinoid necrosis** and onion skinning seen in arterioles in this case. *Glomerulosclerosis* - Generally refers to **scarring of glomeruli** and does not specifically indicate vascular changes like **onion peel appearance**. - Focuses more on glomerular rather than arteriolar pathology. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 945. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 498-499. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 276-277.

Question 303: Granuloma is a pathological feature of all, except which of the following?

A. Giant cell arteritis
B. Granulomatosis with polyangiitis
C. Eosinophilic granulomatosis with polyangiitis
D. Microscopic polyangiitis (Correct Answer)

Explanation: ***Microscopic polyangitis*** - This condition is associated with **necrotizing vasculitis** without significant **granulomatous inflammation** [1]. - Primarily affects small vessels and typically features **pauci-immune** glomerulonephritis [1]. *Giant cell arteritis* - Characterized by **granulomatous inflammation** in the temporal arteries, leading to headaches and vision loss [2]. - It often shows **multinucleated giant cells** in biopsy specimens, confirming the diagnosis [2]. *Churg strauss disease* - Also known as **Eosinophilic Granulomatosis with Polyangiitis**, it features **granulomas** and affects small to medium vessels. - Typically presents with asthma, nasal polyps, and significant **eosinophilia**. *Wegner's granulomatosis* - Now referred to as **Granulomatosis with Polyangiitis**, it prominently features **necrotizing granulomas** in the respiratory tract and kidneys [3]. - Associated with **c-ANCA** (anti-neutrophil cytoplasmic antibodies), confirming its granulomatous nature [3]. **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. 516-517. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 519-520.

Question 304: Which of the following statements about pyogenic granuloma is false?

A. Benign tumor
B. Bleeding
C. Bacterial infection (Correct Answer)
D. Lobular capillary hemangioma

Explanation: ***Bacterial infection*** - Pyogenic granuloma is **not** caused by a bacterial infection; it is a **vascular lesion** that results from trauma or irritation. - The term "pyogenic" may suggest infection, but it actually refers to **pus-producing**, rather than being related to bacteria. *Bleeding* - Pyogenic granulomas are characterized by **easy bleeding** [1], especially when traumatized, due to their highly vascular nature. - They often appear as **red papules** or nodules that can bleed profusely. *Capillary hemangioma* - Pyogenic granulomas are often confused with **capillary hemangiomas**, but they are distinct entities; the former is more reactive. - Both have **vascular features**, but pyogenic granulomas arise typically in response to **injury** [1]. *Benign tumor* - Pyogenic granulomas are classified as **benign tumors** of the skin and mucous membranes. - They do not metastasize but can recur if not removed completely. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 524-525.

Question 305: Which among the following is true about non-bacterial thrombotic endocarditis (NBTE)?

A. Characterized by small, non-invasive vegetations.
B. Does not elicit an inflammatory reaction (Correct Answer)
C. Associated with hypercoagulable states and systemic diseases
D. Commonly associated with malignancy, especially adenocarcinomas.

Explanation: ***Vegetations elicit inflammatory reaction*** - In non-bacterial thrombotic embolism (NBTE), **vegetations do not provoke a significant inflammatory response** compared to infectious endocarditis. - The vegetations seen in NBTE are typically **non-destructive**, lacking the classic inflammatory signs. *Non invasive in nature* - While NBTE is often associated with underlying malignancy and can present similarly to infective endocarditis, it does not undergo the same **invasive changes**. - This statement is misleading since although the lesions are non-infectious, they can still cause significant **embolic phenomena**. *Thrombi on the leaflets of the cardiac valves* - NBTE is characterized by **sterile vegetations** on heart valves, as opposed to **thrombi**, which are clots formed by platelets and fibrin [1]. - These vegetations attach to **valve surfaces** without causing the same level of damage seen in bacterial endocarditis [1]. *Marantic endocarditis* - This term is often used interchangeably with NBTE, describing the presence of **non-bacterial vegetations** related to states of hypercoagulability, particularly in malignancy. - While NBTE does have marantic features, this oes not accurately depict a false statement about the characteristics of NBTE. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, p. 568.

