35 - CVS pathology mcqs - 36 to 40

Question 36
A 51-year-old man has the sudden onset of substernal chest pain which radiates to his left arm and neck. He becomes light-headed and diaphoretic over the next 3 hours. He goes to the emergency room. On examination he is afebrile but has a heart rate of 96/minute with an irregular rhythm. Laboratory studies show a serum CK-MB of 15% with total CK of 524 mg/dL. Which of the following features would be most prominent by histopathologic examination of his myocardium at this point in time?
A Macrophage infiltration
B Contraction band necrosis
C Neutrophilic infiltration
D Capillary proliferation
E Collagen deposition
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(B) CORRECT. This is an initial change as the myocardial fibers begin to die.
(A) Incorrect. Macrophages begin to appear at the end of the first week with an MI.
(C) Incorrect. Neutrophils begin to infiltrate the myocardium after the first day of an MI.
(D) Incorrect. Granulation tissue begins to form as the MI heals.
(E) Incorrect. Collagen is deposited in the healing phase of an MI.
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Question 37
A 58-year-old man has had an enlarging abdomen for 5 months. He has experienced no abdominal or chest pain. On physical examination he has a non-tender abdomen with no masses palpable, but there is a fluid wave. An abdominal CT scan shows a large abdominal fluid collection with a small cirrhotic liver. A chest radiograph shows a globally enlarged heart. He has vital signs showing T 37.1 C, P 78/minute, RR 16/minute, and BP 115/75 mm Hg. Which of the following cardiovascular conditions is he most likely to have?
A Severe occlusive coronary atherosclerosis
B Lymphocytic myocarditis
C Myocardial amyloid deposition
D Nonbacterial thrombotic endocarditis
E Dilated cardiomyopathy
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(E) CORRECT. The cardiomyopathy of chronic alcohol abuse has a dilated or congestive appearance.
(A) Incorrect. In general, persons with chronic alcoholism have less atherosclerosis.
(B) Incorrect. There is no increased risk for myocarditis in alcoholism.
(C) Incorrect. Alcoholism is not a risk factor for amyloidosis of any kind.
(D) Incorrect. Nonbacterial thrombotic endocarditis (NBTE) is a form of non-infective endocarditis that can occur in severely debilitated patients, though hypercoagulability that contributes to this process is not favored by chronic liver disease.
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Question 38
A 77-year-old man has developed increasing dyspnea for the past 3 years. On physical examination he has a diastolic murmur. A chest radiograph shows an enlarged heart and prominent aorta. He dies from complications of pneumonia. At autopsy, the thoracic aorta is aneurysmally dilated. A microscopic section of the aorta shows chronic inflammation and luminal narrowing of vasa vasora. There is disruption of the aortic medial elastic fibers. Which of the following conditions is most likely to cause these findings?
A Hypercholesterolemia
B Marfan syndrome
C Polyarteritis nodosa
D Takayasu arteritis
E Tertiary syphilis
F Wegener granulomatosis
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(E) CORRECT. T. pallidum is the organism that causes syphilis. The endaortitis of the vasa vasora affects the media of the aorta, leading to buckling of the intimal surface in a 'tree bark' pattern, and aneurysmal dilation, including the aortic root, causing aortic regurgitation. This happens decades following initial infection.
(A) Incorrect. Hypercholesterolemia is a risk factor for atheroscclerosis, which most often affects the abdominal aorta, leading to aneurysm formation. Mural thrombus is prone to develop when blood flow patterns are abnormal, as in an aneurysm.
(B) Incorrect. Marfan syndrome leads to cystic medial necrosis, not endaortitis, and appears earlier in life.
(C) Incorrect. Classic polyarteritis nodosa most often involves small to medium-sized muscular arteries, including renal and mesenteric arteries, and sometimes veins, with necrosis and microaneurysm formation.
(D) Incorrect. Takayasu arteritis can involve the aorta, particularly the arch, and branches such as coronary and renal arteries with granulomatous inflammation, aneurysm formation, and dissection. It appears at a much earlier age.
(F) Incorrect. Wegener granulomatosis involves small arteries, veins, and capillaries with mixed inflammation, necrotizing and non-necrotizing granulomatous inflammation withgeographic necrosis surrounded by palisading epithelioid macrophages and giant cells.
