Practice question I Pathology of thyroid
Practice question I
Pathology of thyroid
© Jun Wang, MD, PhD
1. Use this case for the next four
questions. A 45-year-old woman presents with fatigue, lack of motivation
and difficult in concentrating for a year. She has gained 10 pound recently.
She stated she is quite stressful at work recently. Her past medical history is
significant for type II diabetes. She does not smoke cigarette or drink
alcohol, but is a heavy coffee drinker. Physical examination reveals a pulse
rate at 98 bpm and blood pressure at 135/80 mmHg. Mild bilateral ankle non
pitting edema is noted. No other abnormality is noted. Her CBC is normal. What
is a proper next step to approach her diagnosis?
A. Bone marrow aspiration
B. Consulting a psychiatrist for major depression management
C. Head CT
D. Sonographic examination for bilateral deep vein thrombosis
E. Serum thyroid function test
2. A 45-year-old woman presents with fatigue, lack of motivation and
difficult in concentrating for a year. She has gained 10 pound recently. She
stated she is quite stressful at work recently. Her past medical history is
significant for type II diabetes. She does not smoke cigarette or drink
alcohol, but is a heavy coffee drinker. Physical examination reveals a pulse
rate at 98 bpm and blood pressure at 135/80 mmHg. Mild bilateral ankle non
pitting edema is noted. No other abnormality is noted. Her CBC is normal.
Additional laboratory tests reveal a TSH at 42 microIU/ml (normal 05-5
microIU/ml), free T3 at 1.2 pg/ml (normal 2.3-4.2 pg/ml). What is the cause of
her presentations?
A. High pituitary function
B. High thyroid function
C. Low pituitary function
D. Low thyroid function
E. Major depression
3. A 45-year-old woman presents with fatigue, lack of motivation and
difficult in concentrating for a year. She has gained 10 pound recently. She
stated she is quite stressful at work recently. Her past medical history is
significant for type II diabetes. She does not smoke cigarette or drink
alcohol, but is a heavy coffee drinker. Physical examination reveals a pulse
rate at 98 bpm and blood pressure at 135/80 mmHg. Mild bilateral ankle non
pitting edema is noted. No other abnormality is noted. Her CBC is normal.
Additional laboratory tests reveal a TSH at 42 microIU/ml (normal 05-5
microIU/ml), free T3 at 1.2 pg/ml (normal 2.3-4.2 pg/ml).
Sonographic examination reveals a small thyroid. No discrete growth is
identified. A biopsy of thyroid reveals destruction of thyroid follicles in a
background of diffuse lymphoplasmacytic infiltrate. Well-formed lymphoid follicles
are seen. The residual thyroid follicular cells have eosinophic granular
cytoplasm. No nuclear enlargement or abnormal nuclear morphology are noted.
Flow cytometry studies reveals polyclonal lymphoid population. What is the
diagnosis?
A. Diffuse large B cell lymphoma
B. Follicular lymphoma
C. Graves disease
D. Hashimoto thyroiditis
E. Papillary thyroid carcinoma, follicular variant
4. A 45-year-old woman presents with fatigue, lack of motivation and
difficult in concentrating for a year. She has gained 10 pound recently. She
stated she is quite stressful at work recently. Her past medical history is
significant for type II diabetes. She does not smoke cigarette or drink
alcohol, but is a heavy coffee drinker. Physical examination reveals a pulse
rate at 98 bpm and blood pressure at 135/80 mmHg. Mild bilateral ankle non
pitting edema is noted. No other abnormality is noted. Her CBC is normal.
Additional laboratory tests reveal a TSH at 42 microIU/ml (normal 05-5
microIU/ml), free T3 at 1.2 pg/ml (normal 2.3-4.2 pg/ml). Sonographic
examination reveals a small thyroid. No discrete growth is identified. A biopsy
of thyroid reveals destruction of thyroid follicles in a background of diffuse
lymphoplasmacytic infiltrate. Well-formed lymphoid follicles are seen. The
residual thyroid follicular cells have eosinophic granular cytoplasm. No
nuclear enlargement or abnormal nuclear morphology are noted. Flow cytometry
studies reveals polyclonal lymphoid population. What additional test would
likely to be positive?
A. Activated T cells with cross-reaction to TSH receptor
B. Activating autoantibodies against TSH receptor
C. Autoantibodies against thyroid peroxidase
D. Reduced levels of TRH
E. Reduced levels of TSH
5. Use this case for the next two
questions. A 3-month-old boy presents with low activity and lack of
interest. He was born at 38-gestational week after an uneventful labor and
delivery. He has constipatin since birth. Physical examination reveals dry and
coarse skin, both height and weight are at 3rd percentile. He has
poor sucking, and appears to be sluggish. He has enlarged tongue protruding
outside his mouth. Laboratory tests reveals a TSH at 12.5 mIU/ml (normal 0.5-5
mIU/ml), a total T4 at 2.5 ng/dL (normal 6.5-13.5 ng/ml). What is the most
likely the diagnosis?