Question 306: A female who presents with a cough and bloody sputum is diagnosed with granulomatosis with polyangiitis. Which of the following is the characteristic renal histological feature of granulomatosis with polyangiitis?

A. Focal necrotizing glomerulonephritis (Correct Answer)
B. Nodular glomerulosclerosis
C. Rapidly progressive glomerulonephritis
D. Minimal change disease

Explanation: ***Focal necrotizing glomerulonephritis*** - Granulomatosis with polyangiitis is characterized by **focal necrotizing glomerulonephritis**, which is a common renal manifestation [1]. - This histological feature reveals **segmental necrosis** of glomeruli with the presence of crescents, indicative of a **vasculitis-associated kidney injury** [1]. *Minimal change disease* - Primarily associated with **nephrotic syndrome**, does not exhibit the **necrotizing features** typical of granulomatosis with polyangiitis. - Characterized by **foot process effacement** on electron microscopy, which is not relevant in this context. *Rapidly progressive glomerulonephritis* - While granulomatosis may cause this, the specific **histological feature** of interest is the **focal necrotizing pattern** rather than generalized rapid progression. - This term refers to a clinical presentation rather than a distinct histological finding. *Nodular glomerulosclerosis* - Typically associated with **diabetic nephropathy**, not with granulomatosis with polyangiitis. - Histologically manifests as **nodules** in glomeruli, which differ from the **necrotizing lesions** observed in this condition. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 536-537.

Question 307: All are seen in malignant hypertension except?

A. Fibrinoid necrosis
B. Necrotizing glomerulonephritis
C. Hyaline arteriolosclerosis (Correct Answer)
D. Hyperplastic arteriolosclerosis

Explanation: ***Hyaline aeriolosclerosis*** - **Hyaline aeriolosclerosis** is more commonly associated with chronic hypertension rather than malignant hypertension [5], which is characterized by **severe, acute elevations** in blood pressure. - Malignant hypertension typically leads to **end-organ damage**, particularly in the kidneys, through other mechanisms rather than the **hyaline changes** observed in chronic conditions [4]. *Necrotizing glomerulonephritis* - Often seen in malignant hypertension as it leads to **acute kidney injury** characterized by **glomerular capillary damage**. - Associated with **fibrinoid necrosis** in the renal vasculature due to heightened blood pressure adversely affecting renal tissues [1,3]. *Fibrinoid necrosis* - Is a key feature in malignant hypertension, appearing as **deposits of fibrin** in the vessel walls [1,3]. - Characterizes the **acute vascular damage** and is indicative of renal impairment during malignant hypertensive crises [2]. *Hyperplastic aeriolosclerosis* - This condition is linked with malignant hypertension, characterized by **onion skin fibrosis** around arterioles [1]. - It reflects the **severe vascular changes** and is a direct response to the acute elevation in blood pressure [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 945. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 276-277. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 277-278. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 541-542. [5] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 943-945.

Question 308: Which of the following vascular lesions has the least clinical significance?

A. Monckeberg's medial calcification (Correct Answer)
B. Glomus tumor
C. Hyaline arteriolosclerosis
D. Hyperplastic arteriolosclerosis

Explanation: ***Monckeberg's medial calcification*** - This condition involves **calcification** of the media layer of the arteries and is typically **asymptomatic** with little clinical significance. - It does not obstruct blood flow and is usually found incidentally on imaging, making it a benign finding. *Hyperplastic aeriolosclerosis* - This lesion is associated with **hyperplasia** of smooth muscle cells and can lead to complications in conditions such as **hypertension** [1]. - It may indicate underlying vascular disease, thus having more clinical importance than Monckeberg's. *Glomus tumor* - Glomus tumors, while benign, can cause significant pain and discomfort, typically occurring under the nail bed. - Their potential for local invasion and distorting normal anatomy makes them clinically significant. *Hyaline aeriolosclerosis* - This condition is characterized by **hyaline deposition** in small arteries and is often associated with chronic hypertension and diabetes [1]. - It can indicate vascular injury and related complications, thus having more clinical relevance. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 498-499.