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Question 39
A 23-year-old primigravida gives birth following an uncomplicated pregnancy to a 2870 gm girl infant. The baby initially does well, but then approximately 12 hours following delivery develops respiratory difficulty. On examination the infant has a poor color, weak pulses, and oxygen saturation of only 90%. Which of the following cardiac findings is this infant most likely to have?
A Muscular ventricular septal defect
B Hypoplastic left heart
C Complete transposition with no shunt
D Secundum type atrial septal defect
E Congenital infection with Group B streptococcus
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(B) CORRECT. The poor outcome so soon after birth suggests a severe defect, and lack of sufficient left heart to provide appropriate cardiac output can explain these findings. There can be varying degrees of hypoplasia which determine how long the child survives.
(A) Incorrect. Even a large VSD should not be fatal in such a short time.
(C) Incorrect. If a transposition is present with no shunt, then any survival is not possible, as the systemic and pulmonary circulations would be completely separate.
(D) Incorrect. ASD's create a shunt, but the lack of a significant pressure difference between left and right atrium means that cardiac function is not severely affected.
(E) Incorrect. Group B strep infections may produce fetal or neonatal loss, but do not typically produce congenital heart defects. However, congenital rubella in the first trimester can lead to cardiac defects.
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Question 40
A 66-year-old man has had increasing malaise for the past year. On physical examination auscultation of the chest reveals a friction rub. Laboratory studies show a serum urea nitrogen of 100 mg/dl and creatinine of 9.8 mg/dl. Which of the following forms of pericarditis is he most likely to have?
A Fibrinous
B Hemorrhagic
C Purulent
D Serous
E Constrictive
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(A) CORRECT. The uremia leads to exudation of fibrin onto the epicardial and pericardial surfaces.
(B) Incorrect. This is more typical of tuberculosis or metastatic tumor.
(C) Incorrect. This is not common but can occur with spread of infection from lung or mediastinum.
(D) Incorrect. This is more typical for collagen vascular diseases.
(E) Incorrect. This is a late complication of tuberculous pericarditis. It may also follow cardiac surgery or radiation to the chest.
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34 - CVS pathology mcqs - 31 to 35

Question 31
A 27-year-old man has become severely ill with fever and malaise over the past three days. On examination in the emergency room, he has a temperature of 38.8 C, heart rate of 105/minute, respiratory rate of 24, and blood pressure of 80/40 mm Hg. A grade IV/VI diastolic murmur is audible. He has small hemorrhages visible on nail beds. His spleen tip is palpable. Which of the following diseases is most likely to predispose him to this acute illness?
A Hypoplastic left heart syndrome
B Rheumatic heart disease
C Cardiac amyloidosis
D Coronary atherosclerosis
E Hypertrophic cardiomyopathy
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(B) CORRECT. This acquired condition can lead to valvular deformity that predisposes to infective endocarditis.
(A) Incorrect. This congenital condition is incompatible with life.
(C) Incorrect. Amyloidosis involves the myocardium, not the valves and is not a risk for infective endocarditis. It is imperative when infective endocarditis is suspected that an organism be identified and appropriate antibiotic therapy given to reduce the high mortality rate of this condition.
(D) Incorrect. Ischemic heart disease involves the myocardium and not the valves directly, so infection is not a typical complication.
(E) Incorrect. Cardiomyopathies are myocardial diseases that can lead to cardiac enlargement and/or hypertrophy with heart failure, but are typically not complicated by infection.
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Question 32
An epidemiologic study of eating habits is performed. Dietary patterns of adult patients are recorded and compared to risk for cardiovascular diseases. It is observed that persons who eat bacon for breakfast are more likely to have cardiovascular disease that persons who eat oat bran cereal. Which of the following conditions is the "bacon" group most likely to have?
A Mitral annulus calcification
B Ventricular aneurysm
C Left atrial dilation
D Thoracic aortic aneurysm
E Aortic valve stenosis
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(B) CORRECT. This is a complication of myocardial infarction. The incidence of MI is increased with an atherogenic diet.
(A) Incorrect. Mitral ring calcification is rarely of functional consequence and is not related to an atherogenic diet.
(C) Incorrect. This is typically a complication of mitral stenosis with rheumatic heart disease.
(D) Incorrect. Most thoracic aortic aneurysms are a consequence of cardiovascular syphilis.
(E) Incorrect. Most aortic stenosis is a complication of bicuspid valves or senile calcific aortic stenosis unrelated to diet.
