Spleen and Lymphatic System — MCQs

10 questions

Which of the following diseases does not typically present with fever, rash, and lymphadenopathy?

Portal vein is formed by the union of which structures?

A 12 year old boy presents with hematemesis, melena and mild splenomegaly. There is no obvious jaundice or ascites. The most likely diagnosis is:

A 12-year-old boy presents with hematemesis, melena and mild splenomegaly. There is no obvious jaundice or ascites. The most likely diagnosis is:

USG findings of focal anechoic lesion with floating membranes indicate which liver pathology?

Which of the following statements on lymphoma is not true?

All of the following are features of Lymph node histology except:

Identify the structure shown in CT abdomen section. (Recent NEET Pattern 2018-19)

Causes of thickened gallbladder wall on ultrasound examination are all except:

Q10

What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?

Spleen and Lymphatic System Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following diseases does not typically present with fever, rash, and lymphadenopathy?

A. Rheumatic fever (Correct Answer)
B. Toxoplasmosis
C. Rubella
D. Measles

Explanation: ### Original Explanation ***Rheumatic fever*** - While **fever** can be present, rheumatic fever is primarily characterized by migratory polyarthritis, carditis, chorea, erythema marginatum, and subcutaneous nodules, with a **rash (erythema marginatum)** being less common and not often accompanied by significant **lymphadenopathy** [1]. - Its etiology is linked to a prior **Streptococcus pyogenes infection** [1]. *Toxoplasmosis* - **Fever**, widespread **lymphadenopathy**, and a **maculopapular rash** are common features in acute toxoplasmosis, particularly in immunocompromised individuals. - Ocular and neurological involvement can also occur, distinguishing it from other conditions. *Rubella* - Known as **German measles**, it typically presents with a **low-grade fever**, a characteristic **maculopapular rash** that starts on the face and spreads downwards, and prominent **postauricular and occipital lymphadenopathy**. - It is a milder disease than measles but has significant implications during pregnancy. *Measles* - Characterized by **high fever**, a **maculopapular rash** that begins on the face and spreads, and significant **lymphadenopathy**, along with cough, coryza, and conjunctivitis (the "3 Cs") [2]. - **Koplik spots** on the buccal mucosa are pathognomonic for measles [2].

Question 2: Portal vein is formed by the union of which structures?

A. Superior Mesenteric and Splenic Veins (Correct Answer)
B. Superior Mesenteric and Left Renal Vein
C. Inferior Mesenteric and Splenic Vein
D. Superior Mesenteric and Inferior Mesenteric Veins

Explanation: ***Superior Mesenteric and Splenic Veins*** - The **hepatic portal vein** is primarily formed posterior to the neck of the pancreas by the confluence of the **superior mesenteric vein (SMV)** and the **splenic vein** [1]. - The **SMV** drains blood from the small intestine, cecum, ascending colon, and part of the transverse colon, while the **splenic vein** drains blood from the spleen, stomach, and pancreas [2]. *Superior Mesenteric and Left Renal Vein* - The **left renal vein** drains blood from the left kidney and typically empties into the **inferior vena cava (IVC)**, not participating in portal vein formation. - The **SMV** is a component, but its union with the left renal vein does not form the portal vein. *Inferior Mesenteric and Splenic Vein* - The **inferior mesenteric vein (IMV)** typically drains into the **splenic vein** (which then joins the SMV) or, less commonly, directly into the SMV or the junction of the SMV and splenic vein, but it does not directly form the main portal vein with the splenic vein. - The **splenic vein** is a major component, but the IMV's contribution is usually indirect via the splenic vein. *Superior Mesenteric and Inferior Mesenteric Veins* - While both of these are major veins of the portal system, they do not directly unite to form the main **portal vein**. - The **IMV** usually drains into the **splenic vein** before it joins the **SMV** to form the portal vein.

