5 Pathology

AIIMS NOVEMBER 2017 4. A patient presents with has 90% HbF and 3% HbA2. A
peripheral blood smear was done. Which of the following
1. A 35 year old depressed male comes with history of sudden picture/s will be seen?
difficulty in breathing since two days. His chest x ray showed
bilateral diffuse infiltrate with prominent involvement of
right middle and lower lobes. Patient could not be revived
despite treatment. On autopsy the Lung gross specimen

/e
appears normal. Histopathological section of Lung biopsy is
shown below. What is most likely diagnosis?  

,2
sy
F G
Ea
ed
M

PATHO PLATE 8 F, G, H
S

a. F and G b. F and H
IM

PATHO PLATE 54 A c. G and H d. F, G and H

a. Aspiration pneumonia with vegetative matter 5. What is the sequence to be followed for blood sample
b. Necrotizing pneumonia collection for cross matching?  
AI

c. Sarcoid granuloma a. Ask patient to identify himself, Verification of patient

d. Severe fungal pneumonia details in file, blood collection, labelling at the nursing
2. In cases of Cancer breast based on which grade/stage of IHC station
staining, FISH for gene amplification would be done? b. Ask the patient to identify himself, blood collection, cross
a. HER 2 neu 1+ check patient details, labelling at nursing station
b. HER 2 neu 2+ c. Ask the patient to identify himself, labelling tibes bedside,
c. HER 2 neu 3+ blood collection, cross check patient details
d. Done in all cases irrespective of IHC grade/stage d. Ask patient to identify himself, Verification of patient
details in file, blood collection, labelling at the bedside
3. Fixative used for PAP smear is?
a. 95% ethyl alcohol 6. A male patient presented with bilateral proptosis.
b. 10% formalin Histological specimen of the tumor shows following picture.
c. Normal saline Most likely diagnosis is?
d. Air drying a. Rhabdomyosarcoma b. Schwannoma
c. Leiomyoma d. Neurofibroma
230 Section I  •  Subject-wise MCQs and Answers with Explanations

10. When you add Calcium and thromboplastin to PT which

pathway gets activated?
a. Extrinsic pathway b. Intrinsic pathway
c. Common pathway d. Fibrinolysis
11. Blood preserved in blood bank in which container which
has shelf life of 35 days?
a. Citrate Phosphate Dextrose Adenine-1
b. Acid Citrate Dextrose
c. Citrate Phosphate Dextrose
d. Citrate Phosphate 2 Dextrose
12. For electrolyte estimation which of following anticoagulant
is used?
PATHO PLATE 2A a. Lithium heparin b. Na fluoride
7. Chronic lymphocytic leukemia (CLL) and small lymphocytic c. EDTA d. Na citrate
lymphoma (SLL) cell of origin is?
13. A young donor came to the blood bank with platelet count
a. Naive B cells in interfollicular zone
1.95 lac/mm3 is undergoing plasmapheresis for first time.
b. Lymphocytes in germinal centre
He developed perioral numbness, tingling sensation during

/e
c. Lymphocytes in peripheral zone
procedure. His vitals remain stable though. ECG showed
d. Bone marrow progenitors
tachycardia with ST-T changes. What is the reason for his

,2
8. A 30 year old male diagnosed with mitral stenosis with left symptoms?
atrial enlargement following severe dyspnea. Vegetations a. He has low platelet count than required for procedure
present on Mitral valve were excised and HPE image is b. Large infusion of ACD
shown below. What is most likely diagnosis?
sy c. 1st time donation
d. Low platelet index
Ea
14. A 5 year old child presents with bilateral proptosis. Which
test is t be ordered to rule out Chloroma?
a. Peripheral Blood Smear b. WBC count
ed

c. RBC count d. Platelet count

15. All of following are involved in Iron metabolism EXCEPT:
M

a. Ceruloplasmin b. Hepcidin
c. Transthyretin d. Ferritin
S

16. Asymptomatic Hepatitis B is common in 2-3 % normal

population, but there is increased risk of hepatocellular
IM

cancer due to?

PATHO PLATE 32 D a. Inability to produce inflammation against the organism
a. Infective endocarditis b. Rheumatic valvular disease b. High level of transaminases
AI

c. Myxomatous degeneration c. High rate of proliferation of hepatocytes

d. Sarcoidosis d. Risk of integration of viral DNA with Host DNA
9. A 43 year old male comes with 6 month history of dysphagia.
Barium swallow and  endoscopy pictures are shown below. AIIMS MAY 2017
Biopsy of the growth most likely to show?
17. A 35-year-old patient with history of high grade fever
and Tonsillitis 2 months back now presents with cervical
lymphadenopathy. His peripheral blood smear showed
lymphocytosis with WBC count 22 × 109/L. Monospot test
was negative. Tonsillectomy was done and it showed large
cells mixed with lymphocytes. The cells were positive for
CD20, EBV-LMP1, MUM1, CD 79a. Background cells were
positive for CD3. The cells are negative for CD15. Your
most probable diagnosis?
a. Infectious mononucleosis
D E
b. Hodgkin lymphoma
PATHO PLATE 7 E c. EBV positive diffuse large B-cell lymphoma
a. Squamous cell carcinoma b. Adenocarcinoma d. EBV positive mucocutaneous ulcer
c. Large cell carcinoma d. Barrett’s esophagus

AIIMS Nov 2013–May 2011

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 PATHOLOGY  • Questions 231
22. Which of the following is accurate regarding the intracellular
iron metabolism in iron deficiency anemia?
a. Transferrin receptor 1—iron responsive elements (IRE)
increases transferrin receptor mRNA concentration and
synthesis.
b. Transferrin receptor 1—iron responsive elements (IRE)
decreases transferrin receptor mRNA concentration and
increases synthesis
c. Apoferritin mRNA—iron response element (IRE) decreas-
es and ferritin synthesis decreases
d. Apoferritin mRNA—iron response element decreases and
PATHO PLATE 50 ferritin synthesis increases

18. A 20-year-old boy presented with persistent cervical
lymphadenopathy for past 1 year. Histopathology of lymph
node shows RS cell with focal nodularity and background
T reactive lymphocytes. The cells were positive for CD20,
LCA, EMA and negative for CD15 and CD30 and EBV
23. A 50-year-old male diabetic presented with blurring of vision.
Urine examination showed proteinuria. Fundus exam­ination
showed dot and blot haemorrhages, microaneurysm and cotton
wool spots. Histopathology picture of kidney given shows?

/e
negative. Diagnosis is?
a. Nodular lymphocyte predominant HL

,2
b. T cell rich B cell lymphoma
c. Nodular sclerosis Hodgkin
d. Lymphocytic rich HL

19. MHC-2 seen in which cells?
a. Naive T cell sy
Ea
b. Erythrocyte
c. All nucleated cells
d. B cells, dendritic cells and macrophages
ed

20. A 29-year-old female with history of polyarthalgia and back
ache was investigated. She had nucleolar pattern of ANA in
M
PATHO PLATE 51
a. Segmental sclerosis b. Kimmelstiel Wilson lesion
c. Renal amyloidosis d. Crescents

immunoflorescence. Which of the following is the best fit

in her case? 24. A 50-year-old male with frothy urine and periorbital edema
a. Sclerodactyly, Raynaud’s phenomenon, lung fibrosis proteinuria. The DIF and electron microscopic picture of
S

b. Raynaud’s phenomenon, parotid swelling, dry mouth the patient is given below. Diagnosis is?
c. Glomerulonephritis, malar rash, oral ulcer
IM

d. Genital ulcer, skin nodules, lung fibrosis

21. A 30-year-old male presents with hypersalivation, dyspha-
AI

gia, sternal notch tenderness. On endoscopic biopsy histo-

pathological picture is shown. Identify the lesion. What is
most likely diagnosis?

B
PATHO PLATE 31B

a. Crescentic glomerulonephritis
b. Minimal change disease
c. Membranoproliferative glomerulonephritis
d. Membranous glomerulonephritis
25. In order to avoid liver biopsy, which of the following can be
PATHO PLATE 7B
used as biochemical marker to diagnose liver fibrosis?
a. Esophagitis a. Homocysteine and alkaline phosphatase
b. Barrett’s esophagus b. Transaminases
c. Squamous cell carcinoma c. Serum laminin and hyaluronic acid
d. Adenocarcinoma d. Unconjugated bilirubin and GGT

AIIMS Nov 2013–May 2011

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232 Section I  •  Subject-wise MCQs and Answers with Explanations

26. Which stain is used in the staining of liver in the following 35. Latest marker on Mantle cell lymphoma is?
diagram? a. SOX11 b. ITRA 1
c. MyD88 d. LMO2
36. Which of the following is ALK positive cancer?
a. Ewings sarcoma
b. Synovial sarcoma
c. Fibromatosis
d. Inflammatory myofibroblastic tumor
37. A 70-year-old male presented with history of intractable
diarrhea. His bone marrow and renal biopsy as shown below.
PATHO PLATE 52 Which of the following is the most appropriate diagnosis?
a. Grimelius’ silver stain
b. Masson trichome
c. Warthin starry silver stain
d. Sweet reticulin silver stain
27. Which of the following technology is used for gene editing?