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Question 33
A 74-year-old man has had increasingly severe headaches for 2 months, centered on the right. He sees his physician, who records vital signs of T 36.9 C, P 82/minute, RR 15/minute, and BP 130/85 mm Hg. There is a palpable tender cord-like area over his right temple. His heart rate is regular with no murmurs, gallops, or rubs. Pulses are equal and full in all extremities. A biopsy of this lesion is obtained, and microscopic examination reveals a muscular artery with luminal narrowing and medial inflammation with lymphocytes, macrophages, and occasional giant cells. He improves with a course of high-dose corticosteroid therapy. Which of the following laboratory test findings is most likely to be present with this man's disease?
A Erythrocyte sedimentation rate of 110 mm/hr
B Rheumatoid factor titer of 80 IU/mL
C HDL cholesterol of 15 mg/dL
D Anti-double stranded DNA titer of 1:1024
E pANCA titer of 1:160
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(A) CORRECT. These are classic findings for temporal arteritis, the most typical involvement with giant cell arteritis. Corticosteroid therapy typically produces a diminution in the symptoms. Biopsy of the artery can remove the offending site of inflammation and relieve symptoms (don't worry--there are collateral branches). Not treating this condition puts the patient at risk for involvement of other branches of the external carotid artery, the worst of which would be the ophthalmic branch. The elevation of the sed rate is way out of proportion to the extent and amount of inflammation in this one arterial segment.
(B) Incorrect. Rheumatoid arthritis is not typically associated with an arteritis.
(C) Incorrect. A low HDL cholesterol is a risk for atherosclerosis, but atherosclerosis does not produce significant arterial inflammation. Instead, clinical problems result from narrowing of the lumen.
(D) Incorrect. Anti-ds-DNA is very specific for systemic lupus erythematosus, a condition that can be associated with vasculitis caused by antigen-antibody complexes. Vasculitis with SLE is more widespread than giant cell arteritis and typically involves smaller arteries.
(E) Incorrect. Anti-neutrophil cytoplasmic autoantibody can be seen most often with polyarteritis nodosa or Wegener granulomatosis. The pANCA is somewhat more common with polyarteritis.
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Question 34
A 17-year-old girl "blacks out" while out running for exercise one afternoon, as she has done for many years. She is taken to the emergency room, where a physical examination, chest radiograph, head CT scan, CBC, and chemistry panel are all normal. Over the next year, she develops mild dyspnea and fatigue. She experiences several episodes of near-syncope. After another syncopal episode, she is referred to a cardiologist who orders an EKG that shows changes of left ventricular hypertrophy and broad Q waves. An echocardiogram reveals left ventricular and septal hypertrophy, small left ventricle, and reduced septal excursion. The septum has a "ground glass" appearance. She then dies suddenly and unexpectedly. The microscopic appearance of the septum with trichrome stain reveals myofiber disarray. Which of the following is the most likely diagnosis?
A Rheumatic heart disease
B Viral myocarditis
C Systemic lupus erythematosus
D Hypertrophic cardiomyopathy
E Diabetes mellitus
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(D) CORRECT. Myofiber disarray is the key feature of hypertrophic cardiomyopathy, an uncommon condition. The abnormal myocardium can be the focus for development of arrhythmias.
(A) Incorrect. Rheumatic heart disease is best known for causing valvular deformities, most often of the mitral valve, but sometimes the mitral and aortic, or just the aortic valve, and rarely the tricuspid valve.
(B) Incorrect. A viral myocarditis can be the cause for sudden death, but there is myocyte necrosis with interstitial infiltrates of lymphocytes in all chambers.
(C) Incorrect. SLE is best known to cause a Libman-Sacks endocarditis. Pericarditis with effusions is also possible with autoimmune diseases.
(E) Incorrect. Patients with diabetes mellitus are more likely to develop severe coronary atherosclerosis and subsequent myocardial ischemic damage.
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Question 35
A 35-year-old previously healthy woman dies suddenly and unexpectedly. At autopsy, one of her cardiac valves demonstrates attenuation of the chordae tendineae, with rupture of one of the chordae. On microscopic examination, one of the mitral leaflets show myxomatous change. Which of the following is the most likely cause for her death?
A Carcinoid heart syndrome
B Mitral valve prolapse
C Rheumatic heart disease
D Infective endocarditis
E Acute myocardial infarction
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(B) CORRECT. The valve leaflet can balloon upward. This condition can be associated with Marfan's syndrome.
