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NBME 22 Answers

nbme22/Block 4/Question#15 (61.4 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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isTh oen wsa a titell cryk.ti For ihst eon eth kye si het wlo iaiooinddre .uaeptk iTsh itpntea hsa hhgi 4T adn low HTS whihc mseka ssene ni a pyhdtyhieorr t,nieatp rpspaeh ruyo tirfs hgotthu is tath shti nptetai sha Ga’resv a.edisse rHwevo,e in r’sGaev yoru dyritho si bengi litduastem ot mkea reom rohtdyi ehomorn rfom cartcsh dna sa usch udolw eavh na iecdsaern diaonidiroe ekpatu sceubea the ythdiro si grigbinn in hte qreeirdu nwo( ael)daeiordbl .nidieo This si wyh ti is not vseGar rl(“saeee fo ydtrhio orenmoh frmo a iyrdhto sitdlmetua yb .d)aiitbneo”s

So if sti ton vsGer’a whta doucl ti be? rFo sthi ’dyou ehav to kwno ttha oohtHmiass’ shTdrotiiyi (alos owknn as hrocCin hcyimoyptcL odThsyritii dan si fnteo efrerrde ot sa shcu no oabdr aesxm ot hwort you ff)o ahs rthee hspaes - trfis yhte aer dpirretyhh,oy tenh id,erotyhu nhte hte aslicsc hhodryipyot hatt ouy lowud exeptc hiwt low T4 nda gihh H.ST ishT saw het yke ot siht n.esqotiu eTh raesno orf thsi si atth ritayntohdi opseiadexr tnsdioaebi ni sHmsthoio’a uasce eth dhyiotr to leasere lal of tsi rtosed dihyotr norhmeo aikmng the pneatit hirdyeythrpo rfo a otsrh epdrio of m.tie tAref shit amsevsi lersaee of ytdoirh onom,reh het dnoiaietsb akem temh lneabu ot make ewn TH dan hfretereo hety moeceb yeitudhro rof a sohrt operdi nad then iythdpyrooh hiwhc you ldwou xe!tecp Sicen tyhe nta’c amke wne H,T the hdotiry lwli ont ekat pu eth dnoeiariodi nda ftrerheoe ehetr lliw eb wlo iieiradndoo kuatp.e He,cne eaele“rs fo dsreot htordiy ohomern ofmr a idrohty alngd irateintlfd by ph”omyelys.tc aak ytccoymphL“i sh(oh)asitmo sihidoi”.ttyr

I khitn eeerl“sa fo oiryhtd hoormne ormf a hsylotupmmao dihrtyo dan”gl si refgrnrei to smeo dikn of tydhiro ncaecr ni chwih ecas uyo lduow xectep emth to eb rngicsebid a odeunl on noidiroeadi .tuapek

mrumaSy​ oveid eher and aols a rgaet iste in egaerl:n e/nioooq/.rpgnpddsaerheh/lmtdrcnteut/nicaye/doi:ries/

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 +11  
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(1074),
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iThs is a ittneap asce fo spaormtupt .trydotihsii naC ireas up ot a reya tefar dleiyvre dna ash coiycyhmplt r.lietnafti

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(292),
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heT iopantexlna yb nygrieidlvitre slup eht ieoaalntxpn in hte rtelaci toedsp eolbw (m/6pM/9nvwostnP//nes8c9.w9.trt4h./wbchil4g:lpmciiC/.a) aer eth seb,t ujts dene to eb bcmndeoi .:) hTe artideeliffn dianossig lbeat 1 (cc9p/Pbs//ybtnr..4oc8Oe0S.9nwc0iob9thtnMtTvmwl=s1-/-ga/1iretpelMBLh:e1/-r/6l0mliwjao4p?/.4oCnt) cspilfyeacli ifdinseiet hte itndincoo in hits suqtnioe sa pamrptstou hsiirttyo.id

Ul,mttleiya if ouy onwk that yrhtioomdpihsy sha a nrttiaesn rehdiriphytsyom ahpes ue(d to muamotinue rcuteisodnt fo teh sllce wchih deyaral dah eompferrd TH nda os ti asw adrsleee npou n)rttsiducoe eefbro iidypsothyhmor onf(nitognunnic esllc so nt'ca ekat up )eodiin adn thta dootrypihhsyim is a cmctoiyhylp fglrnitatiin oytdsriiti,h uyo lwil onwk eth awnse.r I had a rhda emti uienntdgdansr htis ta irtsf cueaebs we ngela/oatadeseivu aesdb on het senpceer fo OTtPna-i ,Ab but hte ndrlguneiy ieseghspanto fo the ohidrty nsietrtudco si cm-eileledtad (etyp IV tnrtiy)vhyispseie nto bA teidemda peyt( II iytrvihyssi)pente kiel g.rsaev shHa'sitmoo = ocytyplmchi oarfninlitti iwth nrgealim ncrsete wic(hh nca fatrnomrs to B lcle opammlyh) ihtw lehtuhr llcse keri(pn oytclpmas escl)l.




 +1 
submitted by niboonsh(355),
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nCa meoneos pliaenx the eceinrffed eeenwtb .C esealr(e of esdtor hoytidr orhnemo frmo a diotyrh dngla tedilitarfn by clypem)hsoty adn D. (eaeesRl fo iroyhdt ohernom mfor a haoptuyslmmo yidtrho dna.lg

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(1539),
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tl.c/p6ao/9b4png/imh94cCsc8n/rwtet.vsnwm:.hM/iiw9/Pl.

gcnocrdiA to itsh rpa,pe oaupmrsPtt iodrtsiiyhT renesstp with tniT-OPa netiaosdib. heT rsanwe eohcic suse cyolhtye.spm oS siht is a insrantte oashsoimHt pi.rtdiyeoshryHm odoG kucL ithw taht neo!

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



 +0 
submitted by hyperfukus(76),
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I tikhn atth cesni etey'rh gskian for an opaanexilnt fo teh ie'tntsap cuetnrr SxS chwih hwsso hatt 'hess in the aetts fo ensirnTat ypiti:rmyroesHhd hciwh si eud ot :C eesaeRl fo tedrso otidrhy ermohno ofrm a orhdyti nlgad dfitelrinta yb yhymlptoecs