/e
a. GeneXpert b. α PERT
c. CRISPR d. Big Data

,2
28. If the phosphorylation of RB gene is blocked what is the
effect on cell cycle? PATHO PLATE 29E PATHO PLATE 29F



a. Cell cycle gets shorter
b. Affect G1 phase
c. Affect G2 phase

sy a. Multiple myeloma
c. Urate nephropathy
b. Large cell lymphoma
d. Visceral leishmaniasis
Ea
d. It would not affect because normally RB gene is in non-
38. A 7-year-old patient presents with fever, weight loss. On
phosphorylated state
examination with no organomegaly and no lymphadenop-
29. Which gene is responsible for expression of self antigen for
ed

athy. Blood picture showed pancytopenia, bone marrow

deletion of immature T cell? aspiration of the person is as given below. Your diagnosis is?
a. NOTCH1 b. AIRE
M

c. RAG 1 d. RAG 2
30. Which is the antigen that T cell never expresses throughout
its development?
S

a. PAX-5 b. Tdt
IM

c. CD 34 d. CD 1a
31. Which of the following can change the gene expression by
methylation and acetylation without changing content of
AI

the gene
a. Mutation b. Inversion
c. Epigenetics d. Amplification
32. Acetone free methyl alcohol in Leishman’s staining causes?
a. Sterilizes the slide
b. Fixes the cells to the slide
c. Regulates the metabolism of the cells
d. Staining the cell
33. A 26-year-old female with history of breathlessness comes
with 5 g hemoglobin and normal WBC count, absolute
reticulocyte count was 9. What will be the corrected
reticulocyte count?
a. 3 b. 4
c. 4.5 d. 5
34. Red cell distribution width measures?
a. Anisocytosis b. Polychromasia
c. Poikilocytosis d. Hypochromasia
PATHO PLATE 15
a. ALL
b. AML
c. Aplastic anaemia
d. Juvenile myelomonocytic leukemia
39. Which of the following is a negative acute phase reactant?
a. Ferritin b. CRP
c. Haptoglobin d. Albumin
AIIMS NOVEMBER 2016
40. Resolving power of light microscopy not affected by?
a. Sample thickness b. Focal length of eyepiece
c. Wavelength of light d. Aperture size

AIIMS Nov 2013–May 2011

AIIMS (Nov 2017–May 2014) Questions with Explanations Covered in Volume II (Available Separately)

41. The following image is taken from a Neubauer chamber
after charging of fluid. If the dilution factor is 20, what is
the total cell count per cu.mm ?
a. 3000 b. 6000
c. 7000 d. 11000
42. All are true about transfusion related acute lung injury
PATHOLOGY  • Questions 233
45. A patient was found to have splenomegaly, anemia and Jaundice.
All of the following are true in this condition EXCEPT:
a. Increased urobilinogen b. Decreased haptoglobin
c. Increased LDH d. Low reticulocyte count
46. A 26-year-old female presents with pallor with hemoglobin
9.5%, PCV 30 and RBC count 2 million/mm3. The most
probable diagnosis is?
a. Sideroblastic anemia b. Iron deficiency anemia
c. Thalassemia d. Folic acid deficiency
47. Most common histopathological finding of rapidly progress-
ing glomerulonephritis?
a. Crescentic formation b. Mesangial proliferation
c. Loss of foot plate d. IgA deposition
48. Which of the following malignancy cannot be diagnosed on
the basis of FNAC?
a. Adenocarcinoma of lung
b. Squamous cell carcinoma of lung

/e
(TRALI) EXCEPT: c. Follicular carcinoma of thyroid
a. Self Resolving in 2-3 weeks d. Papillary carcinoma of thyroid

,2
b. Role of corticosteroids not clear
c. Morality < 10% 49. Given below is the histopathology of liver biopsy of a patient
d. Supportive care is the mainstay of treatment with hemochromatosis which of the following stain is used?
43. A person with HIV had neck pain, fever, vomiting, nausea and
couldn’t be survived. Autopsy specimen of brain and histo- sy
Ea
pathological slide are provided. What is most likely diagnosis?
ed
M

PATHO PLATE 42C

a. Prussian blue b. Alcian blue
S

c. Von kossa d. Crystal violet

50. Stain used to detect premalignant condition of Lip is?
IM

a. Giemsa b. Toluidine blue

PATHO PLATE 40A and B
c. Crystal violet d. H and E
a. Herpes
AI

b. Toxoplasma gondii 51. MHC antigen are absent in?

c. Cryptococcus neoformans a. Neutrophil b. Erythrocyte
d. Echinococcus multilocularis c. Thrombocyte d. Epithelial cell
44. Which of the following cell marked in the following slide is 52. A 24-year-old young male has recurrent diarrhea and loss of
increase in parasitic infection? weight. On examination the patient has dry tongue and loss of
skin turgor. On endoscopic intestinal biopsy and histopathol-
ogy following picture was observed. Most likely diagnosis is?

PATHO PLATE 41 PATHO PLATE 43

a. 1 b. 2 a. Whipple’s disease b. Giardiasis
c. 3 d. 4 c. Entamoeba histolytica d. H. pylori

AIIMS Nov 2013–May 2011

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234 Section I  •  Subject-wise MCQs and Answers with Explanations

53. A 65-year-old female presents in december with history of
chronic fatigue, cyanosis and pain in finger tips and cyanosis of
the tip of nose along with dyspnoea. Peripheral blood picture is
shown below. What is most likely finding?
AIIMS MAY 2016
56. A 56-year-old lady with provisional diagnosis of carcinoma
beast, biopsy was done and a series of immunohistochemical
stains were done on breast biopsy specimen. Below are
the photographs of ER, PR and HER2Neu. Which of the
following best describes the prognosis of the patient for
PATHO PLATE 30-Column (A)?

PATHO PLATE 45B

a. RBC clumps due to cold AIHA
b. RBC clumps due to warm AIHA
c. RBC clumps due to Hemoglobinopathy
d. RBC clumps due to G6PD deficiency

/e
54. Urine cytology in a post renal transplant patient showed 2–3

,2
pus cells and has raised serum creatinine. Marked structure
in the image is?

sy a. Good prognosis
Ea
b. Poor prognosis
c. Good prognosis with transtuzumab
d. Good prognosis without transtuzumab
ed

57. Direct immunofluorescence for IgG done on a kidney speci-

men as shown in the picture below. Most likely diagnosis is?
M

PATHO PLATE 46A

S

a. Hyaline cast b. Decoy cells

IM

c. Charcot leyden crystal d. Tubular epithelial cells

55. A 25-year-old male with history of road traffic accident
sustained fracture neck of femur and brought to the emergency.
AI

He was intubated for respiratory distress but dies in spite of

ventilatory support. On autopsy the histopathological slide of
lung is shown below. Most likely diagnosis is?

PATHO PLATE 31B

a. Membranous glomerulonephritis
b. Good pasture syndrome
c. Buerger’s disease
d. Systemic lupus erythematosus
58. All are true regarding Giant cell tumor of bone EXCEPT:
a. Commonly seen in 20-40 years age group
PATHO PLATE 48A b. Although benign it can metastasize to lung
a. Diffuse alveolar hemorrhage c. Interspersed proliferating mononuclear cells are tumor
b. Ventilator induced injury cells
c. Pulmonary edema d. Multinucleated osteoclast like giant cells are the tumour
d. Fat embolism cells

AIIMS Nov 2013–May 2011

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 PATHOLOGY  • Questions 235
59. All are causes of a positive direct Coombs test EXCEPT:
a. Aplastic anemia
b. Hemolytic disease of newborn
c. Drug induced autoimmune haemolytic anemia
d. Haemolytic transfusion reaction
60. The following are antigen presenting cells EXCEPT:
a. M cell b. Thymocyte
c. Macrophages d. Langerhans cells
61. An image of Hematoxylin and Eosin stained section of
patient with myocardial infraction shown below. Based on
PATHO PLATE 29A
the findings, identify the age of infarct?
64. The image shown below is of mitral valve with presence
of vegetations along the line of closure of valves. The most
likely diagnosis based on the picture is?