A. Cretinism
B. Granulomatous thyroiditis
C. Graves disease
D. Hashimoto thyroiditis
E. Subacute lymphocytic thyroiditis
6. A 3-month-old boy presents with low activity and lack of interest.
He was born at 38-gestational week after an uneventful labor and delivery. He
has constipation since birth. Physical examination reveals dry and coarse skin,
both height and weight are at 3rd percentile. He has poor sucking,
and appears to be sluggish. He has enlarged tongue protruding outside his
mouth. Laboratory tests reveals a TSH at 12.5 mIU/ml (normal 0.5-5 mIU/ml), a
total T4 at 2.5 ng/dL (normal 6.5-13.5 ng/ml). What is the most likely causing
his presentations?
A. Anatomic defect of thyroid glands
B. Activating autoantibodies against TSH receptor
C. Auto antibodies against thyroid peroxidase
D. Reduced levels of TRH
E. Reduced levels of TSH
7. Use this case for the next for
next four questions. A 25-year-old woman presents with fatigue, facial
sweating, dry eyes and unintentional 20 pound weight loss in one year. She
stated that her appetite is normal. Her past medical history is unremarkable.
Physical examination reveals a heart rate at 87 with irregularly irregular
rhythm. Body temperature and blood pressures are within normal range. Her eyes
appears to be slightly protruding with bilateral lid lag. The thyroid is
slightly enlarged without palpable mass. Edematous changes are seen in both
legs. Neurological examination reveals brisk reflexes and hand tremor. What
abnormal laboratory test is likely to be found?
A. Adrenalins
B. Calcitonin
C. Cortisol
D. Parathyroid hormone
E. TSH
8. A 25-year-old woman presents with fatigue, facial sweating, dry eyes
and unintentional 20 pound weight loss in one year. She stated that her
appetite is normal. Her past medical history is unremarkable. Physical
examination reveals a heart rate at 87 with irregularly irregular rhythm. Body
temperature and blood pressures are within normal range. Her eyes appears to be
slightly protruding with bilateral lid lag. The thyroid is slightly enlarged
without palpable mass. Edematous changes are seen in both legs. Neurological
examination reveals brisk reflexes and hand tremor. Laboratory test reveals a
TSH at 0.005microIU/ml (normal 0.5-5 microIU/ml), free T4 at 52 ng/ml (normal
6.5-13.5 ng/ml). What is most likely the diagnosis?
A. Diffuse simple goiter
B. Graves disease
C. Hashimoto thyroiditis
D. Papillary thyroid carcinoma
E. Pituitary TSH producing adenoma
9. A 25-year-old woman presents with fatigue, facial sweating, dry eyes
and unintentional 20 pound weight loss in one year. She stated that her
appetite is normal. Her past medical history is unremarkable. Physical
examination reveals a heart rate at 87 with irregularly irregular rhythm. Body
temperature and blood pressures are within normal range. Her eyes appears to be
slightly protruding with bilateral lid lag. The thyroid is slightly enlarged
without palpable mass. Edematous changes are seen in both legs. Neurological
examination reveals brisk reflexes and hand tremor. Laboratory test reveals
free T4 at 52 ng/ml (normal 6.5-13.5 ng/ml). What is most likely the cause of
her presentations?
A. Activating autoantibodies against TSH receptor
B. Destruction of follicular cells
C. Ectopic thyroid tissue
D. Hyperfunctioning thyroid neoplasm
E. Iodine deficiency
10. A 25-year-old woman presents with fatigue, facial sweating, dry
eyes and unintentional 20 pound weight loss in one year. She stated that her
appetite is normal. Her past medical history is unremarkable. Physical
examination reveals a heart rate at 87 with irregularly irregular rhythm. Body
temperature and blood pressures are within normal range. Her eyes appears to be
slightly protruding with bilateral lid lag. The thyroid is slightly enlarged
without palpable mass. Edematous changes are seen in both legs. Neurological
examination reveals brisk reflexes and hand tremor. Laboratory test reveals
free T4 at 52 ng/ml (normal 6.5-13.5 ng/ml). What is most likely the cause of
her eye presentations?
