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NBME 22 Answers

nbme22/Block 4/Question#15 (62.6 difficulty score)
A 24-year-old woman, gravida 1, para 1, comes ...
Release of stored thyroid hormone from a thyroid gland infiltrated by lymphocytes🔍,📺
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 +35 
submitted by liverdietrying(101),
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This oen aws a etlitl r.iktyc orF hist one the key is the olw roiiandeoid ue.patk hsTi tpietna ahs high T4 dan low TSH hhwci asekm neses ni a irdheoytpryh ttiae,np rsehppa uyor tisfr httguho si ttha siht anttpei ash ’vaseGr a.isedse eorve,wH in rsG’aev uryo idyrtho is nebgi atlmtdiuse to amek rmeo drhyiot orhneom mfro asrchtc adn as ucsh dwolu vahe na cerdeains indirioaode eakupt caeeubs eht oirtyhd is bgrnigni ni eth reqrideu nw(o dlealoebrid)a .noeiid Tshi is yhw ti si not Grvase s“ee(rlea of oritdhy oerhonm from a yidrtoh dmauttelis yb tn.eib)dsoi”a

oS fi its not r’Gesav hwat ocdul ti eb? roF tihs ’oduy aehv ot wnok taht sshHoam’iot Ttsidirhyoi los(a known as ocrCihn typLcmoiych rithyTsiiod and si otnef rrrdefee ot sa cshu on robda esmax ot ohwrt you )ffo ash ethre sphesa - trfis eyth rea heyd,htioyprr neth ehyro,uidt hten hte scliasc hyoiyptdorh ttha uoy odulw eecpxt tiwh lwo 4T and ighh TSH. Thsi wsa eht eky to hsit si.euqotn eTh aoenrs orf this is thta initatordhy aspreeoxid stbiadneio in ait’sohosmH uesac teh hdtoiyr ot rlaeese lla of its trosde tdhoriy omnerho imgkna het taienpt orpehryyhtid fro a rhtos idpreo fo mi.te terfA htis mveisas seeaerl of ohtydri honrmo,e teh teisbdoian akme htem eunbla ot maek ewn HT nad heeoftrre htey cmebeo uroeyhdti rof a tohsr dpoier nda then hyrihdpyoto hhicw yuo udwol !xtpcee ciSen hyet ’antc eakm nwe ,TH the ridhyot lwli tno etak up teh aodrdniieoi nad roefterhe heert ilwl be olw aodioiidner e.pukat ecen,H saerl“ee of otersd todiyhr honmroe frmo a iyrohtd gnadl tinderalfti yb ehtmsyo.lycp” aka ihyymcpotc“L it(somshoa)h .dsiyhttio”ri

I tkihn rael“ees fo irdtoyh nheroom fmor a uoomtmalshyp hritdyo ”ndlag is erngefrri ot emso inkd fo hyidrot accrne in hhwci ceas you wdoul xcpeet etmh ot eb igrcindesb a udoenl on aeoiniriodd utpka.e

mau​rmSy iodve erhe and alos a trega eits in glnrae:e e/i:moqdiercoayc.nh/rt/updtngltrepediehreia/sndo/on/s

aesalmon  pg 338 of FA lists it under hypothyroidism but it does present as transient hyperthyroidism first +9  
hyperfukus  yep that was the key! Goiter is "HOT" but the remaining answer choices were still kind of bleh D was distracting the hell out of me i spent so long to convince myself to pick C and move on +3  
hello  Pasting nwinkelmann's comment as an addition: Choice "D" is wrong b/c "lymphomatous thyroid gland" = primary thyroid lymphoma (typically NHL, which is very rare) or Hashimoto's thyroid progression. Hashimoto's thyroiditis = lymphocytic infiltrate with germinal B cells and Hurthle cells, which upon continued stimulation, can lead to mutation/malignant transformation to B cell lymphoma. Both of these present with hypothyroidism with low T4 and high TSH (opposite of this patient). +1  
taediggity  I absolutely love your @liverdietrying, however the pathogenesis of postpartum thyroiditis is similar to Hashimoto's, so I think this person has postpartum thyroiditis and your explanation of transient thyrotoxicosis is spot on, which would also occur in postpartum thyroiditis +12  
pg32  I agree with @taediggity. Also note that women eventually recover from postpartum thyroiditis and typically become euthyroid again, which doesn't happen with Hashimoto's. +  
vulcania  In FA (2019 p. 338) it says that thyroid is usually normal size in postpartum thyroiditis, but the patient in this question had a thyroid "twice the normal size." I guess at the end of the day it doesn't matter which diagnosis is right for this question cause they both seem to lead to the same correct answer :) +2  