/e
,2
sy
Ea
PATHO PLATE 27B
a. 6 hours PATHO PLATE 32B
b. 1-2 days a. Rheumatic endocarditis
ed

c. 2 weeks b. Infective endocarditis

d. 3 weeks c. Libman-sack endocarditis
d. NBTE
M

62. Evaluate the specimen kidney shown below. Based on mac-

roscopic examination the diagnosis is? 65. A 33-year-old female presented with 4 month history of per-
sistent cough and hemoptysis. Bronchoscopic examination
S

revealed a intrabronchial polyp. Biopsy shows small cell with

salt and pepper chromatin, necrosis and mitotic figure of
IM

5 per/10 HPF. On immunohistochemistry cells were intensely

positive for synaptophysin/chromogranin. What is the
AI

diagnosis and grade of the tumour?

a. Carcinoid grade I
b. Atypical carcinoid grade II
c. Small cell carcinoid grade IV
d. Large cell neuroendocrine carcinoma stage IV
66. The surgical registrar has performed a testicular biopsy and
has directed you to send it to histopathological examination.
PATHO PLATE 28A Operation theatre nurse asks you about the solution she
a. Amyloidosis should use to send the solution. You answer must be?
b. Flea bitten kidney due to malignant hypertension a. 10% neutral buffered formalin
c. Acute post streptococcal glomerulonephritis b. Zenkers fixative
d. Chronic glomerulonephritis c. Gluteraldehyde
d. Bouin’s fixative
63. An image of H and E section of a tissue showing inflammation
is shown below. Identify the marked cell? 67. Serum sickness is?
a. Plasma cell a. Type I hypersensitivity reaction
b. Eosinophil b. Type II hypersensitivity reaction
c. Lymphocyte c. Type III hypersensitivity reaction
d. Macrophage d. Type IV hypersensitivity reaction

AIIMS Nov 2013–May 2011

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236 Section I  •  Subject-wise MCQs and Answers with Explanations

68. The most reactive free radical is? 75. Which of the following is an immune privileged site?
a. Hydrogen peroxide b. Hydroxyl free radical a. Seminiferous tubule b. Loop of henle
c. Peroxide free radical d. Superoxide anion c. Area postrema d. Optic disc
69. Which of the following complement marker is used in the 76. There are different checkpoints in cell growth and regulations.
detection of humoral rejection? Which is the primary checkpoint of cell growth and regulation?
a. C5a b. C3d
c. C4d d. C3b
70. An image of agarose gel electrophoresis of DNA from
cultured cells is seen under UV light as shown below. Lane C
in the picture represents?

/e
,2
a. End of S phase b. End of G1 phase
c. End of G2 Phase d. End of M phase

sy
77. Identify the urinary crystals shown?
Ea
ed

a. Majority of culture cells are apoptotic

b. Majority of cells with good DNA content
c. The cells in the culture are predominantly necrotic
M

d. Cells have mixture of normal and apoptotic cells

71. Packed red blood cells should be transfused?
a. Through 18 to 20 gauge IV catheter within 4 hours of
S

receiving by patient side

IM

b. Through 18 to 20 gauge IV catheter within 4 hours of issue

from blood bank
c. Through 20 to 22 gauge IV catheter within 4 hours
AI

receiving by patient PATHO PLATE 1A

d. Through 20 to 22 gauge IV catheter within 4 hours of issue
from blood bank
72. The temperature at which RBC is stored in blood banks is?
a. –2° to –4°C b. 2°–6°C
c. 20°–24°C d. 37°C
73. All of the following are EBV positive lymphomas EXCEPT:
a. Lymphomatoid granulomatosis
b. Plasmablastic lymphoma
c. Nodular lymphocytic predominant Hodgkin’s lymphoma
d. NK-T cell lymphoma
AIIMS NOVEMBER 2015
74. Which of the following is not specific but most important
for regulation of iron metabolism?
a. Hepcidin b. DMT-1
c. Ferroportin d. Ferritin
a. Calcium carbonate stone
b. Ammonium phosphate stone
c. Calcium oxalate stone
d. Uric acid
78. Which of the following statements about microalbuminuria
is not true?
a. Cannot be detected by routine lab tests
b. Urine protein ranging from 20-200 mg/24 hours is called
microalbuminuria
c. Microalbuminuria is an independent risk factor for CVS
risk in diabetic patients
d. Microalbuminuria is earliest marker of diabetic nephropathy
79. About frozen section biopsy all are true EXCEPT:
a. Immediate definitive diagnosis of tumor
b. For detecting positive margins after resection
c. To confirm suspected metastasis
d. Sentinel lymph node biopsy in breast carcinoma

AIIMS Nov 2013–May 2011

AIIMS (Nov 2017–May 2014) Questions with Explanations Covered in Volume II (Available Separately)

80. In the histopathology of schwannoma in picture below, the
arrow marked area shows?
PATHOLOGY  • Questions 237
83. Most important prognostic factor in ALL is?
a. Hyperploidy b. TLC > 50,000
c. Organomegaly d. Response to therapy
84. Identify the gross cut section specimen of liver shown?

PATHO PLATE 2A
a. Myxoid tissue
b. Antony A pattern with verocay body
c. Antony B pattern with verucoy cells
d. Antony C pattern - verucoy cells
81. A 17-year-old patient presents with bleeding per rectum
PATHO PLATE 5A
due to intussuception for which he was operated and

/e
histopathology was done for the resected segment as shown a. Nutmeg liver with dark areas of perivenular dead
in the picture shown. Identify the pathology? hepatocytes and gray areas of periportal viable hepatocytes

,2
b. Nutmeg liver with dark areas of perivenular viable
hepatocytes and gray periportal areas of dead hepatocytes

sy
c. Amyloidosis with dark areas of perivenular dead
hepatocytes and gray areas of periportal viable hepatocytes
d. Micronodular cirrhosis
Ea
85. A 17-year-old boy presents with bilateral cervical
lymphadenopathy since 3 years. Lymph node biopsy is
shown in the picture below. What is diagnosis? What is the
ed

etiology? And what characteristic feature will you look for?

a. Hodgkins lymphoma; EBV and Reed Sternberg cells
M

PATHO PLATE 4E b. Hodgkins lymphoma; EBV and Embryo cell

a. Tubulovillous adenoma b. Hamartomatous polyps c. Non Hodgkins lymphoma; HIV and Giant B cell
c. Juvenile polyposis syndrome d. TB, Mycobacterium and tiny granuloma
S

d. Adenocarcinoma
86. A 30-year-old male engineer came with chief complaint of
IM

82. A 29-year-old athlete with family history of heart disease, heart burn. On Endoscopic biopsy Histopathological picture
suddenly collapsed and died during sport activity. Post is shown. Identify the lesion. Which special stain will be
mortem gross specimen of heart is shown below. Gross used? What additional feature is seen?
AI

finding in PATHO PLATE 3 B-1. Most likely diagnosis is?

PATHO PLATE 7B
a. Hypertrophic cardiomyopathy a. Esophagitis, mucin stain, erosions or ulceration
b. Rheumatic heart disease b. Barrett’s esophagus, mucin stain, metaplasia
c. Coronary heart disease c. Squamous cell carcinoma, cytokeratin stain, keratin pearls
d. Arrhythmias d. Adenocarcinoma, methylene blue, goblet cells

AIIMS Nov 2013–May 2011

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 PATHOLOGY  •  Answers with Explanations 241

ANSWERS WITH EXPLANATIONS

AIIMS NOVEMBER 2017 Conditions associated with elevation of hemoglobin

F levels
1. Ans. (a)  Aspiration pneumonia with vegetative matter
Condition Percentage of hemoglobin F
Ref: Robbin’s 9th ed page 525
See PATHO PLATE 54 beta-thalassemia triat <10
Chest X ray findings are suggestive of consolidation/ Delta/beta-thalassemia 5–20
Pneumonia. Histopathological findings confirms aspiration triat
pneumonia of vegetative matter.
Deletional HPFH trait 20–40
2. Ans. (b)  HER 2 neu 2+ Nondeletional HPFH trait 3–30
Ref: Breast Cancer Management and Molecular Medicine edited Homozygous delta/beta- 100
by Martine J. Piccart, William C. Wood, Chie-Mien Hung, thalassemia
Lawrence J. Solin, Fatima Cardoso page 982
Homozygous HPFH 100
HER 2 NEU IHC INTERPRETATION

/e
(deletional)
0 Negative
+1 Negative Homozygous beta- 30–95

,2
+2 Equivocal (Requires FISH amplification to confirm) thalassemia
+3 Positive Homozygous hemoglobin 5–30

3. Ans. (a)  95% ethyl alcohol

Ref: With Text sy
S or hemoglobin S-beta-
thalassemia
Hemoglobin S–HPFH 20–40
Ea
Pap smears are wet-fixed (smears are immersed in fixative Hemoglobin E-beta 10–50
without allowing them to dry). Smears to be stained by thalassemia
Romanowsky stains are air-dried as fixation is affected during
ed

the staining procedure. Fixative used is either equal parts of Hemoglobin C-beta 10–30
ether and 95% ethanol, or 95% ethanol alone, 100% methanol, thalassemia
or 85% isopropyl alcohol. Fixation time of 10-15 minutes at
M

room temperature is adequate. Smear may be left in fixative Fetal hemoglobin (HbF) has two alpha and two gamma
for 24 hour or more (Ref: Pathology Practical Book by Harsh chains (alpha2 gamma2). Adult hemoglobin A (HbA) has
two alpha and two beta chains (alpha2 beta2), whereas
S

Mohan - 3rd ed Page 152)