Question 3: A 12 year old boy presents with hematemesis, melena and mild splenomegaly. There is no obvious jaundice or ascites. The most likely diagnosis is:

A. NCPF
B. Malaria with DIC
C. Cirrhosis
D. EHPVO (Correct Answer)

Explanation: EHPVO - **Extrahepatic portal vein obstruction (EHPVO)** in children commonly presents with upper GI bleeding due to **esophageal varices** caused by portal hypertension, alongside **splenomegaly**. [1] - The absence of jaundice and ascites, paired with the patient's age, is highly suggestive of EHPVO since it primarily affects the portal vein before it reaches the liver, sparing hepatic function initially. NCPF - **Non-cirrhotic portal fibrosis (NCPF)** also causes portal hypertension, splenomegaly, and GI bleeding. However, it is more commonly seen in older adults and is a diagnosis of exclusion. - While it fits some symptoms, EHPVO is a more common cause of portal hypertension in children without underlying liver disease. [1] Malaria with DIC - **Malaria** can cause splenomegaly and, in severe cases, DIC leading to bleeding, but it would typically present with **fever, chills**, and other systemic signs of infection, which are not mentioned. - DIC would also likely present with more diffuse bleeding manifestations beyond hematemesis and melena, and not typically without other signs of severe malaria. Cirrhosis - **Cirrhosis** leads to portal hypertension, splenomegaly, and GI bleeding from varices. However, it is usually accompanied by overt signs of **liver dysfunction** such as **jaundice, ascites**, and encephalopathy, which are reportedly absent in this case. [1] - In a 12-year-old, childhood cirrhosis causes are typically distinct from adult causes and would still manifest with more significant liver compromise.

Question 4: A 12-year-old boy presents with hematemesis, melena and mild splenomegaly. There is no obvious jaundice or ascites. The most likely diagnosis is:

A. Cirrhosis
B. Extrahepatic portal venous obstruction (Correct Answer)
C. Hepatic venous outflow tract obstruction
D. Non-cirrhotic portal fibrosis

Explanation: ***Extrahepatic portal venous obstruction*** - In a 12-year-old boy presenting with **hematemesis** and **melena**, signifying upper GI bleeding, combined with **mild splenomegaly** and the *absence of jaundice or ascites*, **extrahepatic portal venous obstruction** is the most likely diagnosis. - This condition leads to **portal hypertension** [1] proximal to the liver, causing **esophageal varices** (bleeding source) and splenomegaly, without significant hepatic dysfunction. *Cirrhosis* - While cirrhosis also causes **portal hypertension** and its complications (hematemesis, splenomegaly), the **absence of jaundice and ascites** in a child makes it less likely [1]. - **Jaundice and ascites** are common indicators of significant liver dysfunction and decompensation, which are characteristic of cirrhosis. *Hepatic venous outflow tract obstruction* - This condition, also known as **Budd-Chiari syndrome**, typically presents with acute-onset **abdominal pain, ascites, hepatomegaly**, and can lead to liver failure [2]. - The absence of these prominent features, particularly **ascites** and **hepatomegaly**, makes this diagnosis less probable. *Non-cirrhotic portal fibrosis* - **Non-cirrhotic portal fibrosis** (idiopathic portal hypertension) can cause portal hypertension and bleeding, but it is a diagnosis of exclusion and less common in childhood than extrahepatic portal venous obstruction. - While it fits some symptoms like bleeding and splenomegaly without jaundice, it's typically a diagnosis after excluding more common causes of portal vein obstruction in children.

Question 5: USG findings of focal anechoic lesion with floating membranes indicate which liver pathology?

A. Hydatid cyst (Correct Answer)
B. Pyogenic abscess
C. Hemangioma
D. Amoebic abscess

Explanation: ***Hydatid cyst*** - A **hydatid cyst** often presents on ultrasound as a **focal anechoic lesion** with characteristic **floating membranes** (water lily sign) due to detachment of the endocyst. - These cysts are caused by tapeworm larvae (*Echinococcus granulosus*) and can have daughter cysts within the main cyst. *Pyogenic abscess* - A **pyogenic abscess** typically appears as an **ill-defined, hypoechoic liver lesion** with internal debris, sometimes showing gas. - While it can be anechoic, the presence of **floating membranes** is not a characteristic feature. *Hemangioma* - A **hemangioma** is usually a **well-defined, hyperechoic lesion** on ultrasound, without any internal fluid or floating membranes. - Its appearance is distinct from cystic lesions and it often shows characteristic peripheral nodular enhancement on contrast-enhanced imaging. *Amoebic abscess* - An **amoebic abscess** typically presents as a **hypoechoic, often round or oval lesion** with fine internal echoes and poorly defined walls, usually without floating membranes. - It is frequently located in the right lobe of the liver and can be difficult to differentiate from a pyogenic abscess based on imaging alone.

