101. Examination of a peripheral blood smear demonstrates a leukemia composed of smallmature lymphocytes without blast forms. If a diagnosis of chronic lymphocytic leukemia ismade, which of the following is the most likely age of this patient?

A. 1 year

B. 5 years

C. 20 years

D. 45 years

E. 65 years

The correct answer is E. Different leukemias tend to affect populations of different ages. The

disease described is chronic lymphocytic leukemia (CLL), a disease of older adults.

Both the 1-year-old (choice A) and the 5-year-old (choice B) would be most likely to have acute

lymphocytic leukemia (ALL).

The 20-year-old (choice C) would be most likely to have acute myelocytic leukemia (AML).

The 45-year-old (choice D) would be likely to have either AML or chronic myelogenous leukemia

(CML).


 

102. Which of the following serum chemistry studies will MOST likely be abnormal in a

preteen with polydipsia that develops weight loss despite eating large amounts of food over a

three month period?

A. Blood urea nitrogen

B. Serum bicarbonate

C. Serum calcium

D. Serum glucose

E. Serum sodium

The correct answer is D. Although it is commonly known that diabetes mellitus is associated with

polyuria and polydipsia, many do not realize it is also associated with weight loss despite increased

eating, also known as polyphagia. In our extremely weight- and food-conscious society, this

phenomenon may be much more striking to the patient and his family than a change in the amount of

fluid intake. The lesson learned is that a child who develops weight loss despite increased food intake

should have a blood glucose test.

All of the other answer choices would be expected to be normal in this patient.


 

103. Which of the following is involved in hypoxia in a smoker with noticeable increase in

anteroposterior chest width if oxygen therapy is effective?

A. Anemia caused by blood loss

B. Edematous tissues

C. Emphysema

D. Localized circulatory deficiencies

E. Right-to-left cardiac shunts

The correct answer is C. Chronic pulmonary emphysema is characterized by distention of small air

spaces distal to the respiratory bronchioles and destruction of alveolar septa. Long-term cigarette

smoking is the usual cause. The marked loss of lung parenchyma associated with emphysema leads

to a decrease in the diffusion capacity of the lungs that reduces their ability to oxygenate blood and

remove carbon dioxide, contributing to the "barrel chest" appearance of these patients. Cigarettes

also inhibit Alpha-1 antitrypsin allowing trypsin to break down proteins in the alveoli. When arterial

hypoxemia is persistent and severe, oxygen therapy should therefore be considered.


 


 

Oxygen therapy is less effective for treating the hypoxia associated with anemia (choice A),

edematous tissues (choice B), localized circulatory deficiencies (choice D), and right-to-left cardiac

shunts (choice E), because in each case, there is already adequate oxygen available in the alveoli.

The problem in each of these situations is inadequate transport of oxygen to the tissues, blunting the

effects of increasing the oxygen tension of the inspired air. Oxygen therapy nonetheless increases the

amount of dissolved oxygen carried in the blood, which may be life-saving in some instances.


 

104. Which of the following characterizes an eczematous reaction that occurs 72 hours after

wearing latex gloves?

A. Irritant dermatitis

B. Type I reaction

C. Type II reaction

D. Type III reaction

E. Type IV reaction

The correct answer is E. Sensitization to latex has become a major healthcare problem. Local skin

irritations are common but more severe allergic reactions occur, up to and including rare anaphylactic

reactions that are occasionally fatal. The immune responses to latex are immediate-type

hypersensitivity (type I) reactions, expressing themselves in minutes, or delayed-type hypersensitivity

(type IV) reactions that express themselves in 48-72 hours. The type I reactions are caused by the

IgE-mediated sensitivity to latex proteins, whereas the type IV reactions are caused by a cell-

mediated response to the chemicals that are added in the processing of latex. The type IV response

in this circumstance would be referred to as contact dermatitis.