A. Dysfunction of extraocular muscles
B. Edematous changes of conjunctiva
C. Metastatic thyroid neoplasm to retroorbital space
D. Morphological changes of eye due to abnormal sympathetic tones
E. Proliferation of retroorbital connective tissue
11. Use this case for the next for
next three questions. A 35-year-old woman presents with irregular menstrual
periods, difficulty in sleeping, nervousness, dry eyes, palpitation and an
unintentional 15 pound weight loss for a year. Her past medical history is
unremarkable. She has a family history of hyperlipidemia and coronary heart
diseases. Physical examination reveals a regular heart rate at 110. Her blood
pressure and temperature are normal. Her eyes are protruding with bilateral lid
lag. An evenly enlarged thyroid is noted. Sonographyic examination reveals no
evidence of discrete mass. Biopsy of thyroid reveals variable size of follicles
of high cuboidal to columnar follicular cells with focal finger like growth
into follicle. The colloid is pale with vacuoles adjacent to follicular cells.
No follicular destruction or nuclear abnormality is noted. There are scattered
lymphocytes in the stroma. What is the diagnosis?
A. Early heart attack
B. Graves disease
C. Hashimoto thyroiditis
D. Multinodular goiter
E. Papillary thyroid carcinoma
12. A 35-year-old woman presents with irregular menstrual periods,
difficulty in sleeping, nervousness, dry eyes, palpitation and an unintentional
15 pound weight loss for a year. Her past medical history is unremarkable. She
has a family history of hyperlipidemia and coronary heart diseases. Physical examination
reveals a regular heart rate at 110. Her blood pressure and temperature are
normal. Her eyes are protruding with bilateral lid lag. An evenly enlarged
thyroid is noted. Sonographyic examination reveals no evidence of discrete
mass. Biopsy of thyroid reveals variable size of follicles of high cuboidal to
columnar follicular cells with focal finger like growth into follicle. The
colloid is pale with vacuoles adjacent to follicular cells. No follicular
destruction or nuclear abnormality is noted. There are scattered lymphocytes in
the stroma. What laboratory test is most likely abnormal in this patient?
A. Calcitonin
B. Hemoglobin
C. Lymphocyte count
D. Parathyroid hormone
E. TSH
13. A 35-year-old woman presents with irregular menstrual periods,
difficulty in sleeping, nervousness, dry eyes, palpitation and an unintentional
15 pound weight loss for a year. Her past medical history is unremarkable. She
has a family history of hyperlipidemia and coronary heart diseases. Physical
examination reveals a regular heart rate at 110. Her blood pressure and
temperature are normal. Her eyes are protruding with bilateral lid lag. An
evenly enlarged thyroid is noted. Sonographyic examination reveals no evidence
of discrete mass. Biopsy of thyroid reveals variable size of follicles of high
cuboidal to columnar follicular cells with focal finger like growth into
follicle. The colloid is pale with vacuoles adjacent to follicular cells. No
follicular destruction or nuclear abnormality is noted. There are scattered
lymphocytes in the stroma. What is causing her lid lag?
A. Facial nerve paralysis
B. Hyperactivity of superior tarsal muscle by increased sympathetic
tone
C. Hyperactivity of levator palpebrae superioris by
increased parasympathetic tone
D. Myxedematous changes of upper eyelids
E. Proliferation of connective tissue of conjunctiva
14. Use this case for the next for
next two questions. A 29-year-old woman presents with fatigue, lower
abdominal discomfort, irregular menstruation period, palpitations, and heat intolerance
for three months. Her past medical history is unremarkable. Physical
examination reveals dry skin, staring gaze and trembling hands. Pelvic
examination reveals a mass at left adnexa. No proptosis is noted. Thyroid gland
is normal in size. No thyroid abnormality is detected by image studies.
Sonographic examination reveals a 2.5 cm cystic lesion in the left ovary. The
mass is resected and microscopically there are foci of cuboidal epithelial
cells surround eosinophilic amorphous jelly like material. No nuclear
abnormality or immature components are seen. Per immunohistochemistry studies,
these epithelial cells are positive for TTF-1. What is the diagnosis?
A. Diffuse simple goiter
B. Follicular carcinoma
C. Graves disease
D. Hashimoto thyroiditis
E. Struma ovarii
15. A 29-year-old woman presents with fatigue, lower abdominal
discomfort, irregular menstruation period, palpitations, and heat intolerance
for three months. Her past medical history is unremarkable. Physical
examination reveals dry skin, staring gaze and trembling hands. Pelvic
examination reveals a mass at left adnexa. No proptosis is noted. Thyroid gland
is normal in size. No thyroid abnormality is detected by image studies.
Sonographic examination reveals a 2.5 cm cystic lesion in the left ovary. The
mass is resected and microscopically there are foci of cuboidal epithelial
cells surround eosinophilic amorphous jelly like material. No nuclear
abnormality or immature components are seen. Per immunohistochemistry studies,
these epithelial cells are positive for TTF-1. What plasma hormone/marker is
likely to be abnormal?