Question 6: Which of the following statements on lymphoma is not true?

A. In general, follicular (nodular) NHL has worse prognosis compared to diffuse NHL. (Correct Answer)
B. HD more often tends to remain localized to a single group of lymph nodes and spreads by contiguity.
C. Several types of non-Hodgkin's lymphoma (NHL) may have a leukemic phase.
D. A single classification system for Hodgkin's disease (HD) is almost universally accepted.

Explanation: ***In general follicular NHL has worse prognosis compared to diffuse NHL*** - Follicular Non-Hodgkin's lymphoma (NHL) typically has a **more indolent** course than diffuse lymphoma, leading to **better long-term survival** [1]. - Diffuse Large B-cell Lymphoma (DLBCL) is usually more aggressive and tends to have a **poorer prognosis** despite being treatable. *HD tends to remain localized to a single group of lymph nodes and spreads by contiguity* - Hodgkin's Disease (HD) is known for progressing in a **contiguous manner** [2], but it can **spread beyond localized regions** as well. - While it often starts in a single area, advanced stages may show **systemic spread**, contradicting the strict localization concept. *Several types of Non-Hodgkin's lymphoma may have a leukemic phase* - Certain Non-Hodgkin's lymphomas, such as **chronic lymphocytic leukemia (CLL)**, indeed can present with a significant **leukemic phase** [3]. - This characteristic differentiates them from other lymphomas that typically do not exhibit this phase. *A single classification system of Hodgkin's disease is almost universally accepted* - There are **multiple classification systems** for Hodgkin's Disease [4], including the Ann Arbor system and others, indicating no **universal acceptance**. - Ongoing research may lead to updates and varied classification approaches, showing the **evolution of diagnostic criteria**. **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. 561-562. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 557-558. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 560-561. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 559-560.

Question 7: All of the following are features of Lymph node histology except:

A. Red pulp and White pulp are present (Correct Answer)
B. Both Efferent and Afferent are present
C. Cortex and Medulla are present
D. Subcapsular sinus present

Explanation: ***Red pulp and White pulp are present*** - **Red pulp** and **white pulp** are characteristic features of the **spleen**, not lymph nodes [1]. - The **red pulp** is involved in filtering blood and destroying old red blood cells, while the **white pulp** is responsible for immune responses [2]. *Both Efferent and Afferent are present* - Lymph nodes have both **afferent lymphatic vessels** that bring lymph into the node and **efferent lymphatic vessels** that carry filtered lymph away. - This architecture ensures proper filtration and immune surveillance. *Cortex and Medulla are present* - Lymph nodes are histologically divided into an outer **cortex** and an inner **medulla**. - The **cortex** contains B-cell follicles and T-cell zones, while the **medulla** comprises medullary cords and sinuses [3]. *Subcapsular sinus present* - The **subcapsular sinus** is the space located immediately beneath the capsule of a lymph node, which receives lymph from the afferent lymphatic vessels [3]. - This sinus is the initial site of lymph filtration within the node [3]. **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. 569-570. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 568-569. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 553-554.