Ether is highly volatile and explosive, hence ether’s use in hemoglobin A2 (HbA2) has two alpha and two delta chains
IM

alcohol as fixative was discontinued in late 1950s, leaving 95% (alpha2 delta2). Fetal hemoglobin (hemoglobin F, HbF) is
ethyl alcohol alone as the standard fixative for PAP smear. (Ref: the major hemoglobin present during gestation; it constitutes
Cytopreparation: Principles and Practice - By Gary Gill approximately 60 to 80 percent of total hemoglobin in the
AI

Springer Page 104) full-term newborn. It is almost completely replaced by adult

hemoglobin (hemoglobin A, HbA) by approximately 6 to 12
4. Ans. (d)  F, G and H months of age, and it amounts to less than 1 percent of total
hemoglobin in the adult.
Ref: Robbins 9th ed page 447, Wintrobe 12th ed page 1090
Among the inherited conditions associated with increased
See PATHO PLATE 8 HbF levels in adults, some are primary and caused by mutation
Presence of 90% HBF indicates Homozygous beta Thalassemia or genetic variation; these are termed hereditary persistence
(F) Howell-Jolly bodies of HbF (HPFH). Others, such as those associated with sickle
(G) Target cells cell anemia and thalassemia, result from secondary responses
(H) Teardrop cells to the dyserythropoiesis and hemolysis characteristic of these
All three are seen in Beta Thalassemia disorders, modulated by co-inherited genetic variation.
The reference ranges are as follows: •• Hereditary Persistence of Fetal Hemoglobin: HPFH
•• HbA : 95–98%
1
is characterized by the presence of increased levels of
•• HbA : 1.5–3.5% (usually<3.3%)
2
HbF in adult life in the absence of relevant hematologic
•• HbF: < 2% (age-dependent) abnormalities. The amount of HbF is quite variable, ranging
•• HbC: Absent in the carriers from 2.0 to 30%, and this variability reflects a
•• HbS: Absent marked molecular heterogeneity.

PATHOLOGY
242 Section I  •  Subject-wise MCQs and Answers with Explanations

•• Beta thalassemia: HbF levels are normal or slightly elevated

in beta thalassemia heterozygotes. Higher HbF (and HbA2)
levels are found with mutations that involve promoter of
the HBB gene, but variations in HbF levels also reflect the
genetic background of the individual. In homozygous beta
thalassemia, the proportion of HbF ranges from 10 percent
in those with the milder alleles to almost 100 percent
in homozygotes or compound heterozygotes with beta
thalassemia.
•• Sickle cell anemia: The predominant hemoglobin is S; Hb F
is present in varying concentrations; and Hb A2 is normal. Poikilocytic red cells (elliptocytes (1), schistocytes (2), target
There is no Hb A. cells (3), tear drop (4), spherocytes (5) and hypochromic (6) in
Thalassemia major

5. Ans. (d) Ask patient to identify himself, Verification of

patient details in file, blood collection, labelling at the
bedside
Ref: http://www.who.int/infection-prevention/publications/

/e
drawing_blood_best/en/

,2
Recall Bias..................................................
There were many versions of options recalled. We have retained the

sy best out of them. It is advised not to remember just answer but the
complete steps.
Ea
Short Summary of method of collecting blood to be sent to
blood bank for cross matching:
Fig. 1: Blood picture of homozygous b thalassemia •• Ask patient to identify themselves
ed

Microcytic and hypochromic RBCs (1), Nucleated red cells, •• Cross check the patient’s name against: file and blood request
anisopoikilocytosis, target cells (2), Howell Jolly Bodies (3), form
Tear drop cells (4) •• Prepare patient and Take blood
M

•• Label the test tube at patient’s bedside only

S

•• Crosscheck patient’s details and ensure that name and CR No. is matching on both the tubes and form.
IM

Who guidelines on drawing blood best practice in phlebotomy

Step 1 Assemble equipment Laboratory sample tubes, vacuum-extraction blood tubes, blood-sampling devices
(safety-engineered devices or needles and syringes, tourniquet, alcohol hand rub, 70%
AI

alcohol swabs, gauze or cotton-wool, laboratory specimen labels, writing equipment,

laboratory forms, leak-proof transportation bags and containers, Puncture-resistant
sharps container
Step 2 Identify and prepare the Introduce yourself to the patient, and ask the patient to state their full name. Match the
patient patient’s details with the laboratory form, to ensure accurate identification. Discuss the
test to be performed and obtain verbal consent
Step 3 Select the site Extend the patient’s arm and inspect the antecubital fossa or forearm. Locate a vein of
a good size that is visible, straight and clear. The vein should be visible without applying
the tourniquet. Apply the tourniquet about 4–5 finger widths above the venepuncture
site and re-examine the vein.
Step 4 Perform hand hygiene Wash hands with soap and water, and dry with single use towels or if hands are not
and put on gloves visibly contaminated, clean with alcohol rub – use 3 ml of alcohol rub on the palm of
the hand, and rub it into fingertips, back of hands and all over the hands until dry. After
performing hand hygiene, put on well-fitting, non-sterile gloves
Step 5 Disinfect the entry site Clean the site with a 70% alcohol swab for 30 seconds and allow to dry completely
Contd...

AIIMS (Nov 2017–May 2014)

 PATHOLOGY  •  Answers with Explanations 243

Who guidelines on drawing blood best practice in phlebotomy

Step 6 Take blood Anchor the vein by holding the patient’s arm and placing a thumb BELOW the
venepuncture site. Ask the patient to form a fist so the veins are more prominent.
Enter the vein swiftly at a 30 degree angle or less. Once sufficient blood has been
collected, release the tourniquet BEFORE withdrawing the needle. Withdraw the
needle gently and apply gentle pressure to the site with a clean gauze or dry cotton
Step 7 Fill the laboratory sample Use evacuated tubes with a needle and tube holder. If a syringe or winged needle set
tubes is used, best practice is to place the tube into a rack before filling the tube. Before
dispatch, invert the tubes containing additives for the required number of times
Step 8 Draw samples in the Draw blood collection tubes in the correct order, to avoid cross-contamination of
correct order additives between tubes.
Step 9 Clean contaminated Discard the used needle and syringe or blood sampling device into a puncture
surfaces and complete resistant sharps container. Bedside labeling, which is typically the patient’s first
patient procedure and last names, file number, date of birth, and the date and time when the blood
was taken. Check the label and forms for accuracy. Discard used items into the
appropriate category of waste. Perform hand hygiene again. Recheck the labels on the

/e
tubes and the forms before dispatch.
Step 10 Prepare samples for Pack laboratory samples safely in a plastic leak-proof bag with an outside

,2
transportation compartment for the laboratory request form.
Step 11 Clean up spills of blood or If blood spillage has occurred clean it up
body fluids

6. Ans. (b)  Schwannoma sy

Ea
Ref: Robbins 9th ed page 1314
See PATHO PLATE 2 KEY
ed

Histopathological features of Schwannoma is a hot favorite topic of AIIMS exam now a days. Asked in different forms in AIIMS NOV
2017, NOV 2015, NOV 2014, MAY 2014
M

7. Ans. (a)  Naive B cells in interfollicular zone

REF: Robbins Basic pathology 10th ed page 467
S

CLL/ SLL - B cells originate from Pre/ Post Germinal center memory B cell or Naive B cell. Chronic Lymphocytic Leukemia (CLL) and
Small Lymphocytic Lymphoma (SLL) disorders differ only in the degree of peripheral blood lymphocytosis.
IM

Types of lymphoid leukemias and non-hodgkin lymphomas

Diagnosis Cell of Origin Salient Clinical Features
AI

Neoplasms of immature b and t cells

B-cell acute lymphoblastic
leukemia/ lymphoma
T-cell acute lymphoblastic
leukemia/lymphoma
Neoplasms of mature b cells
Burkitt lymphoma
Diffuse large B-cell lymphoma
Extranodal marginal zone
lymphoma
Follicular lymphoma
Bone marrow precursor Predominantly children; symptoms relating to marrow
B cell replacement and pancytopenia; aggressive
Precursor T cell (often of Predominantly adolescent males; thymic masses and variable
thymic origin) bone marrow involvement; aggressive
Germinal-center B cell Adolescents or young adults with extranodal masses;
uncommonly presents as “leukemia”; aggressive
Germinal-center or post All ages, but most common in adults; often appears as a rapidly
germinal center B cell growing mass; 30% extranodal; aggressive
Memory B cell Arises at extranodal sites in adults with chronic inflammatory
diseases; may remain localized; indolent
Germinal-center B cell Older adults with generalized lymphadenopathy and marrow
involvement; indolent
Contd...

