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Retired NBME 21 Answers

nbme21/Block 4/Question#2 (reveal difficulty score)
A 23-year-old woman comes to the student ...
Obliterative endarteritis with lymphocytes and plasma cells ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
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 +18  upvote downvote
submitted by โˆ—wasabilateral(47)
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Syphilis pathogenesis is the inflammation and obliteration of the vasa vasorum (small blood vessels) that feeds bigger blood vessels like aorta, arteries, arterioles. It does not matter what the stage is, T. pallidum infects the vasa vasorum and, in the process, obliterates the nerves and blood vessels. This kills blood supply to those areas = ischemia but no pain (painless chancre). More localized in earlier stages, and in later stage, the spirochetes disseminate, so you have the aorta and spinal cord involvement but same pathogenesis. (Edit: Goljan explained this somewhere.)

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privatejoker  So is the heavily implied step-wise formation of Syphilis symptoms as presented in FA complete BS then? Why break it down into stages and have us learn it as such if this is not the case in real practice? +5
lilmonkey  Exactly, Goljan mentioned this in one of his audio lectures. All kinds of lesions in syphilis caused by vasculitis. +3
lovebug  I know it's silly question. but Could anyone give an why answer is lymphocyte and plasma cell not neutorphiles.? bc syphilis is a bacteria, not virus. +1
trazobone  @lovebug my guess is bc its a spirochete, so it doesnโ€™t act like a normal bacteria. One of the screening test for syphilis is FTA Abs, so a proliferation in plasma cells makes sense. Then by deduction, if its able to affect plasma cells, it can do the same with lymphocytes. But this is me trying to logic everything together so. +1
jatsyuk38  May be worth noting that necrotizing granulomas can be found in the gummas of tertiary syphillis. Doesnt change the correct choice as onset was only 2 weeks +
unknown001  lol, i just love trazobone's comment. he's a smart dude +



 +10  upvote downvote
submitted by โˆ—liltr(25)
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It is syphilis. Syphilis is an endarteritis! :)

โ€œThe pathologic changes associated with syphilis are characterized by obliterative endarteritis that is found in all stages of the disease.โ€
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811633/

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 +1  upvote downvote
submitted by โˆ—oznefu(22)
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Could anyone give an example of what diseases would best match the other answer choices?

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vonhippelindau  Leprosy is a noncaseating granuloma fyi. I found that granuloma with suppuration can be caused by blastomycosis according to Robbins (pg 710): โ€œIn the normal host, the lung lesions of blastomycosis are suppurative granulomas. Macrophages have a limited ability to ingest and kill B. dermatitidis, and the persistence of the yeast cells leads to continued recruitment of neutrophils. In tissue, B. dermatitidis is a round, 5- to 15-ฮผm yeast cell that divides by broad-based budding. It has a thick, double-contoured cell wall, and visible nuclei (Fig. 15-38). Involvement of the skin and larynx is associated with marked epithelial hyperplasia, which may be mistaken for squamous cell carcinoma.โ€ +7
usmleuser007  Pyogranulomatous Inflammation An inflammatory process in which there is infiltration of polymorphonuclear cells into a more chronic area of inflammation characterized by mononuclear cells, macrophages, lymphocytes and possibly plasma cells. Actinomyces sp. is gram-positive, acid-fastโ€“negative filamentous bacteria that cause pyogranulomatous infections in dogs, cats, cattle, goats, swine, horses, foxes and human beings. +2



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