NBME 22 Answers : Block 3 : #47 = A 10-year-old boy receives a renal transplant ...

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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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submitted by nwinkelmann(258),

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uAtce = seewk to ohmstn = argft Ag eatitsavc hsot D4C and 8CD T secll galiden ot amnapehyrlc ellc emda,ag trttsienaili iyctlhmocpy n,itiifrlnaot nda iatnie.hlisoetd /tltpbd/idtphteii/n.yms:ucKylo.tAjkRr/eoi/pM.csrmasmph

Crncohi = tnhoms ot ,eryas oihrcnc HDT y(tep IV priyt)ethsnsiieyv atinerco in veesls llaw idlnaeg ot nltimia hostmo ulmcse lelc oaentliorpfir adn eelvss ,osoucnilc wiht oibyps gswnohi rewdoarn uralavsc munel and iteexsven tomosh .uemcsl

VDGH = agrft lelcs t(mos yalyictlp beon rmroaw asrsttlp)nan ocznieger tosh slcle as sreenfloifg/ dan aeld to ruiesdcotnt of hsto tisesu ilgndea ot r,hsa ej,aiucnd erih,aard and IG mgeahehror ist(h ocucrs baecuse mots oebn owrmra pnantlatrs apisetnt have ogenuednr lluf iadrntioa hwihc akttsca eth pirlyda nvigipodr clesl msot (.i.e ,knis GI a,ucmso ,rhai sta)etceohpy so fratg ordetcntisu of soth sclel in thoes reasa elasd to typmmos)s.

mt:chc.p/tppos/tisu/.m

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submitted by niboonsh(287),

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hTis is a scea of cuate ttnalapsnr cjreno.iet sekwe to shntom tarfe eth nnlrt,aptas ertepncii d8c /arndo d4c t sclel are etciatdav asntiga eht nodro a( ypet 4 )SRH dna eth dnoro tatsrs amikgn btieoaidns aiansgt hte apartn.sntl ishT enepsrts sa a altscusivi wthi dseen realsiinttti ypoicmyclth aitref.ntsli 2F108(A pg 1)19

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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submitted by adisdiadochokinetic(61),

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Can yeaonn alnpexi hyw ibsFuor rcsas iwht salapm lecls is ont the ctrcero swrna?e

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

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submitted by mcl(517),

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egpa 191 ateF ntiPA is insptegren tmnhso rtefa het tprnanasl,t ihhcw ansem ti ca'nt be ptrchaueye elsnsu he sodtepp niaktg sih sroms.pustisemapnun uHGn/cictVroh/ecA eisedas rea ideematd by T cslle fro eht ostm ratp I( i,k)nht so siht ulwod anme phciyltymco tntesli.ifar

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

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submitted by snoochi95(1),

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

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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.