PATHOLOGY
244 Section I  •  Subject-wise MCQs and Answers with Explanations

Types of lymphoid leukemias and non-hodgkin lymphomas

Diagnosis
Hairy cell leukemia
Mantle cell lymphoma
Multiple myeloma/solitary
plasmacytoma
Small lymphocytic lymphoma/
chronic lymphocytic leukemia
Neoplasms of mature t cells or NK cells
Adult T-cell leukemia/lymphoma
Peripheral T-cell lymphoma,
Cell of Origin Salient Clinical Features
Memory B cell Older males with pancytopenia and splenomegaly; indolent
Naive B cell Older males with disseminated disease; moderately aggressive
Post germinal center Myeloma: older adults with lytic bone lesions, pathologic
bone marrow homing fractures, hypercalcemia, and renal failure; moderately aggressive
plasma cell Plasmacytoma: isolated plasma cell masses in bone or soft
tissue; indolent
Naive B cell or memory Older adults with bone marrow, lymph node, spleen, and liver
B cell disease; autoimmune hemolysis and thrombocytopenia in a
minority; indolent
Helper T cell Adults with cutaneous lesions, marrow involvement, and
hypercalcemia; occurs mainly in Japan, West Africa, and the
Caribbean; aggressive
Helper or cytotoxic T cell Mainly older adults; usually presents with lymphadenopathy;

/e
unspecified aggressive
Anaplastic large-cell lymphoma Cytotoxic T cell Children and young adults, usually with lymph node and soft-

,2
tissue disease; aggressive
Extranodal NK/T-cell lymphoma NK-cell (common) or Adults with destructive extranodal masses, most commonly

Mycosis fungoides/Sézary
syndrome
cytotoxic T cell (rare)
Helper T cell sy
sinonasal; aggressive
Adult patients with cutaneous patches, plaques, nodules, or
generalized erythema; indolent
Ea
Large granular lymphocytic Two types: cytotoxic T Adult patients with splenomegaly, neutropenia, and anemia,
leukemia cell and NK cell sometimes
ed
M
S
IM
AI

AIIMS (Nov 2017–May 2014)

 PATHOLOGY  •  Answers with Explanations 245

8. Ans. (b)  Rheumatic valvular disease occur in the distal (Lower ⅓) esophagus. These tumors have
a propensity to invade the gastric cardia and fundus. On the
Ref: Harrison 19th ed page 2152, Robbins 9th ed page 425   other hand Squamous cell carcinoma is commonly seen in
See PATHO PLATE 32 KEY upper and Middle third of esophagus.

WHO diagnostic criteria of diagnosis of Rheumatic heart Clue:

disease is described in Medicine AIIMS MAY 2015 •• Barium swallow picture shows Apple core deformity of the
lower end of esophagus typical of adenocarcinoma
9. Ans. (b)  Adenocarcinoma •• Microscopically, Barrett esophagus is frequently present
adjacent to the tumor. Right half of this slide is Barrett
Ref: Robbins Basic pathology 10th ed page 596, Schwartz’s 9th
esophagus and left half is Adenocarcinoma.
ed chapter 25
See PATHO PLATE 7 KEY 10. Ans. (a)  Extrinsic Pathway

It is not possible to determine the histology of esophageal Ref: Robbins Basic pathology 10th ed page 104
tumors by their radiographic appearance, however some Adding Thromboplastin and calcium will activate Extrinsic
findings may improve specificity. The vast majority of pathway.
adenocarcinomas arise from Barrett’s esophagus and typically

/e
,2
sy
Ea
ed
M
S
IM
AI

11. Ans. (a)  Citrate Phosphate Dextrose Adenine-1

Ref: Wintrobe’s clinical hematology 12th ed page 675

Shelf life of blood components

Component Period of storage /life
RBC (ACD- acid citrate dextrose, CPD-Citrate Phosphate dextose, CP2D- Citrate Phosphate Double 21 days
Dextrose)
RBC (CPDA 1- Citrate phosphate dextrose Adenine 1) 35 days

RBC (Adsol) 42 days

Contd...

PATHOLOGY
246 Section I  •  Subject-wise MCQs and Answers with Explanations
Shelf life of blood components
Component
Platelets
Granulocytes
Factor VIII
Factor V
Factor XI
12. Ans. (a)  Lithium heparin
Ref: Essentials in Hematology and Clinical Pathology By
Ramadas Nayak 1st Ed Pg 337
•• For electrolyte estimation we need to get serum first
and for getting serum coagulation is required and hence
anticoagulants are not added. It’s done in Red coloured
vacutainer system which contains no anticoagulant. If we
still have a select a best answer then Heparin will be the best
answer.
•• Heparin can be  added for instantaneous anticoagulation and
to prevent haemolysis after the blood is drawn. Haemolysis
Ea
may cause spurious elevation in serum potassium report.
Minimal heparin is added, just to wet inner surface of
syringe.
ed
•• Heparin is also used in osmotic fragility test (for
spherocytosis), Red cell enzyme studies (G6PD and PK
studies), Arterial blood gas analysis.
M
•• Sodium fluoride is an antiglycolytic agent which inhibits
use of glucose by blood cells.Used for estimation of blood
glucose
S
•• EDTA (Ethyl Diamine Tetra Acectic acid) chelates calcium
and is used for CBC, HbF estimation and Hb electropheresis.
IM
AI
ECG Changes in
Hypocalcemia
(2.1 mmol/L or 9 mg/dl)
14. Ans. (a)  Peripheral Blood smear
Ref: Robbins basic pathology 10th ed page 480
AML occasionally presents as a localized soft-tissue mass
known variously as a myeloblastoma, granulocytic sarcoma, or
chloroma. AML can usually be diagnosed from the peripheral
smear, but bone marrow aspirate and biopsy should always be
performed to determine proper classification
AIIMS (Nov 2017–May 2014)
Period of storage /life
5 days
24 hours
2 days
4-5 days
6-7 days
•• Sodium citrate chelates calcium and is used in
anticoagulation studies and estimation of ESR
13. Ans. (b)  Large infusion of ACD
/e
Ref: Wintrobe’s Clinical Hematology 12th Ed page 674
Perioral numbness with tingling sensation points towards
,2
Hypocalcemia. ECG changes are also consistent with
Hypocalcemia. Now we need to look into options to check
which one causes hypocalcemia.
sy The anticoagulant used for essentially all transfusable blood
components today is citrate, which chelates ionized calcium in
donor blood, making it unavailable to the calcium-dependent
stages of coagulation. After transfusion, citrate is readily
metabolized into bicarbonate by the liver of the recipient.
Apheresis donors face the additional potential complication
of transient hypocalcemia from the citrate infused when
anticoagulated blood components are returned to them from the
apheresis device. Symptoms consist of tingling or muscle cramps.
Citrate symptoms are treated by slowing the flow of the device
or giving the donor oral calcium supplements. Intravenous
calcium infusions are needed only during prolonged apheresis
procedures such as those for HPC collection
Main ECG change is prolonged QT interval mainly
due to prolonged ST
Narrow QRS complex
Reduced PR interval
T wave flattening and inversion
Prominent U-wave
15. Ans. (c)  Transthyretin
Ref: Wintrobe 11th ed page 811, Robbin’s 9th ed page 649
Option (A)
Ceruloplasmin is copper containing enzyme with ferroxidase
activity
 PATHOLOGY  •  Answers with Explanations 247
Option (B)
Hepcidin is produced in the liver, present in the plasma and excreted through the kidneys .Hepcidin expression is increased  with iron
overload induced by carbonyl iron, suggesting that its production might be part of a compensatory response to limit iron absorption
expression of hepcidin is decreased in the setting of iron deficiency anemia, hypoxia, or inflammation.
Finally, patients with inappropriate expression of hepcidin develop an iron-restricted anemia.
It is structurally similar to antimicrobial peptides involved in innate immunity, and it has been shown to have antimicrobial properties.
Option (C)
Transthyretin (TTR) is a transport protein in the serum and cerebrospinal fluid that carries the thyroid hormone thyroxine (T4) and
retinol-binding protein bound to retinol. This is how transthyretin gained its name: transports thyroxine and retinol.
Option (D)
Once in the cytosol, iron enters a chelatable pool from which it is used by several enzymes or is stored in ferritin.

/e
,2
sy
Ea
ed
M

16. Ans. (d)  Risk of integration of viral DNA with Host DNA
S

Ref: Int J Exp Pathol. 2001 Apr; 82(2): 77–100.

