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Step I USMLE images

Started by Zuhal
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Zuhal

Zuhal

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68 yo male patient presents to your clinic with postprandial pain. X-ray below, whats the dx?
 

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The stem led us away from the question... the only real clue was the histology; and that wasn't no easy histo to get.....

....SLC, you been using too much UWORLD (the ones where only 10% get it right)
 
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Hurthle cells can become malignant though

from Schwartz text
Hürthle cell carcinomas account for approximately 3% of all thyroid malignancies and, under the World Health Organization classification, are considered to be a subtype of follicular thyroid cancer. Hürthle cell cancers also are characterized by vascular or capsular invasion and can, therefore, not be diagnosed by FNAB. Tumors contain sheets of eosinophilic cells packed with mitochondria, which are derived from the oxyphilic cells of the thyroid gland. Hürthle cell tumors differ from follicular carcinomas in that they are more often multifocal and bilateral (about 30%), usually do not take up RAI (about 5%), are more likely to metastasize to local nodes (25%) and distant sites, and are associated with a higher mortality rate (about 20% at 10 years). Hence, they are considered to be a separate class of tumors by some groups.
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Not to belabor the point, but why would you need cytology to diagnose Hashimotos? Through a quick search according to mayo you can get TSH and antibody tests and that should be sufficient to diagnose hashimots. Additionally those cells are showing a certain degree of atypia, which really makes me think it is a neoplasm instead of hashimotos.
 
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addo said:
Not to belabor the point, but why would you need cytology to diagnose Hashimotos? Through a quick search according to mayo you can get TSH and antibody tests and that should be sufficient to diagnose hashimots. Additionally those cells are showing a certain degree of atypia, which really makes me think it is a neoplasm instead of hashimotos.
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Oh you wouldn't need cytology. But I've seen plenty of practice Q's with extraneous (but still relevant) info that's designed to test what you know.

There are plenty of questions that will offer up info that you normally wouldn't have/need before making a Dx...

It was a terrible question though, I thought I was being smart, but I didn't even know that Hürthle cells are also sometimes associated with Follicular Thyroid Cancer.

I could probably have gotten away with calling it a diffuse mass rather than just a mass, follicular thyroid cancer is usually noticed as a thyroid nodule rather than a diffusely enlarged thyroid. Additionally, Follicular Thyroid Carcinoma is normally a euthyroid condition rather than a hyper/hypo thryroid condition.

But either way, the question mainly focused on Hürthle cells, with a little bit of natural history of disease for Hasimoto's thrown in to spice it up a bit. Since Hürthle cells are not unique to Hashimoto's like I thought they were. That made the question a bad one without a lot more info that I should have included.

But now nobody should miss a question about them, should they randomly show up on their USMLE, right? right?
 
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addo said:
Not to belabor the point, but why would you need cytology to diagnose Hashimotos? Through a quick search according to mayo you can get TSH and antibody tests and that should be sufficient to diagnose hashimots. Additionally those cells are showing a certain degree of atypia, which really makes me think it is a neoplasm instead of hashimotos.
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Thyroid autoantibodies: Presence of typically anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibodies delineates the cause of hypothyroidism as Hashimoto thyroiditis or its variant; however, 10-15% of patients with Hashimoto thyroiditis may be antibody negative

http://emedicine.medscape.com/article/120937-overview
 
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SLC said:
Oh you wouldn't need cytology. But I've seen plenty of practice Q's with extraneous (but still relevant) info that's designed to test what you know.

There are plenty of questions that will offer up info that you normally wouldn't have/need before making a Dx...

It was a terrible question though, I thought I was being smart, but I didn't even know that Hürthle cells are associated with other Follicular Thyroid Cancer.

I could probably have gotten away with calling it a diffuse mass rather than just a mass, follicular thyroid cancer is usually noticed as a thyroid nodule rather than a diffusely enlarged thyroid. Additionally, Follicular Thyroid Carcinoma is normally a euthyroid condition rather than a hyper/hypo thryroid condition.

But either way, I was focused on Hürthle cells, and they are not unique to Hashimoto's like I thought they were. That made the question a bad one without a lot more info that I should have included.
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Fair enough, its all good. There was just a little bit of disconnect between the history and the picture, but good question either way, now we all know a little bit more. And youre right follicular carcinoma is usually euthyroid, good point.
 
