USMLE-Rx Step 1 Qmax Challenge #4045

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USMLE-Rx Step 1 Qmax Challenge #4045A 49-year-old man presents with a 3-month history of arthralgias, weight loss, diarrhea with fatty stools, and abdominal pain. After careful observation and testing, his physician obtains a biopsy of the lamina propria of the small intestine. The image shows the biopsy specimen.

What is the cause of this man’s symptoms?

A. Celiac sprue
B. Crohn disease
C. Mucosa-associated lymphoid tissue tumor
D. Ulcerative colitis
E. Whipple disease


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12 thoughts on “USMLE-Rx Step 1 Qmax Challenge #4045”

  1. D. Picture shows macrophages (foamy macrophages) in the lamina propia. It will be nice to see PAS staining.

  2. E – Whipple Disease

    Mnemonic: WAD TAMP
    W = weight loss
    A = Arthralgias
    D = Diarrhea
    T = Tropheryma whippeli
    A = Abdominal Pain
    M = Multiple system involved
    P = Periodic Acid-schiff

  3. FirstAid-RStigall

    The correct answer is E. The cause of these four common symptoms (arthralgias, weight loss, diarrhea, and abdominal pain) is Tropheryma whipplei, which can exist throughout the intestinal tract, lymphoreticular system, and central nervous system as a result of exposure to soil microbes. This is a gram-positive, non-acid-fast, periodic acid-Schiff (PAS)-positive bacillus with a recognizable trilaminar plasma membrane. Biopsy of the lamina propria shows accumulation of macrophages with brightly stained PAS-positive intracellular material.

    A is not correct. Celiac sprue is an autoimmune disorder that affects the small intestine. Patients with the disease make autoantibodies to the gluten in wheat and other grains (gliadin). Symptoms include chronic diarrhea, abdominal pain, and malabsorption. Biopsy of the small intestine in celiac sprue shows flattened villi, decreased brush border enzymes, and lymphocytic infiltration.

    B is not correct. Crohn disease is a type of inflammatory bowel disease that has intestinal complications such as chronic diarrhea, malabsorption, and abdominal pain, as well as extraintestinal symptoms such as rashes (eg, erythema nodosum), arthritis, and uveitis. Major findings of intestinal biopsy in Crohn disease include focal ulcerations as well as acute and chronic inflammation.

    C is not correct. Gastric mucosa-associated lymphoid tissue tumor (or MALToma) is a subtype of lymphoma that is frequently associated with chronic infection with Helicobacter pylori. On biopsy, dense, monotonous, lymphoid infiltrate in the lamina propria and pale-staining marginal zone B cells surrounding the epithelium are apparent.

    D is not correct. Ulcerative colitis is a type of irritable bowel disease that typically begins at the rectum (spares the anus) and spreads continuously up the colon. It can present with bloody diarrhea, abdominal pain, and extraintestinal symptoms such as arthritis. Major findings of intestinal biopsy include crypt abscesses and chronic changes including branching of the crypts, atrophy of glands, and loss of mucin in goblet cells.

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