IM

Chronic hepatitis B virus (HBV) infection is a major global cause of hepatocellular carcinoma (HCC). There are two explanations for
the development of HCC in patients who have apparently recovered from chronic HBV infection.
1. HBV DNA may persist in low concentration in the serum and liver tissue after the disappearance of HBsAg from the serum.
AI

2. Alternatively, HBV DNA may become integrated into host DNA during an early stage of infection before the elimination of the virions

PATHOLOGY
248 Section I  •  Subject-wise MCQs and Answers with Explanations

AIIMS MAY 2017 B-cell immortalization by inducing the expression of

17. Ans. (a)  Infectious mononucleosis
Ref: Robbins 9th ed page 436, Devita 8th ed page 2423, Harrison
19th ed page 1168, Modern Pathology (2012) 25, 1149–1159
doi:10.1038/modpathol.2012.70; published online 25 May 2012
See PATHO PLATE 50 KEY
This is the most controversial and difficult question of the whole
session. Monospot negative is given to confuse you. When
such a patient appears to OPD and a provisional diagnosis of
Infectious mononucleosis is made, monospot test is the first
thing to be done. If monospot comes negative, Hodgkins and
DLBCL are added in the list of differentials.
Hints to diagnosis:
•• Monospot test is the screening method of active EBV
bcl-2, which inhibits programmed death of the infected cells.
LMP-1 is also considered to be an oncogene, and deletions
near the 3 end of the LMP-1 gene, in a region that affects the
half-life of the LMP-1 protein, have been reported in some
lymphoproliferative disorders. (Devita 8th ed page 2423)
•• The monospot test is not recommended for general use.
The antibodies detected by monospot can be caused by
conditions other than infectious mononucleosis. Moreover,
studies have shown that the monospot produces both
false positive and false negative results. For example, the
heterophile antibodies detected by monospot are often not
present in children with infectious mononucleosis. At best,
the monospot test may indicate that a person has a typical
case of infectious mononucleosis, but does not confirm the
presence of EBV infection.
•• Lymphocytosis is characteristic of IM and not seen in
DLBCL

/e
infection and negative monospot cannot rule out infectious •• Lage cells in the background points to IM, DLBCL will show
mononucleosis. Tests for heterophile antibodies are positive sheets of large cells only

in 40% of patients with 1M during the first week of illness
and in 80-90% during the third week. Test is positive up to
3 months. If monospot test is negative other confirmatory
serological tests are done which is positive in this case.
•• The latent membrane protein 1 (LMP-1) is one of the EBV-
Ea
encoded proteins believed to have an important role in
,2
•• IHC profile of both IM and DLBCL are not exactly same
but matching and cannot be differentiated on the basis of
markers provided in the question, except CD3 positive cells
sy ••
in the background seen in IM but not seen in DLBCL
CD 15 negative rules out Classical Hodgkins.

Features Infectious Mononucleosis EBV Positive Diffuse Large B-cell Lymphoma

ed

Age group Adolescent/Young adults Most common in older age groups (Most
common lymphoma of adult group)
M

Fever, tonsillitis, Present Present

lymphadenopathy
S

Peripheral leucocytosis Present with large atypical cells (10000–20000/μL). No

Lymphocytosis is usually demonstrable, with >10%
IM

atypical lymphocytes (Downey cells)

Monospot test Positive. May be positive
AI

(Heterophile reaction) (Note: Monospot negative infectious mononucleosis is

known, although uncommon. In such cases, serological
tests and titres need to be seen)
Histology Large cells on background of lymphocytes Large cells in sheets only, hardly any
background cells
Markers Both B cells and T cell markers CD20+, CD 30+, MUM1/ B Cell markers (CD 19, CD20, CD3, CD5, CD10,
IRF4+, occasional CD3+ immunoblast-like cells, CD10- CD45, CD 79a, Bcl-2, Bcl-6, Ki-67, IRF-4/MUM-1,
(Germinal center marker), CD15-, BCL-6, BCL2 weekly +, MYC
Splenomegaly Almost in all cases May be present

About option (B) Hodgkin’s Lymphoma:
CD 15 negative rules out classical Hodgkin’s. Both Hodgkins
and RS cells are CD 15 positive.
Option (C) EBV Positive Diffuse Large B Cell Lymphoma:
•• Diffuse large B cell lymphoma is the most common type of
lymphoma in adults, accounting for approximately 50% of
adult NHLs.
•• It includes several subtypes that share an aggressive natural
history.
•• The majority of patients (57%) presented with cervical
lymphadenopathy.
•• The other common presenting symptoms were growth
or ulcer on the tonsil (38%), dysphagia or foreign-body
sensation (36%), odynophagia or otalgia (20%), change in
voice (5.8%)

AIIMS (Nov 2017–May 2014)


•• Although the median age at presentation is about 60 years,
diffuse large B cell lymphomas can occur at any age; they
constitute about 15% of childhood lymphomas.
•• Patients typically present with a rapidly enlarging, often
symptomatic mass at one or several sites.
•• Extranodal presentations are common. Although the
gastrointestinal tract and the brain are among the more
frequent extranodal sites, tumors can appear in virtually any
organ or tissue.
•• The neoplastic B cells are large (at least three to four times
the size of resting lymphocytes) and vary in appearance
from tumor to tumor.
•• In many tumors, cells with round or oval nuclear contours,
dispersed chromatin, several distinct nucleoli, and modest
amounts of pale cytoplasm predominate.
•• These mature B cell tumors express pan-B cell antigens,
such as CD19 and CD20.
•• Many also express surface IgM and/or IgG. Other antigens
(e.g., CD10, BCL2) are variably expressed.
•• EBV-associated diffuse large B cell lymphomas arise in
the setting of the acquired immunodeficiency syndrome
(AIDS), iatrogenic immunosuppression (e.g., in transplant
recipients), and the elderly.
•• In the post-transplantation setting, these tumors often
begin as EBV-driven polyclonal B cell proliferations that
may regress if immune function is restored.
Ea
Option (D) EBV Positive Mucocutaneous Ulcer:
Generally seen in immunocompromised patients. Also, large
ed
cells show CD30 strong positive and CD20 reduced expression.
18. Ans. (a)  Nodular lymphocyte predominant HL
M
Ref: Robbins’s 9th ed page 441
Read this question in connection and continuation to previous
S
question. CD15-points towards Hodgkins Lymphoma. How
see other features to find out Subtype
IM
See PATHO PLATE 6 for details of Hodgkin’s lymphoma
and its classification
AI
19. Ans. (d)  B cells, dendritic cells and macrophages
Ref: Robbins 9th ed page 102
Indirect repeat Pathology AIIMS NOV 2016 (All except was
asked, See for explanation)
MHC-2 is seen in all antigen presenting cell including B cell,
macrophages and dendritic cells.
20. Ans. (a)  Sclerodactyly, Raynaud’s phenomenon, lung fibrosis
Ref: Robbins 9th ed page.125
This is a case of systemic sclerosis or scleroderma sclerodactyly,
Raynauds and lung fibrosis are all seen in scleroderma
•• Antinuclear antibodies (ANAs) are directed against nuclear
antigens and can be grouped into four categories:
ƒƒ Antibodies to DNA
ƒƒ Antibodies to histones
ƒƒ Antibodies to nonhistone proteins bound to RNA
PATHOLOGY  •  Answers with Explanations 249
ƒƒ Antibodies to nucleolar antigens.
•• The most widely used method for detecting ANAs is indirect
immunofluorescence.
•• The pattern of nuclear fluorescence suggests the type of
antibody present in the patient’s serum. Four basic patterns
are recognized:
ƒƒ Homogeneous or diffuse nuclear staining: Usually
reflects antibodies to chromatin, histones, and occasion-
ally, double-stranded DNA.
ƒƒ Rim or peripheral staining patterns: Most often indicative
of antibodies to double-stranded DNA.
ƒƒ Speckled pattern: Refers to the presence of uniform or
variable-sized speckles. This is one of the most commonly
observed patterns of fluorescence and therefore the least
specific. It reflects the presence of antibodies to non-
DNA nuclear constituents. Examples include Sm antigen,
ribonucleoprotein, and SS-A and SS-B reactive antigens.
ƒƒ Nucleolar pattern: Presence of a few discrete spots of
/e
fluorescence within the nucleus and represents antibodies
to RNA. This pattern is reported most often in patients
,2
with systemic sclerosis.
Scleroderma/Systemic Sclerosis (SS)
•• An immunologic disorder characterized by excessive
sy fibrosis in multiple tissues, obliterative vascular disease,
and evidence of autoimmunity, mainly the production of
multiple autoantibodies.
•• It is commonly called scleroderma because the skin is a
major target, but this disorder is better labeled “systemic”
because lesions are present throughout the body.
•• Cutaneous involvement is the usual presenting manifestation
and eventually appears in approximately 95% of cases,
but it is the visceral involvement—of the gastrointestinal
tract, lungs, kidneys, heart, and skeletal muscles—that is
responsible for most of the related morbidity and mortality.
•• SS can be classified into two groups on the basis of its
clinical course:
ƒƒ Diffuse scleroderma, characterized by initial widespread
skin involvement, with rapid progression and early
visceral involvement.
ƒƒ Limited scleroderma, with relatively mild skin
involvement, often confined to the fingers and face.
Involvement of the viscera occurs late, so the disease in
these patients generally has a fairly benign course. This
clinical presentation is also called the CREST syndrome
because of its frequent features of calcinosis, Raynaud
phenomenon, esophageal dysmotility, sclerodactyly, and
telangiectasia.
•• SS affects women three times more often than men, with a
peak incidence in the 50- to 60-year age group.
•• There is a substantial overlap in presentation between SS
and RA, SLE, and dermatomyositis.
•• The distinctive feature of SS is the striking cutaneous involve-
ment. Almost all patients exhibit Raynaud phenomenon, a
vascular disorder characterized by reversible vasospasm of
the arteries.
•• Typically the hands turn white on exposure to cold,
reflecting vasospasm, followed by change to blue as ischemia
PATHOLOGY
250 Section I  •  Subject-wise MCQs and Answers with Explanations