(A) Incorrect. There is endocardial sclerosis of the right ventricular endocardium with carcinoid heart syndrome.
(C) Incorrect. Acute rheumatic fever produces small verrucous valvular vegetations. Chronic rheumatic changes include thickening and shortening of chordae tendineae.
(D) Incorrect. The large friable vegetations of infective endocarditis can lead to valvular destruction.
(E) Incorrect. There may be valve prolapse, but from rupture of a papillary muscle.
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33 - CVS pathology mcqs - 26 to 30

Question 26
A 51-year-old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. On physical examination her vital signs show T 36.9 C, P 80/minute, RR 20/minute, and BP 110/75 mm Hg. She has no pedal edema. On brain MR imaging there is a 1.5 cm cystic area in the left parietal cortex. A chest radiograph shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 165 mg/dL. Which of the following cardiac lesions is she most likely to have?
A Cardiac amyloidosis
B Left atrial myxoma
C Tuberculous pericarditis
D Mitral valve prolapse
E Ischemic cardiomyopathy
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(B) CORRECT. Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output. They may embolize small portions of themselves or thrombus forned over their surface.
(A) Incorrect. Amyloidosis can lead to a restrictive (infiltrative) cardiomyopathy with more gradual onset of congestive heart failure (Note: under anesthesia, cardiac amyloidosis can lead to intractable arrhythmias).
(C) Incorrect. A caseous pericarditis can resolve to a constrictive pericarditis, and syncopal episodes are not likely with this condition.
(D) Incorrect. Mitral prolapse can be a sudden event, though most often there is minimal symptomatology.
(E) Incorrect. Her total cholesterol, at least, does not indicate a risk for ischemic heart disease, and her heart is not enlarged.
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Question 27
A 58-year-old man develops deep venous thrombosis during a hospitalization for prostatectomy. He exhibits decreased mental status 10 days postoperatively, with right hemiplegia. A CT scan of the head shows an acute cerebral infarction in the distribution of the left middle cerebral artery. A chest radiograph reveals cardiac enlargement and prominence of the main pulmonary arteries consistent with pulmonary hypertension. Laboratory studies show a serum troponin I of <0.4>
A Coarctation of the aorta
B Tetralogy of Fallot
C Ventricular septal defect
D Pulmonic stenosis
E Dextrocardia
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(C) CORRECT. This is the infamous 'paradoxical embolus' from right to left. This can only happen if there is a defect that allows passage from right-to left. This can happen across a patent foramen ovale. In this case, the pulmonary hypertension suggests that there may have been a shunt persistent for a long time--a so-called Eisenmenger complex. An atrial or a ventricular septal defect can provide the shunt.
(A) Incorrect. Coarctation does not lead to cyanosis.
(B) Incorrect. Tetralogy leads to a right-to-left shunt.
(D) Incorrect. This is usually part of tetralogy of Fallot, which has a right-to-left shunt from birth.
(E) Incorrect. This is just a malposition of the heart, with the appropriate connections in place and no shunts.
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Question 28
A 25-year-old man dies suddenly and unexpectedly while at a Beverly Hills (or Kings Cross, or Soho...) nightclub late one evening. The medical examiner performs an autopsy. There is no evidence for trauma on external examination of the body. There are no gross pathologic findings of internal organs. Postmortem toxicologic findings are significant for high blood levels of cocaine and its metabolite benzoylecgonine. Which of the following is the most likely histopathologic finding involving his heart?
A Contraction band necrosis
B Myocarditis
C Myofiber disarray
D Coronary thrombosis
E Pericardial tamponade
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(A) CORRECT. This finding has been associated with sudden death and cocaine use. It is thought that it may be mediated by high norepinephrine levels.
(B) Incorrect. Though lymphocytes may be present, they are seen less frequently and prominently than contraction band necrosis.
(C) Incorrect. Myofiber disarray is a feature of hypertrophic cardiomyopathy.
(D) Incorrect. Though atherosclerotic changes can occur with cocaine use, thrombosis of coronaries is not frequent, because the vessels involved are usually smaller coronary branches.
(E) Incorrect. Myocardial rupture does not typically occur with cocaine use, because a large myocardial infarction is not usually found.

