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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