and cyanosis supervene. Finally, the color changes to red as
reactive vasodilation occurs.
•• Progressive collagen deposition in the skin leads to atrophy
of the hands, with increasing stiffness and eventually complete
immobilization of the joints.
•• Difficulty in swallowing results from esophageal fibrosis
and resultant hypomotility. Eventually, destruction of the
esophageal wall leads to atony and dilation.
•• Malabsorption may appear if the submucosal and muscular
atrophy and fibrosis involve the small intestine.
•• Dyspnea and chronic cough reflect the pulmonary chang-
es; with advanced lung involvement, secondary pulmonary
hypertension may develop, leading to right-sided cardiac
failure.
•• Renal functional impairment secondary to both the
advance of SS and the concomitant malignant hypertension
is frequently marked.
•• Virtually all patients of systemic sclerosis have ANAs that
21. Ans. (b)  Barrett’s esophagus
Ref: Robbin’s 9th ed page 757, Basic histology Text and Atlas by
Luiz Carlos Junqueira 11th ed chapter 4, Text Book of Histology
Krishna Garg 4th Edn Page 93, 94
See PATHO PLATE 7 KEY
Repeat Pathology AIIMS NOV 2015 (Same slide was given,
also stain and additional feature was asked) (See for details)
22. Ans. (a)  Transferrin receptor 1—iron responsive elements
(IRE) increases transferrin receptor mRNA concentration
and synthesis.
Ref: Williams Hematology 8th ed Chapter 42
•• The regulation of iron metabolism at the cytoplasmic mRNA
level by interaction of iron-regulatory protein (IRP-1)
and the iron-responsive elements (IREs) to apoferritin

/e
mRNA (Mechanism 1) and transferrin receptor (TfR)
react with a variety of nuclear antigens.
mRNA (Mechanism 2).
•• Two ANAs strongly associated with systemic sclerosis have

been described.
•• DNA topoisomerase I (anti-Scl 70), is highly specific.
Depending on the ethnic group and the assay, it is present
in 10% to 20% of patients with diffuse systemic sclerosis.
Patients who have this antibody are more likely to have
Ea
pulmonary fibrosis and peripheral vascular disease.
•• Anticentromere antibody, is found in 20% to 30% of
patients, who tend to have the CREST syndrome or limited
ed
,2
•• When the cytoplasmic iron concentration is low, IRP-1 binds
to the IREs of both mRNAs. This represses the translation
of apoferritin mRNA, where the IRE is at the 5′ end of the
sy mRNA, thereby reducing the amount of apoferritin formed.
•• It stabilizes and increases the translation of TfR mRNA
where the IRE is at the 3′ end of the mRNA, thereby
increasing the amount of TfR formed.
•• Conversely, when there is an abundance of iron in the
cytoplasm, IRP-1 is displaced from both species of mRNA.

cutaneous systemic sclerosis. Only rarely does the same This results in derepression of apoferritin synthesis and
patient have both antibodies. destabilization and degradation of TfR mRNA.
M
S
IM
AI

AIIMS (Nov 2017–May 2014)

 PATHOLOGY  •  Answers with Explanations 251

23. Ans. (b)  Kimmelstiel Wilson lesion
Ref: Robbin’s Basic Pathology 10th edition. Pg 781-783
See PATHO PLATE 51 KEY
24. Ans. (d)  Membranous glomerulonephritis
Ref: Robbin’s 9th ed ch 20,
http://unckidneycenter.org/kidneyhealthlibrary/glomerular-
disease/membranous-nephropathy
See table of Major Primary Glomerulonephritis in
PATHOLOGY AIIMS NOV 2016
See PATHO PLATE 31 KEY
Immunofluorescence picture of membranous glomerulone-
phritis was asked in Pathology AIIMS MAY 2016, now they
have added electron microscopy picture in the same question.
Keith D Lindor page 119, Complications of Cirrhosis: Evaluation
and Management edited by Andrew Keaveny, Andrés Cárdenas
page-39
Non-invasive methods have been proposed as surrogate
markers for liver biopsy. It was shown that serum hyaluronic
acid (HA) and laminin (LN) levels increase with the
development of liver fibrosis and has been proved its utility.
Simplest non-invasive index of liver fibrosis is AST/ALT ratio.
Non-invasive biomarkers of liver fibrosis are direct (Class 1)
and indirect (Class 2).
•• Non-specific markers: Includes age, gender, laboratory
markers of liver injury or dysfunction including aspartate
transaminase (AST), alanine transaminase (ALT), gamma
gutamyl transferase (GGT), bilirubin, heptoglobin, platelet
count, prothrombin time, cholesterol, apoprotein A1 and
alpha 2 macroglobulin (A2M).
•• Specific markers: Includes extracellular matrix proteins
like hyaluronic acid (HA), serum laminin, matrix

/e
metaloproteinase-2, tissue inhibitor of metaloproteinase-1,
25. Ans. (c)  Serum laminin and hyaluronic acid amino-terminal peptide of type III procollagen.

,2
Ref: Zakim and Boyer’s Hepatology: A Textbook of Liver Disease
E-Book By Thomas D. Boyer, Arun J. Sanyal, Norah A Terrault,

sy
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Biomarkers of Liver Fibrosis
Test Components Pltfalls
ed

AST/ALT ratio AST, ALT Alcohol, muscle breakdown

AST/platelet ratio AST, platelet count Alcohol, muscle breakdown, extrahepatic cause of thrombocytopenia
M

index

FIB-4 Age, AST, ALT, platelet count Alcohol, muscle breakdown, extrahepatic cause of thrombocytopenia
S

NAFLD fibrosis score Age, BMI, diabetes (the presence of), Alcohol, muscle breakdown, extrahepatic causes of
IM

AST, ALT, albumin, platelet count thrombocytopenia malnutrition

FibroSure/Fibro test Age, sex, bilirubin, GGT, apoliprotein Alcohol, Gilbert syndrome, renal disease, hemolysis, statin, use,
AI

A1, haptoglobin, and a2-macroglobulin inherited dyslipidemia

HepaScore/FibroScore a2-Macroglobulin, bilirubin, GGT, Alcohol, Gilbert syndrome, renal disease, extrahepatic fibrosis
hyaluronic acid

FibroMeter Age, sex, platelet count, a2- Alcohol, Gilbert syndrome, renal disease, anticoagulation
macroglobulin, ALT, AST GCT, INR,
blood urea nitrogen

FibroSpect a2-Macroglobulin, hyaluronic acid, Renal disease, extrahepatic fibrosis, chronic inflammatory diseases
tissue inhibitor of metalloproteinase

Enhanced liver fibrosis Hyaluronic acid, tissue inhibitor Renal disease, extrahepatic fibrosis, chronic inflammatory diseases
score of metalloproteinase, N-terminal
propeptide of type III procollagen

PATHOLOGY
 Pathology
PATHO PLATE 1

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A B C

sy
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ed
M

D E F
S
IM
AI

G H I

J K
1066 Section II  •  Subject-wise Color Plates
PATHO PLATE 1 KEY
Crystal
1A = Calcium oxalate dihydrate
1B = Calcium oxalate
monohydrate
1C = Calcium oxalate
monohydrate (picket fence)
1D = Calcium carbonate
1E = Uric acid
1F = Ammonium biurate
1G = Struvite crystals
(magnesium ammonium
phosphate, triple phosphate)
1H = Calcium phosphate
IM
AI
1I = Hippuric acid
1J = Bilirubin crystals
1K = Cystine crystals
Note:
•• All abnormal crystals precipitate in the urine at acidic pHs.
•• Crystals by drugs are often caused by sulphadiazine (appearance of sheaves of wheat), acyclovir (birefringent, needle-sharp crystals)
and vitamin C.
AIIMS
Urinary Crystals
Shape
Colorless Octahedron (Envelope Acidic or pH insensitive in the
shaped), diamond shape physiologic pH range of 5 to 8
Colorless, Spindle (arrow), oval
(Hemp seed), or dumbbell
shape,
A particular form of calcium
oxalate monohydrate are flat,
elongated, six-sided crystals
(“picket fences”) which are the
larger crystals
Yellow to colorless dumbells or
spheres with radial striations
Amber in color, Rhomboic, 4
sided plates, prism, oval with
Ea
pointed ended
Brown or yellow-brown
ed
spherical bodies with irregular
protrusions (“thorn-apples”)
Colorless, three-dimensional,
M
prism-like crystals (“coffin lids”)
S
Large flat-shaped plates or
wedge-shaped prisms in
rosettes. Single prisms are
usually blunt on one end and
pointed on the other end.
Colorless prisms, plates,
or needle-like often
conglomerated into masses
Yellow-brown needles or
granules. Form from conjugated
bilirubin.
Flat colorless, thin, hexagonal
plates with equal or unequal
sides
Favorable pH Comments
Artifact of storage (can develop
in stored urine). Associated with
food high in oxalate (tomatoes,
asparagus, ascorbic acid
Acidic or pH insensitive in the Associated with food high in
physiologic pH range of 5 to 8 oxalate (tomatoes, asparagus,
ascorbic acid
Acidic or pH insensitive in the Seen in ethylene glycol toxicosis
physiologic pH range of 5 to 8
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Alkaline urine Usually large crystals and can
be readily observed at low
sy
5-5.5 (Acidic Urine)
magnification.
Alkaline pH Can be observed under low
magnification
Neutral and Alkaline pH is UTI with urease positive
favourable. bacteria promote struvite
crystalluria
Alkaline urine
They are frequently attached
to the surface of cells. Bilirubin
crystals are seen in several
hepatic disorders
Acidic urine Cystine crystals are found in the
inherited condition, cystinuria.
Cystine crystals are the most
frequent cause of kidney stones
in children.
 PATHOLOGY  • Color Plates 1075

