Bone And Arthritis - Pt.5

Explanation
http://upload.wikimedia.org/wikipedia/commons/3/30/Paget_Disese_of_the_Nipple.jpg
Paget's disease of the breast (also known as Paget's disease of the nipple [1]) is a malignant condition that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. The condition occurs when Paget's cells, which are large and irregular, form in the skin of the nipple. Although Paget believed the cells were not cancerous, it was later proved that the cells were themselves malignant, in addition to indicating another underlying breast cancer.[2] Since the condition in itself is often innocuous and limited to a surface appearance, it is sometimes dismissed, although actually indicative of a very serious underlying condition, breast cancer Paget's disease's symptoms may vary based on the stage of the disease. However, the main symptoms that can occur in Paget's disease include flaky or scaly skin on the nipple, straw-colored or bloody nipple discharge, skin and nipple changes in only one breast or the flattened nipples. Patients may also experience crusty, oozing or hardened skin resembling eczema, on the nipple, areola or both and fluctuating skin changes early on, making it appear as if the skin is healing on its own. Some patients complain of burning sensations on the nipples or breasts. These symptoms usually occur in more advanced stages, when serious destruction of the skin often prompts the patient to consult. Lumps or masses in the breast occur in 50% of the patients.[5] In more advanced stages, the disease may cause tingling, increased sensitivity and pain.[6] The first symptom is usually an eczema-like rash, usually only affecting one nipple. The skin of the nipple and areola may be red, itchy and inflamed. Some women have an itching or burning sensation. Fluid (discharge) may leak from the abnormal area of cells. The nipple may turn inwards (be inverted). There may or may not be a lump in the breast, and there may be redness, oozing and crusting, and a sore that does not heal. The symptoms usually affect the nipple and then spread to the areola and then the breast. It is common for the symptoms to disappear for a while, which may make the patient think incorrectly that the condition has cleared up spontaneously. Most women do not visit the doctor because they take Paget's disease to be minor contact dermatitis or eczema. A lump or skin irritation that does not seem to heal for over a month indicates that attention by a specialist is needed.

Explanation
Lobular breast carcinoma is commonly bilateral, meaning it often affects both breasts. This is in contrast to other types of breast cancer, which typically occur in only one breast.

Explanation
Warthins tumor of the salivary gland is a benign tumor that commonly occurs in the parotid gland. It is characterized by the presence of lymphoid tissue, which is a key histological feature of this type of tumor. The tumor is composed of a mixture of lymphoid tissue and epithelial cells, and it typically forms cystic spaces. Although the tumor may exhibit some features that can be mistaken for malignancy, such as squamous differentiation and invasive characteristics, it is ultimately a benign tumor with lymphoid tissue being the most prominent feature.

Explanation
The correct answer is "often contains cholesterol 'clefts'". This is because the description of the mass in the middle ear consisting of keratinous debris, granulation tissue, and foreign-body giant cells is characteristic of a cholesteatoma. Cholesteatomas are non-malignant growths that can occur in the middle ear and mastoid region. They often contain cholesterol clefts, which are areas of cholesterol crystals surrounded by foreign-body giant cells. Cholesteatomas are typically treated with surgical removal, as antibiotics alone are not effective in curing them. They can be unilateral or bilateral.

Explanation
Infection of the nasopharynx with Epstein-Barr virus has been associated with the development of undifferentiated squamous carcinoma. Epstein-Barr virus is a known causative agent for various types of cancers, including nasopharyngeal carcinoma. This type of carcinoma is characterized by the presence of undifferentiated squamous cells. The virus can cause genetic alterations and promote the growth of abnormal cells, leading to the development of cancer. Therefore, the association between Epstein-Barr virus infection and undifferentiated squamous carcinoma is well-established.

Explanation
The histologic examination findings of terminal lobules distended by relatively small neoplastic cells infiltrating the stroma in an "Indian file" pattern are characteristic of invasive lobular carcinoma. This type of breast cancer starts in the lobules and has the ability to spread to surrounding tissues. Invasive lobular carcinoma is different from in situ lobular carcinoma, which is confined to the lobules without invasion of the surrounding tissues. Invasive ductal carcinoma is the most common type of breast cancer, but the histologic findings described in the question are not consistent with this diagnosis. Paget's disease refers to a type of breast cancer that involves the nipple and areola, which is not described in the question.