Irritant dermatitis (choice A) can be observed in the early stages of sensitization and can be caused

by sweating, rubbing, and residual soap. The timing of the reaction after 72 hours points to the type IV

reaction rather than an irritant dermatitis.

A type I reaction (choice B) would have been apparent within minutes with characteristic rhinitis,

conjunctivitis, urticaria, asthma, angioedema, or anaphylaxis immediately after wearing latex gloves.

A type II reaction (choice C) is a cytolytic response mediated by an antibody. The type II reaction is

observed in the context of hemolytic anemias, thrombocytopenia, and neutropenia.

A type III reaction (choice D) is an immune-complex response that sets into motion an inflammatory

response.


 

105. What is the explanation for an older person having a fainting spell with a resting blood

pressure of 130/60 mm Hg and a pulse reading of 40 beats per minute?

A. Aortic valve obstruction

B. Cardiac tamponade

C. Complete heart block

D. Heart failure

E. Hypertension

The correct answer is C. In complete (third degree) heart block, the ventricles beat independently of

SA node activity and P waves become completely dissociated from QRS-T complexes. The rate of the

ventricular beat is usually 30-45 per minute. Because resting cardiac output (CO) is normal and

because CO = stroke volume x heart rate, the stroke volume is increased in complete heart block.

When the stroke volume increases, a greater amount of blood must be accommodated in the arterial

tree with each heartbeat, which causes a greater increase and decrease in pressure during systole

and diastole. Note that the pulse pressure is 70 mm Hg (normal pulse pressure is 30-50 mm Hg).

The pulse pressure is decreased in aortic valve obstruction (choice A), cardiac tamponade (choice

B), heart failure (choice D). This is clearly not hypertension (choice E).


 


 

106. A well-behaved toddler, accompanied by his parents, presents with multiple fractures,

humpback and blue sclera. What is the probable diagnosis?

A. Child abuse

B. Ehlers- Danlos syndrome

C. Osteogenesis imperfecta

D. Scurvy

The correct answer is choice C. Osteogenesis imperfecta, also known as Brittle bone disease, is

characterized by retarded wound healing. . The most common form is autosomal dominant with

abnormal collagen type 1 synthesis due to a mutation in the collagen gene.

Choice A- Child abuse is unlikely in this well-behaved toddler with no other signs and symptoms of

abuse. Blue sclera are also typical of osteogenesis imperfecta, and not related to child abuse.

Choice B- Mutation in the collagen gene and lysine hydroxylase gene results in hyperextensible,

fragile skin, hypermobile joints, dislocations, varicose veins, ecchymoses, and arterial intestinal

ruptures. Inheritance varies. There are 10 types with any one of several enzyme deficiencies.

Choice D- Scurvy is characterized by anemia, petechiae, ecchymoses, bleeding gums, loose teeth,

poor wound healing and poor bone development. Deficient hydroxylation of collagen due to vitamin C

deficiency results in defective connective tissue.


 

107. When a histologic section is taken of an intraoral abscess, many of the observed

neutrophils show a degenerative change in which the nucleus has undergone fragmentation.

This process is known as

A. caseous necrosis

B. coagulative necrosis

C. karyolysis

D. karyorrhexis

E. pyknosis

The correct answer is D. Karyorrhexis refers to a pattern of nuclear degradation in which a pyknotic

or partially pyknotic nucleus undergoes fragmentation followed by complete lysis. This pattern is

common in the neutrophils present in acute inflammation.

The type of necrosis seen in an abscess is liquefactive necrosis. Caseous necrosis (choice A) is

seen in tuberculosis and some other granulomatous diseases; coagulative necrosis (choice B) is

seen following infarctions of many organs (other than the brain).

Karyolysis (choice C) is also a degenerative change affecting nuclei. In this case, however, it is seen

as a decrease in nuclear basophilia, which is presumably the result of DNAse activity.