PATHO PLATE 7

A B C

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D E sy F
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F. Squamous cell carcinoma esophagus Histopathology: Typical
PATHO PLATE 7 KEY keratinizing conventional, well differentiated squamous cell
ed

carcinoma with keratin pirls (arrow). Most squamous cell

A. Barrett esophagus endoscopy: Esophageal squamous epithelium carcinomas are moderately to well-differentiated. Squamous cell
(Black arrow) is replaced by metaplastic columnar epithelium carcinoma begins as an in situ lesion termed squamous dysplasia.
M

(Blue arrow- Salmon coloured mucosa in Endoscopy)

Barrett Esophagus
B. Barrett esophagus histopathology: Esophageal squamous
•• Barrett esophagus is a complication of long standing gastroesoph-
S

epithelium is replaced by metaplastic columnar epithelium

containing intestinal goblet cells (Red arrow). Note the squamous ageal reflux, occurring over time in up to 10% of patients with
symptomatic GERD.
IM

epithelium on the right side and collumnar epithelium on the left

side •• It is single most important risk factor of esophageal adenocarcinoma.
C. Adenocarcinoma Esophageal endoscopy: Upper-gastrointestinal •• In Barrett esophagus distal squamous mucosa is replaced by
AI

endoscopy showing lower-esophageal ulceroproliferative tumor metaplastic columnar epithelium as a response to prolonged
measuring 2.5 cm × 2.5 cm. Lower third esophageal cancers are injury (columnar metaplasia)
mostly adenocarcinoma. •• Two criteria are required for the diagnosis of Barrett esophagus:
D. Adenocarcinoma of Esophagus Histopathology: ƒƒ Endoscopic evidence of columnar epithelium lining above the
Microscopically, Barrett esophagus is frequently present adjacent gastroesophageal junction
to the tumor. Right half of this slide is Barrett esophagus and left
ƒƒ Histological evidence of intestinal metaplasia in biopsy
half is Adenocarcinoma. Tumors most commonly produce mucin
specimen from columnar epithelium
and form glands, often with intestinal-type morphology; less
frequently tumors are composed of diffusely infiltrative signet- Locations of Goblet Cells
ring cells (similar to those seen in diffuse gastric cancer)
Goblet cells are glandular simple columnar epithelial cells whose sole
E. Squamous cell carcinoma esophagus endoscopy: In contrast to
function is to secrete mucin, which dissolves in water to form mucus.
adenocarcinoma, half of squamous cell carcinomas occur in the
They use both apocrine and merocrine methods for secretion. They
middle third of the esophagus. Early lesions appear as small, gray-
are found scattered among the epithelial lining of organs, such as the
white, plaque-like thickenings. It is polypoid or exophytic and
intestinal and respiratory tracts. They are found inside the trachea,
protrude into and obstruct the lumen. Or it can either ulcerated
bronchus, and larger bronchioles in respiratory tract, small intes-
or diffusely infiltrate. These may invade surrounding structures
tines, the colon, and conjunctiva in the upper eyelid. They may be an
including the respiratory tree, causing pneumonia; the aorta,
indication of metaplasia, such as in Barrett’s esophagus.
causing catastrophic exsanguination; or the mediastinum and
pericardium.

PATHOLOGY
1076 Section II  •  Subject-wise Color Plates

Staining of Goblet Cell-Alcian Blue •• Stained parts are blue to bluish-green

•• Common “routine” stain (not an immunohistochemical stain) to
detect mucins
•• At pH 2.5, detects acidic mucins, At pH 1.0, detects highly acidic
mucins
•• PAS-Alcian blue may be best pan mucin combination; PAS also
stains glycogen, but predigestion with diastase will remove the
glycogen
•• Alcian blue-high iron diamine detects sulfomucins (brown) and
sialomucins (blue)

PATHO PLATE 8

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A B C D

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E F G H
ed
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PATHO PLATE 8 KEY

A. Acanthocytes
S

B. Basophilic stippling
C. Bite cells
IM

D. Burr cells
E. Cabot Rings
F. Howell-Jolly bodies
AI

G. Target cells
H. Teardrop cells
Pathologic Red Cells in Blood Smears
Red Cell Type Description Underlying Change Disease State Associations
Acanthocyte (spur Altered cell membrane lipids Abetalipoproteinemia, parenchymal
cell) liver disease, postsplenectomy

Irregularly spiculated red cells with

projections of varying length and dense
center
Basophilic stippling Precipitated ribosomes (RNA) Coarse stippling: Lead intoxication,
thalassemia
Fine stippling: A variety of anemias

Punctuate basophilic inclusions

Contd…

AIIMS
 PATHOLOGY  • Color Plates 1077

Pathologic Red Cells in Blood Smears

Red Cell Type Description Underlying Change Disease State Associations
Bite cell Heinz body pitting by spleen Glucose-6-phosphate dehydrogenase
(degmacyte) deficiency, drug-induced oxidant
hemolysis

Smooth semicircle taken from one edge

Burr cell May be associated with Usually artifactual; seen in uremia,
(echinocyte) or altered membrane lipids bleeding ulcers, gastric carcinoma
crenated red cell

Red cells with short, evenly spaced

spicules and preserved central pallor
Cabot rings Nuclear remnant Postsplenectomy, hemolytic anemia,
megaloblastic anemia

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Circular, blue, threadlike inclusion with
dots
Ovalocyte
(elliptocyte)
sy
Abnormal cytoskeletal
proteins
Hereditary elliptocytosis
Ea
Elliptically shaped cell
ed

Howell-Jolly Nuclear remnant (DNA) Postsplenectomy, hemolytic anemia,

bodies megaloblastic anemia
M

Small, discrete, basophilic, dense

inclusions; usually single
S

Hypochromic red Prominent central pallor Diminished hemoglobin Iron deficiency anemia, thalassemia,
IM

cell synthesis sideroblastic anemia

Macrocyte Red cells larger than normal (>8.5 μm), Young red cells, abnormal red Increased erythropoiesis; oval
well filled with hemoglobin cell maturation macrocytes in megaloblastic anemia;
AI

round macrocytes in liver disease

Microcyte Red cells smaller than normal (<7.0 μm) — Hypochromic red cell
Pappenheimer Iron-containing siderosome or Sideroblastic anemia, postsplenectomy
bodies mitochondrial remnant

Small, dense, basophilic granules

Poly Ribosomal material Reticulocytosis, premature marrow
chromatophilia release of red cells

Grayish or blue hue often seen in

macrocytic RBC lacking central pallor.

Contd…

PATHOLOGY
1078 Section II  •  Subject-wise Color Plates

Pathologic Red Cells in Blood Smears

Red Cell Type Description Underlying Change Disease State Associations
Rouleaux Red cell clumping by Paraproteinemia
circulating paraprotein

Red cell aggregates resembling stack of

coins
Schistocyte Mechanical distortion in Microangiopathic hemolytic
(helmet cell) microvasculature by fibrin anemia (disseminated intravascular
strands, disruption by coagulation, thrombotic
prosthetic heart valve thrombocytopenic purpura, prosthetic
heart valves, severe burns)
Distorted, fragmented cell; two or three
pointed ends

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Sickle cell Molecular aggregation of HbS Sickle cell disorders, not including S
(drepanocyte) trait

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Bipolar, spiculated forms, sickle shaped,
pointed at both ends sy
Ea
Spherocyte Decreased membrane surface Hereditary spherocytosis,
area immunohemolytic anemia
ed
M

Spherical cell with dense appearance

and absent central pallor, usually
decreased diameter
S

Stomatocyte Membrane defect with Hereditary stomatocytosis, Alcoholism,

abnormal cation permeability immunohemolytic anemia
IM
AI

Mouth or cuplike deformity

Target cell (AKA- Increased redundancy of cell Liver disease, postsplenectomy,
Mexican hat cells/ membrane thalassemia, hemoglobin C disease
codocyte)

Target like appearance, often

hypochromic
Teardrop cell — Myelofibrosis, myelophthisic anemia,
(dacryocyte) Thalassemia

Distorted, drop-shaped cell

AIIMS