A. AFP
B. CA125
C. CEA
D. hCG
E. TSH
16. A 23-year-old woman presents with fever, back pain, severe nausea
and vomiting for 1 day. She was diagnosed with Graves disease 6 months ago. She
has been smoking cigarette half pack a day for 5 years. She does not drink
alcohol. She is compliance with her anti-thyroid medication. She stated she is
under tremendous stress due to national examination. Her vital signs include a
temperature at 39 degree Celsius, heart rate at 130 beat per minute, blood
pressure at 150/95 mmHg. Physical examination reveals redness of eyes, swelling
in periorbital areas, dry skin and trembling hand. Bilateral proptosis is
noted. Her conjunctiva has jaundice. Laboratory test reveals a TSH at 0.001
mIU/ml (normal 0.5-5 microIU/ml), free T3 at 49 pg/ml (normal 2.5-3.9 pg/ml) and
a serum creatinine at 2.1 mg/dl (normal 0.6-1.3 mg/dl). What is the most
appropriate diagnosis?
A. Acute renal failure
B. Acute thyroiditis
C. Hypothyroidism
D. Myxedema
E. Thyroid storm
17. Use this case for the next for
next two questions. A 67-year-old woman presents with depression, palpitation
and an unintentional 20 pound weight loss for 6 months. She has a history of
lung adenocarcinoma diagnosed 10 years ago that was treated with surgery and chemotherapy.
She does not smoke cigarette nor drink alcohol. Physical examination reveals an
irregularly irregular pulse rate at 140 beats/min. Her temperature and blood
pressure are within normal range. She has an apathetic face and appears to be
depressed. She has bilateral ankle edema and marked weakness and wasting of
shoulder and pelvic girdle muscles. EKG reveals atrial fibrillation. Laboratory
test reveals a T4 at 16 microgram/dl (normal 4.6-11.5 microgram/dl). What
additional abnormal laboratory test is likely to be seen?
A. High TSH, high T3
B. High TSH, low T3
C. Low TSH, high T3
D. Low TSH, low T3
18. A 67-year-old woman presents with depression, palpitation and an
unintentional 20 pound weight loss for 6 months. She has a history of lung
adenocarcinoma diagnosed 10 years ago that was treated with surgery and chemotherapy.
She does not smoke cigarette nor drink alcohol. Physical examination reveals an
irregularly irregular pulse rate at 140 beats/min. Her temperature and blood
pressure are within normal range. She has an apathetic face and appears to be
depressed. She has bilateral ankle edema and marked weakness and wasting of
shoulder and pelvic girdle muscles. EKG reveals atrial fibrillation. Laboratory
test reveals a T4 at 16 microgram/dl (normal 4.6-11.5 microgram/dl). What is most likely the diagnosis?
A. Apathetic hyperthyroidism
B. Granulomatous thyroiditis
C. Graves disease
D. Hashimoto thyroiditis
E. Recurrent adenocarcinoma of lung
19. Use this case for the next for
next two questions. A 31-year-old woman presents with palpitation, sweating
and dizziness for 1 hour. She has had anterior neck pain and shortness of
breath for a week. Her past medical history is unremarkable. Physical examination
reveals a temperature at 40 degree Celsius, heart rate at 130 beat/min,
respiratory rate at 30 per minute, and a blood pressure at 150/80 mmHg. She appears
to be agitated. Her thyroid is slightly enlarged and tender, and painful upon
palpation. No other abnormality is seen. Sonographic examination reveals a slightly
enlarged left thyroid lobe without discrete mass. Biopsy reveals destruction of
follicles with abundant multinucleated giant cells in a background of
lymphocytes and plasma cells. Scattered droplets of colloid are seen within
these multinucleated cells. No significant nuclear atypia is noted. Microbiology
studies are negative. What is the most likely diagnosis?
A. Acute thyroiditis
B. Granulomatous thyroiditis
C. Graves disease
D. Hashimoto thyroiditis
E. Recurrent adenocarcinoma of lung
20. A 31-year-old woman presents with palpitation, sweating and
dizziness for 1 hour. She has had anterior neck pain and shortness of breath
for a week. Her past medical history is unremarkable. Physical examination
reveals a temperature at 40 degree Celsius, heart rate at 130 beat/min,
respiratory rate at 30 per minute, and a blood pressure at 150/80 mmHg. She appears
to be agitated. Her thyroid is slightly enlarged and tender, and painful upon
palpation. No other abnormality is seen. Sonographic examination reveals a slightly
enlarged left thyroid lobe without discrete mass. Biopsy reveals destruction of
follicles with abundant multinucleated giant cells in a background of
lymphocytes and plasma cells. Scattered droplets of colloid are seen within
these multinucleated cells. No significant nuclear atypia is noted. What
additional abnormal laboratory test is likely to be seen?
A. High TSH, high T3
B. High TSH, low T3
C. Low TSH, high T3
D. Low TSH, low T3
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