Pyknosis (choice E) is characterized by nuclear shrinking and basophilia, apparently as a result of

DNA condensation.


 

108. If hypocalcemia is noted, excessive secretion of which of the following hormones MOST

likely contributed to hand and forearm bone erosion and resorption during chronic renal

failure?

A. Aldosterone

B. Calcitonin

C. Parathyroid hormone

D. Renin

E. Vitamin D

The correct answer is C. In renal failure, the ability of the kidney to secrete phosphate is impaired.

The resultant hyperphosphatemia causes hypocalcemia and triggers excretion of large amounts of

parathyroid hormone. The released parathyroid hormone is a major contributor to bony changes (e.g.,

osteitis fibrosa, a form of localized bone resorption) seen with chronic renal failure. Note that excess

parathyroid hormone normally causes hypercalcemia, but calcium resorption still cannot bring calcium

levels back to normal.

Aldosterone (choice A) is a regulator of serum sodium.

Calcitonin (choice B) levels are usually low in chronic renal failure unless the parathyroids have so

hypertrophied as to cause "tertiary hyperparathyroidism" with hypercalcemia.

Renin (choice D) is normally secreted by the kidney and may be decreased or increased in varying

stages and forms of kidney disease. Renin regulates blood pressure and aldosterone secretion, rather

than bone metabolism.

The active form of vitamin D (choice E), cholecalciferol, is formed in the kidney from vitamin D

absorbed from the gut and then processed by the liver. Uremia interrupts this pathway and

consequently causes a functional vitamin D deficiency.


 

109. Which of the following would be MOST likely present on a biopsy of a thyroid gland and

associated tissues that has a woody hardness when palpated but the needle biopsy shows no

evidence of malignancy?

A. Marked fibrous reaction with gland destruction

B. Masses of hyperplastic follicles

C. Multinucleated giant cells

D. Small foci of lymphocytic infiltration

E. Prominent lymphocytic infiltrate with gland destruction

The correct answer is A. With Riedel's thyroiditis, an uncommon form of chronic (possibly

autoimmune) thyroiditis that is characterized by dense fibrosis that destroys the thyroid gland and also

extends into the adjacent muscle and connective tissue of the neck. The condition is clinically

important because it may mimic malignancy. A key to the diagnosis is the woody hardness of fibrosis.

All other choices are likely to be swollen and soft by palpation.

Masses of hyperplastic follicles (choice B) are a feature of multinodular goiter.

Multinucleated giant cells (choice C) are a feature of de Quervain thyroiditis.

Lymphocytic infiltration (choice D) is a part of many thyroid diseases, but is seen in isolation in

subacute lymphocytic thyroiditis.

Sheets of lymphocytes with gland destruction (choice E) are seen in Hashimoto's thyroiditis.


 

110. Which of the following gastrointestinal diseases is most likely to be associated with

megaloblastic anemic who has been found to be deficient in vitamin B12, while the levels of all

other essential vitamins are within normal limits?

A. Atrophic gastritis

B. Celiac sprue

C. Duodenal ulcer

D. Ulcerative colitis

E. Zollinger-Ellison syndrome

The correct answer is A. An important cause of vitamin B12 deficiency is pernicious anemia

(megaloblastic), an autoimmune disease associated with atrophic gastritis. In atrophic gastritis, the

gastric epithelium undergoes intestinal metaplasia, replacing gastric chief and parietal cells with

goblet cells. The metaplastic epithelium produces insufficient intrinsic factor to bind the dietary vitamin

B12deficiency.


 


 

Celiac sprue (choice B) is a condition associated with weight loss, flatulence, greasy stools, and

increased fecal fat. Clinical improvement is seen with a gluten-free diet (a diet free of wheat, rye,

barley, and oats).

Duodenal ulcers (choice C) may also produce iron deficiency anemia because of chronic blood loss.

They are caused by damage to the duodenal epithelium by gastric acids and are associated with

cirrhosis, COPD, chronic renal failure, and hyperparathyroidism.

