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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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 +2  upvote downvote
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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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  

 +0  upvote downvote
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  

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.