Question 8: Identify the structure shown in CT abdomen section. (Recent NEET Pattern 2018-19)

A. Inferior vena cava
B. Portal vein (Correct Answer)
C. Splenic vein
D. Superior mesenteric vein

Explanation: ***Portal vein*** - The arrow points to a vessel receiving blood from the splenic and superior mesenteric veins, which is characteristic of the **portal vein** entering the **liver parenchyma**. - The portal vein is typically seen anterior to the **inferior vena cava** and posterior to the **common hepatic artery** at this level. *Inferior vena cava* - The **inferior vena cava (IVC)** is a large, retroperitoneal vessel located posterior to the liver and to the right of the aorta. - The structure indicated by the arrow is clearly within the liver substance, not in the typical position of the IVC. *Splenic vein* - The **splenic vein** runs horizontally behind the body of the pancreas and joins with the superior mesenteric vein to form the portal vein. - The vessel shown is within the liver, distal to the formation of the portal vein. *Superior mesenteric vein* - The **superior mesenteric vein (SMV)** typically runs vertically in the mesentery and joins the splenic vein to form the portal vein. - The indicated structure is within the liver hilum, not in the anatomical location of the SMV.

Question 9: Causes of thickened gallbladder wall on ultrasound examination are all except:

A. Congestive cardiac failure
B. Postprandial state
C. Kawasaki disease (Correct Answer)
D. Cholecystitis

Explanation: ***Kawasaki disease*** (Correct Answer) - While Kawasaki disease can cause **gallbladder hydrops** (distension with bile), the primary ultrasound finding is an **enlarged, distended gallbladder** rather than isolated wall thickening. - When gallbladder involvement occurs in Kawasaki disease, it manifests as **acalculous cholecystitis** with hydrops, but this is **not a typical or common presentation** compared to the other causes listed. - The hallmark features of Kawasaki disease are **coronary artery aneurysms** and systemic vasculitis, not primary gallbladder pathology. - In clinical practice, gallbladder wall thickening would **not be attributed to Kawasaki disease** as a primary differential diagnosis. *Incorrect: Congestive cardiac failure* - **Systemic fluid overload** and venous congestion in CHF leads to gallbladder wall thickening due to **transudative edema**. - This is a **common cause** of non-inflammatory gallbladder wall thickening (>3mm). - The wall appears thickened, hypoechoic, and **edematous** without pericholecystic fluid. *Incorrect: Postprandial state* - After eating, the gallbladder **contracts to release bile**, causing the wall to appear thicker on ultrasound due to **accordion-like folding** of the mucosa. - This is a **normal physiological finding** and typically resolves within 1-2 hours. - Scanning should ideally be done after **6-8 hours of fasting** to avoid this pseudo-thickening. *Incorrect: Cholecystitis* - **Acute cholecystitis** is the **classic cause** of gallbladder wall thickening (>3mm, often >5mm). - Associated findings include **gallstones, pericholecystic fluid, positive sonographic Murphy's sign**, and wall edema. - The wall shows **layering** (subserosal edema) and hyperemia on Doppler imaging.

Question 10: What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?

A. USG of the abdomen
B. Retrograde urogram
C. IVP
D. CECT (Correct Answer)

Explanation: ***Correct Answer: CECT*** - **Contrast-enhanced computed tomography (CECT)** is the investigation of choice for evaluating blunt abdominal trauma with hematuria as it accurately assesses the extent of injury to the **kidneys, ureters, bladder**, and surrounding structures. - It provides detailed images for detecting **renal lacerations, hematomas, urine extravasation**, and other abdominal organ injuries. - **Gold standard** in trauma protocols for comprehensive evaluation of renal and abdominal injuries. *Incorrect: USG of the abdomen* - **Ultrasound** can identify gross abnormalities like large hematomas or free fluid but is less sensitive than CECT for subtle renal injuries or collecting system disruptions. - It is often used as an initial screening tool (FAST exam) but not the definitive investigation of choice in this context. *Incorrect: Retrograde urogram* - A **retrograde urogram** primarily evaluates the **lower urinary tract** (ureters and bladder) by injecting contrast directly into the urethra. - It is not suitable for assessing the extent of renal parenchymal injury or other abdominal organ damage in blunt trauma. *Incorrect: IVP* - **Intravenous pyelogram (IVP)** uses intravenous contrast to visualize the kidneys, ureters, and bladder, but it has largely been replaced by CECT due to its lower sensitivity and specificity for traumatic injuries. - It provides less detailed anatomical information about surrounding soft tissues and can miss subtle parenchymal or vascular injuries.

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