Ulcerative colitis (choice D) is an inflammatory bowel disease almost entirely restricted to the large

intestine. It usually causes intestinal distress and diarrhea, and it may produce a malabsorption

syndrome that includes vitamin B12deficiency.

Zollinger-Ellison syndrome (choice E) is caused by gastric acid hypersecretion leading to peptic ulcer

disease. Diarrhea is common.


 

111. If left untreated, severe squamous dysplasia on a vocal cord of a hoarse smoker may

progress to which of the following?

A. Adenocarcinoma

B. Lymphoepithelioma

C. Mucoepidermoid carcinoma

D. Squamous cell carcinoma

E. Squamous papilloma

The correct answer is D. Squamous cell carcinoma is the most frequent type of cancer of the larynx.

As with squamous cell carcinoma of the uterine cervix, the development of laryngeal carcinoma is

related to an orderly sequence of morphologic changes. These begin with epithelial hyperplasia,

proceed through increasingly severe degrees of dysplasia up to in situ carcinoma, and culminate with

invasive carcinoma. Cigarette smoking is the most important risk factor for the development of

laryngeal carcinoma. Any patient over the age of 50 years with hoarseness that has persisted beyond

2-3 weeks should be evaluated by indirect laryngoscopy. Odynophagia, hemoptysis, weight loss,

referred otalgia, vocal cord immobility and cervical adenopathy suggest more advanced disease.

Adenocarcinoma (choice A) and mucoepidermoid carcinoma (choice C) are rare forms of laryngeal

cancer. Squamous dysplasia is not a precursor of either type of tumor.

Lymphoepithelioma (choice B) is a form of squamous cell carcinoma that most frequently occurs in

the nasopharynx, although it has been reported in the larynx also. Its name is derived from the fact

the tumor is rich in lymphocytes. This tumor occurs frequently in southern China and certain regions in

Africa. Epstein-Barr virus is implicated in its pathogenesis.

Squamous papilloma (choice E) is a benign laryngeal neoplasm caused by human papillomavirus

types 6 and 11. It is not associated with squamous dysplasia.


 

112. What is the BEST explanation for the significant elevation of liver enzymes, ammonia, and

hypoglycemia experienced five days after the onset of chicken pox in a child that was given

aspirin for fever-control?

A. Crigler-Najjar syndrome

B. Dubin-Johnson syndrome

C. Gilbert's syndrome

D. Reye's syndrome

E. Rotor's syndrome

The correct answer is D. The use of aspirin in a child with chicken pox can cause Reye's syndrome.

Reye's syndrome (fatty liver with encephalopathy) is an acute (and potentially fatal) postviral injury

that is characterized by severe mitochondrial damage affecting the liver, brain, skeletal muscle, heart,

and kidneys. The rapidly progressive hepatic failure and encephalopathy is associated with a 30%

fatality rate. Most are children, although adult cases have been described. Varicella and influenza A

and B are the most common precipitating illnesses. Aspirin use has been linked to the development of


 


 

this disorder, but cases occur in the absence of salicylate ingestion. Hypoglycemia, elevated serum

aminotransferases and blood ammonia, prolonged prothrombin time, and change in mental status all

occur within 2-3 weeks after onset.

Crigler-Najjar (choice A) syndrome is a rare, mild to severe form of inherited unconjugated

hyperbilirubinemia.

Dubin-Johnson syndrome (choice B) is an inherited conjugated hyperbilirubinemia associated with a

darkly pigmented liver.

Gilbert's syndrome

(choice

C)

is

a

common,

benign

form

of

inherited

unconjugated

hyperbilirubinemia.

Rotor's syndrome (choice E) resembles Dubin-Johnson syndrome, but is associated with a normal-

colored liver.

Although most of these other symptoms are rare, it is important to recognize the signs, symptoms,

and causes of Reye's syndrome.