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tumblr_mdathhjwQb1r8vrhxo1_500.jpg


Patient that returns from a mission trip to Nigeria comes in with a red inflamed wrist that is tender palpation, upon examining his eyes you see the above picture.

What do you use to treat this condition?
 
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SLC said:
Papilledema secondary to obstructive sleep apnea?
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It is papilledema, but it is due to idiopathic intracranial hypertension or pseudomotor cerebri. Obesity predisposes to this condition, although obesity obviously also predisposes to obstructive sleep apnea, but in that case it would be more likely to develop pulmonary hypertension.
 
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addo said:
It is papilledema, but it is due to idiopathic intracranial hypertension or pseudomotor cerebri. Obesity predisposes to this condition, although obesity obviously also predisposes to obstructive sleep apnea, but in that case it would be more likely to develop pulmonary hypertension.
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Yep, no mention of anything like that to make me thing Pulm-HTN either, I was thinking Obesity--Chronic Headaches--OSA. :smack:

Man I hope I don't read too much into questions on the real thing...It's starting to become a habit for me.

I did better on Qbanks before I started reviewing everything.
 
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SLC said:
Yep, no mention of anything like that to make me thing Pulm-HTN either, I was thinking Obesity--Chronic Headaches--OSA. :smack:

Man I hope I don't read too much into questions on the real thing...It's starting to become a habit for me.

I did better on Qbanks before I started reviewing everything.
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Yea, the more you know the harder it is to keep everything separate, and also the harder it becomes to make the connections between seemingly separate but related information. Im right there with you
 
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SLC said:
Yep, no mention of anything like that to make me thing Pulm-HTN either, I was thinking Obesity--Chronic Headaches--OSA. :smack:

Man I hope I don't read too much into questions on the real thing...It's starting to become a habit for me.

I did better on Qbanks before I started reviewing everything.
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lmao yea. It's always cool when you think for 5 minutes on one question and you narrowed it down to two choices, then when you review, uworld has like 80% picked one choice, and 5% picked the choice you did. And you just sit there like, did people not even spare a thought towards this, yet I spent about 5 minutes on this bs? feelsbadbro
 
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JP2740 said:
lmao yea. It's always cool when you think for 5 minutes on one question and you narrowed it down to two choices, then when you review, uworld has like 80% picked one choice, and 5% picked the choice you did. And you just sit there like, did people not even spare a thought towards this, yet I spent about 5 minutes on this bs? feelsbadbro
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happens to me all day - literally
 
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A child from a developing country is seen in the ER for stupor, malaise, and headaches. On physical exam, an enlarged liver is found, and a biopsy is done. Past medical history is significant for palmar erythema, conjunctivitis, and a rash. Here is the biopsy:

8-4-12.jpg


What's going on in this patient?
 
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JP2740 said:
A child from a developing country is seen in the ER for stupor, malaise, and headaches. On physical exam, an enlarged liver is found, and a biopsy is done. Past medical history is significant for palmar erythema, conjunctivitis, and a rash. Here is the biopsy:

8-4-12.jpg


What's going on in this patient?
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Reye syndrome?
 
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addo said:
Reye syndrome?
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Yea good job lol. I was thinking of leaving some more info out and making it tougher but figured screw it. He had no vaccinations (developing). He got kawasaki->treated with aspirin->infected with VZV or influenza B->reye syndrome with MICROvesicular change (you can tell this just from the histo).
 
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JP2740 said:
Yea good job lol. I was thinking of leaving some more info out and making it tougher but figured screw it. He had no vaccinations (developing). He got kawasaki->treated with aspirin->infected with VZV for influenza B->reye syndrome with MICROvesicular change (you can tell this just from the histo).
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does not sound fun for the kid... microvesicular steatosis got that drilled in my head.
 
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JP2740 said:
Yea good job lol. I was thinking of leaving some more info out and making it tougher but figured screw it. He had no vaccinations (developing). He got kawasaki->treated with aspirin->infected with VZV or influenza B->reye syndrome with MICROvesicular change (you can tell this just from the histo).
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I am unknowledgable about this, why is microvesicular change important?
 
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tiedyeddog said:
I am unknowledgable about this, why is microvesicular change important?
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I think all the other fatty liver problems may have some microvesicles but will always without a doubt have macrovesicles too so it's virtualy diagnostic. I THINK. If not that if it ever mentions microvesicular in a child then look for anything that can point to reye's
 
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