Question 309: Which of the following statements about cavernous hemangioma is false?

A. Not associated with VHL disease
B. Less infiltrative than capillary hemangioma
C. Intravascular thrombosis and dystrophic calcification are seen commonly
D. Undergo spontaneous regression (Correct Answer)

Explanation: ***Undergo spontaneous regression*** - This statement is **false** because **cavernous hemangiomas** typically do not undergo spontaneous regression. They are persistent lesions. - Spontaneous regression is more characteristic of **capillary hemangiomas** (also known as infantile hemangiomas), especially those occurring in early childhood. *Less infiltrative than capillary hemangioma* - This statement is **true**. Cavernous hemangiomas are generally **well-circumscribed** and less infiltrative than capillary hemangiomas, which can sometimes spread more diffusely. - Their distinct, large vascular channels make them easier to delineate from surrounding tissue. *Intravascular thrombosis and dystrophic calcification are seen commonly* - This statement is **true**. The slow blood flow and large, irregular vascular spaces within cavernous hemangiomas predispose them to **thrombosis**. - Subsequent organization of thrombi and **fibrin deposition** often leads to **dystrophic calcification**, which can be visualized radiographically. *Not associated with VHL disease* - This statement is **true**. **Cavernous hemangiomas** are generally **not associated with von Hippel-Lindau (VHL) disease**. - VHL disease is primarily linked to **hemangioblastomas**, particularly in the CNS and retina, which are distinct from common cavernous hemangiomas.

Question 310: A 45-year-old male having a long history of cigarette smoking presented with gangrene of the left foot, which was treated with an amputation. Representative sections from the specimen revealed the presence of arterial thrombus with neutrophilic infiltrate in the arterial wall, as well as inflammation extending into the adjacent veins and nerves. What is the most probable diagnosis?

A. Takayasu arteritis
B. Giant cell arteritis
C. Hypersensitivity angiitis
D. Thromboangiitis obliterans (Correct Answer)

Explanation: ***Thromboangiitis obliterans*** - This condition is strongly linked to **heavy smoking** and is characterized by segmental, thrombosing inflammation of medium-sized and small arteries, along with associated veins and nerves, leading to **gangrene** in the extremities [1]. - The presence of **arterial thrombus with neutrophilic infiltrate** in the arterial wall, and inflammation extending to adjacent **veins and nerves**, is a classic histopathological finding [1]. *Takayasu arteritis* - This is a **large-vessel vasculitis** primarily affecting the aorta and its main branches, leading to **absent pulses** ("pulseless disease") and claudication in the upper extremities [2]. - It typically does not involve the small and medium-sized arteries of the distal extremities or present with inflammation extending to adjacent veins and nerves as described. *Giant cell arteritis* - This is a **large-vessel vasculitis** predominantly affecting the temporal arteries and other arteries originating from the aorta in individuals over 50 years of age, presenting with **headache**, **jaw claudication**, and **visual disturbances** [2]. - Histopathology reveals **granulomatous inflammation** with giant cells, not the neutrophilic infiltrate and involvement of veins/nerves seen in this case [2]. *Hypersensitivity angiitis* - This refers to **leukocytoclastic vasculitis** affecting small vessels (arterioles, capillaries, venules) and is often associated with drug reactions or systemic diseases, typically presenting with **palpable purpura** [3]. - It primarily involves small vessels and lacks the characteristic segmental thrombosing inflammation of arteries, veins, and nerves seen in the given scenario, nor is it definitively linked to smoking leading to gangrene [3]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 280-281. [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 Cardiovascular Disease, pp. 279-280.

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