 

113. Which of the following is the MOST likely the reason for persistent and marked anasarca

noted with jaundice?

A. Lymphatic obstruction

B. Reduced central venous pressure

C. Reduced plasma oncotic pressure

D. Sodium retention

E. Venous thrombosis

The correct answer is C. Hepatic failure occurring in cirrhosis reduces the capacity of the liver to

synthesize sufficient quantities of plasma proteins (mostly albumin) necessary to maintain plasma

oncotic pressure. Low plasma oncotic pressure allows fluid from the intravascular fluid component to

move into the interstitial space, producing plasma volume contraction and edema.

Lymphatic obstruction (choice A) occurs as a result of mechanical blockage of lymphatics by tumor,

inflammatory processes, or certain parasitic infections. Cirrhosis does not lead to lymphatic

obstruction.

Reduced central venous pressure (choice B) does not cause edema. Conversely, increased central

venous pressure, which may arise with congestive heart failure, thrombosis, or cirrhosis can lead to

increased hydrostatic pressure and edema.

Sodium retention (choice D) is an important cause of edema in patients with poor renal perfusion.

The kidneys respond by retaining sodium and increasing plasma volume in an effort to increase renal

blood flow. Any sodium retention in cirrhosis is secondary to the decrease in plasma oncotic pressure

and consequent decrease in plasma volume.

Venous thrombosis (choice E) can lead to edema; however, the diminished synthesis of coagulation

proteins in cirrhosis predisposes to bleeding, not thrombosis.


 

114. What of the following is characterized by left lower quadrant periumbilical pain in an

elderly person, with the presence of fever, tender abdomen, leukocytosis, nausea, and

vomiting?

A. Acute appendicitis

B. Diverticulitis

C. Gallstones

D. Pancreatitis

E. Pyelonephritis


 

The correct answer is B. Diverticulitis is a disease of the elderly and usually involves the distal

colon. In severe cases, however, the diverticula may extend throughout the colon and up to the

cecum. Inflammation of a cecal diverticulum can closely mimic acute appendicitis. The essentials of

diagnosis for diverticulitis are acute abdominal pain and fever, left lower abdominal tenderness, and

mass. Leukocytosis is commonly present together with nausea and vomiting.

Acute appendicitis (choice A) is usually a disease of young adults (and sometimes children). It is

rarely seen in the elderly.

Pancreatitis (choice D), pyelonephritis (choice E), and gall bladder disease (choice C), refer pain to

the mid back, lateral back, and right upper quadrant, respectively.


 

115. Which of the following would most likely be associated with Type A chronic gastritis

resulting from autoimmune destruction of parietal cells?

A. Decreased growth of luminal bacteria

B. Decreased likelihood of developing gastric carcinoma

C. Decreased plasma concentration of gastrin

D. Increased production of macrocytic red blood cells

E. Increased secretion of pancreatic bicarbonate

The correct answer is D. Autoimmune destruction of parietal cells would lead to decreased secretion

of gastric acid and intrinsic factor. The diminished availability of intrinsic factor would result in poor

absorption of dietary vitamin B12. Over time, the vitamin B12 deficiency could lead to pernicious

anemia, which is characterized by increased production of macrocytes (megaloblasts) by the bone

marrow.

Because of the decrease in gastric acid secretion, luminal bacteria (choice A) would most likely

exhibit increased (not decreased) growth. One of the functions of HCl secreted by the parietal cells is

to sterilize the gastric lumen.

Patients with Type A gastritis have an increased likelihood of developing gastric carcinoma (not

decreased, choice B).

A decrease in acid secretion leads to increased secretion of gastrin (not decreased, choice C) by

antral G cells. This is because low gastric pH (less than 3.0) inhibits gastrin secretion by way of

paracrine release of somatostatin from cells in the gastric mucosa that can sense the acidity. With

decreased parietal cells, the pH of the gastric lumen would rise and remove this inhibitory component.