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Question 29
A 49-year-old man has the sudden onset of substernal chest pain with radiation to his left arm. This persists for the next 6 hours. He goes to the emergency department and on examination is afebrile. Laboratory studies show a serum troponin I of 18 ng/mL and CK-MB of 8%. Angiography reveals a thrombosis of the left anterior descending coronary artery. During the next 24 hours, which of the following is the most likely complication he will experience?
A Constrictive pericarditis
B Cardiac arrhythmia
C Hepatic necrosis
D Thromboembolism
E Myocardial rupture
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(B) CORRECT. A primary reason for putting a patient with an acute myocardial infarction in hospital is to prevent arrhythmias.
(A) Incorrect: A constrictive pericarditis is typically a complication of tuberculosis, not acute myocardial infarction.
(C) Incorrect. Heart failure following an acute myocardial infarction is not uncommon, but most often the left heart is most affected, with left heart failure leading to pulmonary congestion and edema. Over time, left heart failure may lead to right heart failure which, if severe, may lead to profound hepatic congestion with centrilobular necrosis.
(D) Incorrect. Mural thrombi can form and embolize following acute myocardial infarction, but this is more likely to happen days to weeks to months later.
(E) Incorrect. This is a potential complication with a transmural acute myocardial infarction that happens from 3 to 7 days following the initial ischemic event.

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Question 30
A 60-year-old man had chest pain and was hospitalized. On the first day of admission, his CK-MB fraction was 9.8% of a total CK of 423 U/L. A coronary angiogram revealed 75% stenosis of the left anterior descending artery. Four days later he suddenly becomes worse, with marked hypotension. A pericardiocentesis is performed and returns 150 cc of bloody fluid. Despite aggressive resuscitative measures, he expires. Which of the following microscopic findings is most likely to be present in his left ventricular myocardium at the time of his death?
A Extensive transmural collagen deposition
B Lymphocytic interstitial infiltrates
C Perivascular and interstitial amyloid deposition
D Necrosis with neutrophils and macrophages
E Edema and loss of cross striations
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(D) CORRECT. He has had an acute myocardial infarction complicated by rupture. This is a typical complication about 3 to 5 days following the onset. 75% arterial narrowing is the point at which coronary occlusion becomes very serious.
(A) Incorrect. Collagenization occurs with healing weeks to months following an acute myocardial infarction, and rupture at this point is highly unlikely
(B) Incorrect. Lymphocytic infiltrates are typical for a viral myocarditis, not myocardial infarction
(C) Incorrect. Amyloidosis of the heart leads to a restrictive cardiomyopathy, not to infarction, and rupture does not occur
(E) Incorrect. Edema and loss of cross striations would be seen in the first day of an acute myocardial infarction, but rupture at this point is unlikely.
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31 - CVS pathology mcqs - 16 to 20

Question 16
A 21-year-old man has had increasing malaise over the past three weeks. On physical examination his vital signs show T 39.2 C, P 105/minute, RR 29/minute, and BP 80/40 mm Hg. The physician auscultates a loud systolic cardiac murmur. His lungs on auscultation have bibasilar crackles. Needle tracks are seen in his left antecubital fossa. He has splinter hemorrhages noted on fingernails, as well as painful erythematous nodules on palmar surfaces. A tender spleen tip is palpable. A chest radiograph shows pronounced pulmonary edema. Which of the following laboratory test findings is most likely to be present in this patient's peripheral blood?
A Creatine kinase-MB of 8% with a total CK 389 U/L
B Positive blood culture for Pseudomonas aeruginosa
C Total serum cholesterol of 374 mg/dL
D Blood urea nitrogen of 118 mg/dL
E Antinuclear antibody titer of 1:512
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(B) CORRECT. The history points to infectious endocarditis and acute congestive heart failure. Staphylococcus aureus and Pseudomonas aeruginosa are the most likely organisms to be found with a history of injection drug use.
(A) Incorrect. The CK-MB is typically elevated with ischemic heart disease, which would be unusual at his age.
(C) Incorrect. A cholesterol in this range could be seen with heterozygous familial hypercholesterolemia, which would be unlikely to manifest with ischemic heart disease at this age.
(D) Incorrect. His heart failure, if severe, could reduce cardiac output and lead to pre-renal azotemia if he survives.
(E) Incorrect. An autoimmune disease such as systemic lupus erythematosus can lead to non-infective endocarditis (Libman-Sacks endocarditis) in which there are small, non-destructive vegetations and no emboli.