 +22 
submitted by hayayah(1081),
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sTih si a tiapten easc fo pmstpotrau tsdtih.ioiry Cna reais pu to a yare refta liydreve nda sha lyhocmyctip fieilnat.rt

almondbreeze  FA 2019 pg 338 +1  
waterloo  Although history seems to point towards that, she has an enlarged thyroid, and in postpartum thyroiditis, thyroid usually normal in size (from FA). regardless either would have lymphocytes infiltrating. +  



 +3 
submitted by nwinkelmann(297),
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eTh eatxoainnpl by edlntireyvirig sulp eht aeinoptnlax in the ctrleia pdoset obwle (ripl//4w/9c6ts.98/lhtt9:cgmebnPm4i/ah.wp.nMos/nc.iwCv) aer hte tb,se tujs ende ot be odcbemin :.) ehT artfleiiefnd gisinasod alebt 1 (0Schb/1.ancPpo64l/4-onrvwp.LM.he=o9j9-rl1cO?sl:8t0/et/cp9eCw.-iribsBbti/anmo10ltMTt/tewg/nm4/y) ileisfccpaly ftndsiieei eth idooncnit ni tish tounsqie sa stptmaporu irtyho.idist

eyati,mUtll fi ouy owkn taht rhtsiohmdiopyy hsa a tesnntria emdhpohisrryiyt eahps (ued ot onmuuaiemt dsicoutnert of het sclel hchwi edarlay dah dfprormee HT dan so it was rsdleaee nuop nietdsucort) ereobf tpisohymhdryoi inngitnnocf(nuo eslcl so an'tc teka pu )doinei dan thta yydsihthmopior si a hcimcolpyyt rtanlifitign yoiisttd,hir ouy ilwl okwn hte wnaesr. I hda a dhar ietm ngntirdenudas hits ta isrtf bueasce ew eadaevngt/osiueal saedb no eth cnseeepr fo PnOati-T ,Ab utb the rleugninyd htssoaegnipe fo eht tordhiy sdtrnocutei is ecldleti-emad eytp( IV sisviryiype)thent not bA deeatdmi pt(ey II ti)enriptyhyiesvs lkei rega.vs ihmo'satosH = icmyphlcoyt toiilifnrtan ithw rmnigeal sceertn hci(wh nca mnaotrrsf to B lelc oyplm)amh twhi hhtrule llsce pkern(i syaoptlmc .c)lsel




 +1 
submitted by niboonsh(360),
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aCn eosmeon lenxpia eth nfereficde eeenbtw C. eesle(ra of etrdos rdthiyo renohmo ofmr a idhryto anlgd tartfndiiel yb l)mpytehsyoc dna D. eRseeal( fo ityrhod mrnohoe morf a muhymtooalsp hoydtir dnga.l

drdoom  @niboonsh, ending a comment with a question mark will make it appear on the "comments seeking answers" lists +4  
nwinkelmann  A lymphomatous thyroid gland can either be due to primary thyroid lymphoma (which is almost always NHL, but is very rare) or due to Hashimoto's thyroid progression. Hashimoto's thyroiditis = lymphocytic infiltrate with germinal B cells and Hurthle cells, which upon continued stimulation, can lead to mutation/malignant transformation to B cell lymphoma. These, I believe, would still present with hypothyroidism, and thus would have low T4 and high TSH (opposite of this patient). +1  



 +0 
submitted by seagull(1583),
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/cgnnnshw9s.8wic:p9/.ttpwm4mi46PMhlv.r/o/t/Cebc/.il9a

cgnoArdci to tish aprpe, utPtprasom iToshidriyt ertspnes twhi -aTtOPin oba.sidneit Teh neraws ccieoh suse eysptlomcyh. So shti si a enritnats ihtmsHoaso rtyrmhyHdoiispe. ooGd kLcu ihtw atht eo!n

seagull  EDIT: Lymphocytes are also present in this as well. My bad +1  



 +0 
submitted by hyperfukus(79),
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I itnkh ttha eicsn reyeh't ksagni rof na enonixptlaa of eht pesint'ta ncetrur SxS cwhih shosw htta esh's in het tetsa fo aetTsnrin yHeystordr:hmpii wchih is ued ot C: eeRlsae of otedsr idytohr emonorh rfmo a htrodyi andgl rtlfinaitde by mylphcoetys