Because less acid would be delivered to the duodenum with parietal cell destruction, less secretin

would be released into the blood. This would result in decreased pancreatic bicarbonate secretion

(not increased, choice E).


 

116. What is present in an older woman when there is increased serum levels of calcium and

urinary cAMP levels, below normal levels of serum phosphate, and no other complaints but

weakness?

A. A calcitonin-secreting tumor

B. Primary hyperparathyroidism

C. Primary hypoparathyroidism

D. Thyrotoxicosis

E. Vitamin D deficiency

The correct answer is B. Primary hyperparathyroidism is often asymptomatic and only incidentally

discovered during routine blood work, however, there may be vague complaints of fatigue or

weakness and constipation. These neuromuscular manifestations are caused by the hypercalcemia

that can "hyperstabilize" excitable tissue membranes and reduce normal responsiveness. Primary

hyperparathyroidism incidence increases greatly after age 50 years, and is more common in women

than men. The hypercalcemia is caused by the excess plasma concentration of parathyroid hormone

(PTH). Approximately 80% of cases are caused by a single adenoma in a parathyroid gland. In the


 

other 20% of cases, the hypersecretion of PTH is caused by hyperplasia in multiple parathyroid

glands. The increased PTH also causes renal excretion of phosphate, producing hypophosphatemia.

PTH acts by increasing cAMP formation in target tissues. The cAMP formed in renal tubules can

diffuse into the lumen and be measured in the urine.

Tumors that secrete calcitonin (choice A) include medullary carcinoma of the thyroid and occasionally

small and large cell carcinomas of the lung. Despite calcitonin's high blood concentration, serum

phosphate is rarely abnormal and calcium levels would decrease rather than increase.

Primary hypoparathyroidism (choice C), which is caused by decreased secretion of PTH, is

associated with hypocalcemia and hyperphosphatemia. Furthermore, urinary cAMP concentration

would be decreased. The low calcium in extracellular fluid "destabilizes" excitable tissue membranes

and can lead to spontaneous action potentials that produce tetany.

Thyrotoxicosis (choice D) or hyperthyroidism is associated with sweating, anxiety, heat intolerance,

irritability, fatigue, muscle weakness, tachycardia, and warm moist skin. With vitamin D deficiency

(choice E), serum calcium is decreased because of diminished absorption from the diet. PTH

secretion is increased to compensate, resulting in bone demineralization (osteomalacia).


 

117. If there is a large retinal detachment in the right eye and nothing noted in the left, how do

the eyes react to a pupillary light reflex examination?

A. Constriction of the right pupil and constriction of the left

B. Constriction of the right pupil and dilatation of the left

C. Dilatation of the right pupil and constriction of the left

D. Dilatation of the right pupil and dilatation of the left

E. No reaction of the right pupil and constriction of the left

The correct answer is D. The eyes are exhibiting the Marcus-Gunn phenomenon. When light strikes

the retina, the pupillary light reflex is automatically triggered, leading to simultaneous constriction of

both pupils. In the absence of adequate light entering the eye, for example, following retinal

detachment or optic neuritis, paradoxic dilatation of the pupils occurs. The retina receives far less light

than it normally would, and the pupils dilate to absorb as much light as possible.


 

118. Which of the following findings is particularly indicated with a marked elevation in serum

C-reactive protein?

A. Developing autoimmune reaction

B. Ineffective immune response

C. Respiratory compromise

D. Nonspecific inflammation

The correct answer is D. C-reactive protein is one of the most commonly measured acute-phase

reactants, which are a group of serum proteins showing a rapid increase in concentration in response

to any inflammatory process. This finding is entirely nonspecific. It only indicates a recent

inflammatory process. C-reactive protein would be expected to be elevated following a dental

procedure and in cases of pharyngitis (viral and bacterial).

