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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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hsiT one saw a tllite y.cirtk Fro tihs eon het yke si eht low iiiddoonrea taue.kp hTsi epttain ash hihg 4T dna wlo THS hwhci skmea nsees in a trryyoihdphe na,pitte aphresp yruo ftisr htohugt si that isht pteinta sha arseG’v dsae.eis wevrH,eo in asverG’ uyor idhrtoy si genib tsimdeuatl to amke mero ohyditr oheomrn ormf hcstacr adn sa suhc doulw avhe an ariesnced inoiroeiadd eaukpt eecbusa teh ditryoh is igbrgnni in eth rdeqeuri now( radboel)laeid eiidno. Thsi is wyh ti si ton avGers re“ela(se fo rihdoyt monerho ormf a iohtryd uestitdmla yb tabin”iedo.s)

So fi sit nto r’eavGs athw oducl it be? For ihst yudo’ avhe ot nkow htat smaitHo’sho hyirTidiots la(os kownn as cohnCri yyphccLtimo ydihtirTsio nad si fetno erredefr ot sa hcus on brado masxe to throw you ff)o ash rtehe asesph - tisfr htye era do,hpirheyyrt hten derh,tuoiy nthe eht lcaicss hoyoridpyht atht uyo wdoul ecpxet htwi wlo 4T nad hghi .HST hisT swa eht eky ot sthi iqetsun.o hTe oersan orf tshi si htta oyathditrni opsxiaeedr tadeiisbno ni aHshtio’mso saeuc hte tyrhiod ot ereasle lal fo sit edotrs ityrdho nehomro mgiakn hte ptnatie odheiyryphtr rof a tshro iedorp of meit. fetrA tshi sivmesa aeeselr of yihtdro rmeh,noo the tnaiedobis amke ehmt uaebln to kaem new TH adn oertreefh ethy obmece iydhreuot orf a osrht pirdeo nda then oiodprhhyyt cihhw uoy uwdol !tcepex Secni yeth ta’nc maek new ,HT eth hyitord lwil nto aket up het iddaoeoinir nda trefeeohr reteh iwll be wol rneidaoidoi te.aupk H,ence “aseeerl of stredo doirhty ormhneo omfr a ytrhido ldang fnrdititale by yylpmehsot.c” aak pmcohL“yityc i)osh(stahom tiyihsotr.d”i

I knthi “seeeral of rydioht nrooehm mofr a ltsuhooaymmp dhtoiry dl”agn is ernigferr ot semo dink fo otyidrh acrcne ni hwich easc oyu wloud xpecte hmet ot be bgicnsride a ounlde on riioeidonad pukea.t

yau​rSmm viedo rhee dan soal a gtrae iets in :ergelan aqiomo/ptrceid/e/rnntodehruh/dielyancips/gnt/ere.ods:

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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iTsh is a eiaptnt case of ortaptmups isiyth.rtdio Cna aires up to a raye eftra lieedryv dan sah himctolyypc ltni.rifate

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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hTe noxtnpaaeil yb retyireignldvi splu hte naxielopatn in het clteiar petods wlebo (ln4r9l.ca/i.hPChwcbwt4sMiim./vgmpw6cn/9/9n/e:t/t.po8s) rea hte ,esbt juts ende ot be idcebnom .:) ehT ftelaefrdnii dagosisni blate 1 (/b/t-1/ah/nwyssei/bo.ntl-/icLtwa/9S.44ecem1B1c/Tpr-liPlthwg0=.vjm:9nMCcbeponrM8.40tl6r?t9po0oO) yepsclicifla isfenedtii eht ootidcnin in ihts qneitous sa utppmtrsao oitd.ihtsiry

ylUtatiem,l fi you nowk ttha oyphtymidroshi ahs a sirttnane shreidrmpoyhiyt sheap eu(d to muontumaie surticndeto fo het eclls ihcwh lyraade dha dporefemr HT nad os ti wsa eleaersd puno d)ortcsentiu ebefro dyitmhhsporiyo nnguoiintcnof(n escll so 'catn aket pu eiin)do dna ttah hsphtiyyoormid is a lcihoyyctmp rnigaftlitni i,itohyrdist yuo will nokw teh arwen.s I ahd a rhad meit itrnedangsnud htsi at frtsi bascuee ew eeldvaniastuo/ega dsabe on eth seenercp of PTt-naiO b,A but the ldgnnreuyi toeihnsaspeg of teh dhtoyri euctoridtns is -atelledeimdc pye(t VI ivsieyt)penirsyth nto bA mddiaeet (epty II y)iseseitriyvthpn klie av.ersg sts'oaohimH = yoylhmctpic niifialotrtn ihwt lnmiager cersten cw(hhi nca rfnasortm ot B lcle h)oapmmyl twih lrtheuh lelcs e(rknip pyltomasc lles)c.




 +1 
submitted by niboonsh(360),
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Cna ooensem npixlae het ediefnrecf tebneew C. ls(eaere of odrets thioydr horneom form a rytohid gadnl dttriainfel yb lcsho)epyytm adn D. esR(elea fo rdyhoti hemroon orfm a oymhatsupmlo toihyrd land.g

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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8C4t/Pmih6mo/499l/vrsswM9iap/p../tgiwcl.wnbc/hecn:.tn

cgrndAcio ot shit r,ppea tsoaurtmPp Ttsidyihior tsersenp htiw O-PnTati ideitasbno. Teh enawsr hecioc uess lstcyoyme.hp oS shti si a ttainsrne saohmstHoi Hiemysotyr.iprdh odoG kcLu with thta en!o

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



 +0 
submitted by hyperfukus(79),
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I thkin thta escni h'retye kansig rfo na anoexpiantl fo eht s'ptniate nrutrce SSx hwhic ohwss ttha hs'es ni eth tesat of resTtnnia ihrs:teHmioryydp hwchi is eud to :C alReees of rdotse hitydor hooremn fomr a trohidy lndag nirtdtfliae yb htolypseycm