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Question 17
A 2-year-old child has had failure to thrive for a year, becoming increasingly listless. On examination she is found to have a soft, rumbling systolic ejection murmur. An echocardiogram reveals a large membranous ventricular septal defect. Which of the following complications is she most likely to experience as an adult 2 decades later if this lesion remains untreated?
A Rib notching
B Mitral valve prolapse
C Pulmonary hypertension
D Myocardial infarction
E Cardiac tamponade
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(C) CORRECT. The left-to-right shunt eventually leads to pulmonary hypertension and reversal of the shunt (Eisenmenger complex).
(A) Incorrect. Rib notching is a rare finding that can be seen with post-ductal coarctation of the aorta.
(B) Incorrect. There is upward ballooning of a mitral leaflet with prolapse, due to attenuated chordae tendineae. (Note: a VSD sometimes becomes closed when a tricuspid leaflet adheres to the opening).
(D) Incorrect. Congenital heart disease is, in general, not a risk for ischemic heart disease.
(E) Incorrect. The defect is between the ventricular chambers and not connected to the pericardial sac.
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Question 18
A 42-year-old woman has noted increasing dyspnea for the past 6 years. On examination rales are auscultated in both lungs. She is afebrile. A chest radiograph shows an enlarged cardiac silhouette and bilateral pulmonary edema. Past history reveals that, as a child she suffered recurrent bouts of pharyngitis with group A beta hemolytic streptococcal infections. Which of the following cardiac valves are most likely to be abnormal in this woman?
A Aortic and tricuspid
B Mitral and pulmonic
C Aortic and pulmonic
D Tricuspid and pulmonic
E Mitral and aortic
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(E) CORRECT. She has chronic rheumatic valvulitis with scarring associated with rheumatic heart disease. If the tricuspid valve is involved, then the mitral and aortic are probably involved as well. The most common single valve involved is the mitral.
(A) Incorrect. The tricuspid valve is not often affected. When it is, the mitral and aortic valves are also affected, too.
(B) Incorrect. The mitral valve is the most common valve to be involved. The pulmonic valve is almost never involved.
(C) Incorrect. The aortic valve is the second most common valve to be involved. The pulmonic valve is almost never involved.
(D) Incorrect. The left side of the heart is involved far more commonly than the right with rheumatic heart disease.
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Question 19
A 25-year-old previously healthy woman has had worsening fatigue with dyspnea, palpitations, and fever over the past week. On physical examination her vital signs show T 38.9 C, P 103/minute, RR 30/minute, and BP 95/65 mm Hg. Her heart rate is slightly irregular. An ECG shows diffuse ST-T segment changes. A chest x-ray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvular vegetations. Laboratory studies show a troponin I of 12 ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findings best explains the underlying etiology for these events?
A Anti-streptolysin O titer of 1:512
B Total serum cholesterol of 537 mg/dL
C Coxsackie B serologic titer of 1:160
D Blood culture positive for Streptococcus, viridans group
E ANCA titer of 1:80
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(C) CORRECT. She has findings that suggest myocarditis, which can have features of cardiomyopathy. One of the most likely organisms is Coxsackie B virus.
(A) Incorrect. An elevation of the ASO titer suggests a recent streptococcal infection that might be associated with rheumatic fever. The infection, typically a pharyngitis, is gone by the time the ASO titer is elevated and the cardiac lesions, including myocarditis, are present.
(B) Incorrect. This level of cholesterol could be associated with familial hypercholesterolemia and risk for ischemic heart disease, even at a young age. This does not explain the fever.
(D) Incorrect. Viridans group of streptococcus is best known as a causative organism for subacute endocarditis, and valvular vegetations are present with forms of infective endocarditis.
(E) Incorrect. An antineutrophil cytoplasmic autoantibody can be detected with vasculitis, typically polyarteritis nodosa or Wegener granulomatosis.
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Question 20
A 44-year-old man has had no major medical problems throughout his life, except for arthritis pain involving all extremities for the past 5 years. He has had worsening orthopnea and pedal edema in the past 6 months. There is no chest pain. On examination he is afebrile. A chest radiograph shows cardiomegaly with both enlarged left and right heart borders, along with pulmonary edema. Laboratory studies show serum sodium 139 mmol/L, potassium 4.3 mmol/L, chloride 99 mmol/L, CO2 25 mmol/L, urea nitrogen 18 mg/dL, creatinine 1.3 mg/dL, and glucose 167 mg/dL. Which of the following additional laboratory test findings is he most likely to have?