An autoimmune reaction (choice A), which is certainly a concern with streptococcal pharyngitis, is

suggested by the development of a rising ASO (antistreptolysin O) titer weeks after the illness. Acute

phase reactants are not specific to autoimmune processes.

Increases in C-reactive protein indicate a healthy immune response to an infective pathogen. An

ineffective immune response (choice B) would not elicit acute-phase reactions.

Respiratory compromise (choice C) produces changes in arterial blood gases and blood pH. Acute-

phase reactants do not reflect respiratory status.


 


 

119. Which of the following is characteristic when there is a blood pressure of 165/95 mm Hg,

tiredness, muscle weakness, polydipsia, while plasma sodium and serum aldosterone is

slightly increased and plasma potassium and plasma renin activity is significantly decreased?

A. Addison's disease

B. Conn's syndrome

C. Cushing's syndrome

D. Type 1 diabetes mellitus

E. Pheochromocytoma

The correct answer is B. Conn's syndrome, or primary hyperaldosteronism, results from an adrenal

tumor that secretes excessive aldosterone. The increased mineralocorticoid effects of aldosterone

lead to renal sodium and water retention (which explains the hypertension) and increased renal

potassium excretion (hypokalemia). The volume expansion also explains the decrease in hematocrit.

The increased blood volume, increased blood pressure, and hypernatremia all tend to suppress renin

secretion in an attempt to compensate for the increased aldosterone.

Addison's disease (choice A), or primary adrenal insufficiency, is characterized by low plasma

concentration of aldosterone, hyponatremia, hypotension, and hyperkalemia.

In Cushing's syndrome (choice C), blood pressure may be increased because of crossover

mineralocorticoid activity of the increased plasma cortisol. Furthermore, cortisol makes blood vessels

more responsive to catecholamines, which could increase peripheral resistance. The combination of

increased blood pressure and hypokalemia would, if anything, tend to suppress secretion of

aldosterone.

Type 1 diabetes mellitus (choice D) is associated with polyuria, polydipsia, muscle weakness, and

chronic tiredness. Renin and aldosterone levels are normal.

Pheochromocytoma (choice E) is another endocrine cause of hypertension. The increased plasma

concentration of catecholamines can cause increased cardiac output and increased peripheral

resistance. Plasma renin activity may be increased because of increased beta receptor activation on

juxtaglomerular cells. This could produce increased aldosterone secretion and subsequent salt

retention.


 

120. Which of the following BEST describes the inflammatory response that occurs upon

contact with certain plants and presents as a weeping, vesicular, erythematous, and itchy rash

on exposed arms, legs, neck, and face?

A. Erythema nodosum

B. Pemphigus

C. Psoriasis

D. Spongiotic dermatitis

E. Urticaria

The correct answer is D. Spongiotic dermatitis (intracellular edema of the epidermis) is seen in with

contact dermatitis, such as poison ivy exposure. The accumulation of inflammatory cells in the

superficial dermis causes marked edema, which splays epidermal keratinocytes apart and gives a

spongy appearance to intercellular bridges. Grossly, the skin has a weepy appearance with frequent

blistering. Erythema nodosum (choice A) is a form of panniculitis, which is chronic inflammation in the

subcutaneous fat lobules. Erythema nodosum presents as painful erythematous nodules, often with

fever and malaise. It is associated with infections and drug reactions and is not a contact dermatitis.

Pemphigus (choice B) is a genetic blistering disorder caused by the production of antibodies to the

intercellular cement substances in skin and mucous membranes. Psoriasis (choice C) is a common

chronic inflammatory disease causing plaques and scales, typically on elbows, knees, and scalp. The

pathogenesis of psoriasis is still unclear; it may be a complement-mediated autoimmune process.

Urticaria (choice E) is an IgE-driven hypersensitivity process. Urticaria is characterized by wheals

(edematous pruritic plaques) and typically affects the trunk and distal extremities.

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