Explanation
The correct answer is Laryngeal nodule. Laryngeal nodules are small benign growths that develop on the vocal cords due to vocal strain and overuse. The symptoms typically include hoarseness, a rough or raspy voice, and vocal fatigue. In this case, the opera singer's active participation in Wagnerian opera, which requires intense vocal projection and strain, suggests that the coarsening of her voice is likely due to the development of laryngeal nodules.

Explanation
Nasal polyps resulting from recurrent bouts of allergic rhinitis are essentially edematous, polypoid mucosa. This means that they are composed of swollen, inflamed tissue that forms polyp-like growths in the nasal cavity. These polyps are not usually malignant, do not demonstrate an inverted growth pattern, and are not strongly associated with the Epstein Barr virus. They can cause symptoms such as nasal congestion, runny nose, and decreased sense of smell.

Explanation
The patient's symptoms of exophthalmos, heat intolerance, palpitations, weight loss, and pretibial myxedema are consistent with Graves disease. Graves disease is an autoimmune disorder that causes the thyroid gland to produce excessive amounts of thyroid hormone. The diffusely enlarged thyroid gland and increased uptake of radioactive iodine throughout the entire gland seen on the scintillation scan further support the diagnosis of Graves disease. Hashimoto's thyroiditis is characterized by hypothyroidism and would not present with the symptoms of hyperthyroidism seen in this patient. Toxic multinodular goiter, toxic adenoma, and subacute thyroiditis would also not present with all of the symptoms described.

Explanation
The correct answer is serum insulin-like growth factor 1 (IGF 1) level. This patient's symptoms of increased hat size, shoe size, and inability to wear his wedding ring, along with his elevated blood pressure and fasting glucose, suggest a diagnosis of acromegaly. Acromegaly is caused by excessive production of growth hormone (GH) by the pituitary gland, leading to increased production of IGF-1. Measuring serum IGF-1 levels is the most reliable test to confirm the diagnosis of acromegaly.

Explanation
The patient's presentation of hypercalcemia, multiple gastric ulcers, galactorrhea, and amenorrhea, along with increased levels of PTH, gastrin, and prolactin, is consistent with Multiple Endocrine Neoplasia Type 1 (MEN I). MEN I is an autosomal dominant disorder characterized by the development of tumors in multiple endocrine glands, including the parathyroid, pancreas, and pituitary. This disorder is commonly caused by a mutation involving the RET protooncogene. Therefore, the most likely explanation for this patient's symptoms is MEN I.

Explanation
The patient's presentation is consistent with Cushing's syndrome, characterized by truncal obesity, moon facies, buffalo hump, abdominal striae, hyperglycemia, and hypertension. The increased urine free cortisol level and decreased serum ACTH level suggest an adrenal cause of Cushing's syndrome. Additionally, the lack of cortisol suppression after administration of dexamethasone indicates autonomous cortisol production, further supporting an adrenal etiology. Among the options given, an adrenal cortical carcinoma is the most likely cause of these findings.

Explanation
A large nonfunctioning pituitary adenoma that compresses the pituitary stalk can disrupt the normal secretion of hormones from the anterior pituitary gland. This disruption can lead to hyperprolactinemia, which is characterized by elevated levels of prolactin hormone. One of the common manifestations of hyperprolactinemia is galactorrhea, which is the spontaneous flow of milk from the breasts unrelated to breastfeeding. Therefore, a 30-year-old female with a large nonfunctioning pituitary adenoma that compresses the pituitary stalk is most likely to have galactorrhea.

Explanation
The patient presented with signs of tetany, short stature, round facies, hypocalcemia, hyperphosphatemia, elevated serum parathormone levels, normal BUN and creatinine, and skeletal abnormalities. These findings are consistent with pseudohypoparathyroidism, type 1 (Albright hereditary osteodystrophy). This condition is characterized by resistance to the action of parathyroid hormone, resulting in hypocalcemia and hyperphosphatemia. The skeletal abnormalities, such as shortening of the metacarpal bones, are also characteristic of this condition. Vitamin D levels were within normal limits and calcium intake was adequate, ruling out other causes of hypocalcemia.