A Spherocytes on his peripheral blood smear
B Hemoglobin of 10.7 g/dL with MCV of 72 fL
C Erythrocyte sedimentation rate of 79 mm/Hr
D Anti-centromere antibody titer of 1:320
E Serum ferritin of 8700 ng/mL
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(E) CORRECT. He has findings of a cardiomyopathy with right and left heart failure. Hereditary hemochromatosis can produce iron deposition in visceral organs, including the heart. The serum ferritin is a good indicator of body iron stores. Hemochromatosis affects the pancreas as well, leading to diabetes mellitus. Deposition of iron in joints leads to arthritis. The onset of disease is typically in the 40's in males and 60's in females.
(A) Incorrect. Spherocytosis can lead to a mild hemolytic anemia that stresses the heart somewhat to produce mild hypertrophy.
(B) Incorrect. An iron deficiency anemia in an adult could chronically lead to increased cardiac output. If severe enough, there could be a high-output cardiac failure. The heart will tend to enlarge somewhat. This does not explain his arthritis or hyperglycemia, though.
(C) Incorrect. An increased sed rate is a non-specific indicator of inflammation somewhere in the body.
(D) Incorrect. Anti-centromere antibody can be detected with sclerodema, which can produce cardiac findings resembling a cardiomyopathy, but hyperglycemia and joint problems are not part of scleroderma.
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29 - CVS pathology mcqs - 6 to 10

Question 6
A 72-year-old woman has had no major illnesses throughout her life. She has had 3 syncopal episodes over the past 2 weeks. Over the past 2 days she has developed shortness of breath and a cough with production of frothy white sputum. On physical examination she is afebrile. Her blood pressure is 135/90 mm Hg. She has no peripheral edema. A chest radiograph reveals a prominent left heart border in the region of the left ventricle, but the other chambers do not appear to be prominent. There is marked pulmonary edema. Laboratory studies show a total serum cholesterol of 170 mg/dL. Which of the following is the most likely diagnosis?
A Acute rheumatic fever
B Mitral valve stenosis
C Atherosclerotic aortic aneurysm
D Calcific aortic stenosis
E Infective endocarditis
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(D) CORRECT. Senile calcific aortic stenosis is a condition in which there is gradual calcification of a an aortic valve with three cusps. The condition is seen in the elderly and is idiopathic. Aortic valvular stenosis may not manifest itself clinically until there is narrowing of the outflow orifice to less than 1 square centimeter. Aortic valve disease can remain silent and then suddenly result in symptoms.
(A) Incorrect. This is most common in children who have not been adequately treated for a strep throat, a pharyngitis with group A beta hemolytic streptococcus. There may be a myocarditis with rheumatic fever as well.
(B) Incorrect. Mitral valve disease tends to be symptomatic early and then become slowly progressive over years.
(C) Incorrect. An atherosclerotic aneurysm of the aorta is typically located below the renal arteries and can cause abdominal pain when it enlarges.
(E) Incorrect. This is associated with signs of infection, such as fever, murmur, and splenomegaly. Sometimes splinter hemorrhages in nail beds can be seen.
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Question 7
A 17-year-old girl is brought to the physician because she remains short in stature for her age. She has not shown any changes of puberty. On physical examination her vital signs include T 37 C, RR 18/minute, P 75/minute, and BP 165/85 mm Hg. She has a continuous murmur heard over both the front of the chest as well as her back. Her lower extremities are cool with poor capillary filling. She has a webbed neck. A chest radiograph reveals a prominent left heart border, no edema or effusions, and rib notching. Which of the following cardiovascular abnormalities is she most likely to have?
A Shortening and thickening of chordae tendineae of the mitral valve
B Constriction of the aorta past the ductus arteriosus
C Supravalvular narrowing in the aortic root
D Lack of development of the spiral septum and partial absence of conus musculature
E Single large atrioventricular valve
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(B) CORRECT. She has coarctation of the aorta, and the constriction is postductal, allowing prolonged survival. Her physical characteristics also suggest Turner syndrome (monosomy X).
(A) Incorrect. These findings are found with chronic rheumatic valvulitis that is typically seen in adults years after episode(s) of rheumatic fever.
(C) Incorrect. Some forms of aortic stenosis can have supravalvular narrowing.
