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NBME 22 Answers

nbme22/Block 3/Question#47 (35.4 difficulty score)
A 10-year-old boy receives a renal transplant ...
Lymphocytes infiltrating tubular epithelium🔍

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 +4  upvote downvote
submitted by nwinkelmann(258),
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yreaHtcpeu = itmuesn to u,rosh shto rpedmofre Ab asingta ratgf idoneahltel lelc gA = pomlnmceit v,ntcaitoai eleahotindl ,dmagea nmaanlotmiif t(wniih eht esutsi, ONT iitteu)r,isnmt intlotcg ca,dscea hicecsim rseoncsi nda tshosimbo.r t.m.noeyllttiicj/mcpAtrepksuh.sR//piacHsKdit/muyp:bhr/

eAtuc = sewek ot ntsmho = frtga gA vacaitste thso CD4 dan 8CD T lcsle ngldiae to yramanlchpe ecll egm,daa tiiersnitalt ycplihmocyt fl,rniinoitta adn

hiornCc = osmnht to ,rasey coincrh DTH pty(e IV )epvsnirsityheyit eaoctirn in leevss llwa ilgnade ot inmilat stoomh mlcseu clle froatroilneip dna selsve ccnioos,ul ihwt bposiy wisgnho darnwore lrvcauas unlem dan sevxtenei sothmo ecm.lsu

HDGV = frgat elcls tos(m lyycpalit oebn owmarr anttasnrsl)p ineegzcro tsoh lcles as enirose/lffg nad ldea to tuerstncodi fo ohst euists adelnig ot ,asrh aie,ucjnd ahriadr,e dan GI hmoaehregr st(ih scourc ebsuace sotm ebon roawrm ntpstnlraa nteistap avhe neudrnego ulfl naotairid hhicw ktaacst eht apdylri dogniipvr llesc otsm e.i.( is,kn GI sacoum, ah,ri s)phattoeyec os frgat tuesrcnotdi fo hsto celsl ni teohs aares sleda to syotm)


 +2  upvote downvote
submitted by niboonsh(287),
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hTis is a scae fo ceuta tanlrnsatp ctrj.ieone ekwse to mhsnot aefrt eht raasltpnt,n ntiprieec cd8 ord/an 4dc t lsecl rae ittadvcae tnsagai the ordon a( pyet 4 S)HR nda teh rdoon tasrts aknmig edoiabntis asiatgn het pralnatnst. iTsh seesntrp sa a islusavcit wiht nseed iainilsttrte tymccoyhlip arifti.nelst F2A8(01 gp 11)9

ls3076  Actually was confused about this due to a UW explanation. UW said acute txp rejection has two types - humoral and humoral and cellular. Humoral has Neutrophilic infiltrate + necrotizing vasculitis while cellular has lymphocytosis. Can anyone simplify/explain this please? +2  
apurva  We usually look for c4d complement for humoral response in acute graft rejection. Because c4d makes covalent bond with the endothelium can can be found on staining because it is long lasting. +  

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anC eannyo xaelipn why uibFosr sacsr thwi pslmaa lcles is ont the ercrtoc swrena?

osler_weber_rendu  Exactly. Three months can fall under chronic rejection as well. FA pg 119 states "interstitial fibrosis". Chronic rejection is predominantly Bcell mediated (plasma cells). +  
beto  chornic rejection > 6 month acute < 6 month +2  
beto  also there are no B cells in the site of fibrosis. humoral response due to antibody themself,not by direct B cells response +2  

 +0  upvote downvote
submitted by mcl(517),
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aepg 191 aetF itPnA is nisergeptn shtonm refta eth patnr,nslat iwhch msean it nc'ta eb hepayrecut lseusn he psteopd antgki his trasmpumue.osnipnss Gci/ecntuhocArHV/ dseaise rae etmdedai yb T elscl orf eth mtso ratp I( i)kn,th so isth wuold emna iopcythmylc erttifasin.l

usmleuser007  It is very unlikely to be GVH disease b/c it's more common if the host is suppressed as in if host had ablated bone marrow. (FA states that it's more common with bone marrow & liver transplants) +1  
usmleuser007  any one care to explain why fibrous scars with plasma cells not a good option?... +2  

Does anyone know why this is not Chronic rejection? They both fit within the time frame.

 +0  upvote downvote
submitted by lowyield(11),

I think the three most reasonable answers can be put into the different boxes of rejection

Glomerular neutrophils and necrosis->hyperacute (? I usually just think neutrophils are the earlier onset things)

Lymphocytes infiltrating tubular epithelium-> Acute [<6 mo]

Fibrous scars and plasma cells ->these two key words seem more like chronic etiologies (this extends beyond graft rejection)

My best guess at the other options are:

Arteriolar C3 deposition- some sort of nephritic syndrome, whether it's SLE, PSGN etc.

Dilation of Bowman's space-post-renal obstruction

RBC casts- nephritic something something, basically it's glomerular rather than interstitial bleeding

Subcortical necrosis- diffuse cortical necrosis caused by obstetric catastrophes/septic shock/DIC etc.