(D) Incorrect. When the spiral septum does not develop properly, a truncus arteriosus can result, with mixing of right and left heart blood, leading to cyanosis.
(E) Incorrect. A single AV valve would not lead to selective hypertension in upper extremities. Endocardial cushion defects can be seen with trisomy 21.
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Question 8
A 65-year-old man has sudden onset of severe abdominal pain. Physical examination reveals his temperature is 37 C, heart rate 110/minute, respirations 25/minute, and blood pressure 145/100 mmHg. He has diminished pulses in the lower extremities. There is a pulsatile abdominal mass. His serum creatine kinase is not elevated. He has had fasting blood glucose measurements in the range of 140 to 180 mg/dL for over 20 years. Which of the following conditions is he most likely to have?
A Superior mesenteric artery thrombosis
B Atherosclerotic aortic aneurysm
C Polyarteritis nodosa
D Septic embolization
E Monckeberg's medial calcific sclerosis
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(B) CORRECT. The aorta involved with an atherosclerotic aneurysm is markedly enlarged and filled with thrombus. Risk factors for atherosclerosis include both diabetes mellitus and hypertension. Atherosclerotic aortic aneurysms are typically located in the abdominal portion below the renal arteries.
(A) Incorrect. Abdominal pain could be caused from mesenteric artery thrombosis from bowel infarction, but there should be no pulsatile mass.
(C) Incorrect. Arteritides do not cause significant arterial enlargement, and polyarteritis does not affect the aorta.
(D) Incorrect. Septic embolization could produce a mycotic aneurysm, but this would be rare in the abdominal aorta.
(E) Incorrect. Medial calcific sclerosis involves small muscular arteries and is an incidental finding.
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Question 9
A 49-year-old woman had atrial fibrillation that was poorly controlled, even with amiodarone therapy. She suffered a "stroke" and died. At autopsy, her 600 gm heart is noted to have a mitral valve with partial fusion of the leaflets along with thickening and shortening of the chordae tendineae. There is an enlarged left atrium filled with mural thrombus. Which of the following underlying causes of death is she most likely to have?
A Systemic lupus erythematosus
B Coronary atherosclerosis
C Marantic endocarditis
D Rheumatic fever
E Amyloidosis
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(D) CORRECT. This can lead to rheumatic mitral stenosis with left atrial enlargement.
(A) Incorrect. SLE can produce a serous pericarditis with an effusion. In a few cases SLE can produce a Libman-Sacks endocarditis, but valvular scarring does not regularly occur.
(B) Incorrect. There may be some degree of cardiac enlargement, including the left atrium, with the heart failure produced by ischemic heart disease, including myocardial infarction, but it is not marked, and valves are not scarred or stenotic as a consequence.
(C) Incorrect. Small valvular vegetations of non-bacterial thrombotic endocarditis are unlikely to produce enough mitral valvular deformity to produce stenosis that dilates the left atrium.
(E) Incorrect. Amyloid can be found in endocardium and myocardium, but it is best known as a cause for an infiltrative cardiomyopathy.
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Question 10
A 23-year-old woman has had worsening malaise along with a malar skin rash persisting for 3 weeks. On physical examination, she has an audible friction rub on auscultation of the chest, along with a faint systolic murmur. An echocardiogram reveals small vegetations on the mitral valve and adjacent ventricular endocardium. Laboratory studies show a positive antinuclear antibody test, with a titer of 1:2048. Which of the following is the most likely diagnosis?
A Polyarteritis nodosa
B Progressive systemic sclerosis
C Systemic lupus erythematosus
D Wegener's granulomatosis
E Adenocarcinoma of the pancreas
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(C) CORRECT. Patients with systemic lupus erythematosus can develop Libman-Sacks endocarditis, but the vegetations are never large and they rarely embolize, so the endocarditis is not clinically significant in most cases. She probably has a fibrinous pericarditis as a result of uremia from renal failure.
(A) Incorrect. Libman-Sacks endocarditis is associated with systemic lupus erythematosus.
(B) Incorrect. Scleroderma is not typically associated with an endocarditis.
(D) Incorrect. Wegener's granulomatosis with vasculitis uncommonly involves the heart and does not involve the endocardium or pericardium.
(E) Incorrect. This is related to nonbacterial thrombotic (marantic) endocarditis, which can result from a hypercoagulable state that is a paraneoplastic syndrome (Trousseau syndrome).
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