At autopsy, the kidneys of a 44-year-old woman who died suddenly are found to be of normal size. Their surfaces appear finely granular. There are small hemorrhages noted. The cortices appear pale. Microscopically, many small renal arteries and arterioles demonstrate concentric intimal thickening with marked luminal narrowing. These findings are most likely to be present as a result of which of the following underlying diseases?
(C) CORRECT. Hyperplastic arteriolosclerosis is typically seen with severe hypertension, which can occur with progressive systemic sclerosis (scleroderma).
(A) Incorrect. Amyloid deposits can be seen in small arteries and glomeruli in the kidney, but do not produce a hyperplastic arteriolosclerosis.
(B) Incorrect. Lupus nephritis may be accompanied by a vasculitis, but not hyperplastic arteriolosclerosis.
(D) Incorrect. There are no prominent vascular changes with rheumatoid arthritis.
(E) Incorrect. Cryoglobulinemic vasculitis may complicate some cases of hepatitis B or C infection. In general viral infections do not involve the vasculature.
(F) Incorrect. Diabetes mellitus leads to accelerated atherosclerosis of medium to large arteries. There may also be hyaline arteriolosclerosis, but not hyperplastic arteriolosclerosis.
A 35-year-old previously healthy woman notes that she has bruises form on her arms and legs with just minor trauma. Physical examination reveals areas of purpura from 1 to 3 cm in size over her trunk and extremities, but no swelling, warmth, or erythema. Peripheral pulses are all palpable and full. Her blood pressure is 110/70 mm Hg. An ultrasound examination of her lower extremities with Doppler flow measurement reveals no evidence for thrombosis. Laboratory findings include serum urea nitrogen of 20 mg/dL, LDH 300 U/L, total protein 6.9 g/dL, albumin 5.3 g/dL, alkaline phosphatase 50 U/L, AST 40 U/L, and ALT 20 U/L. Which of the following additional laboratory findings is most likely to be present in this patient?
(D) CORRECT. The platelets are responsible for dealing with small leaks in vessels. Thrombocytopenia is marked by petechiae and purpura. She does not have evidence for peripheral vascular disease, since her circulation is good. Venous thrombosis should lead to swelling and tenderness.
(E) Incorrect. She has no evidence for liver disease, which would reduce prothrombin production. The pattern of her bleeding fits best with lack of platelets, not coagulation factors.
(A) Incorrect. Diabetes mellitus is a disease marked by hyperglycemia that leads to early and advanced atherosclerosis with peripheral vascular disease.
(C) Incorrect. Poor tissue perfusion leads to increased anaerobic glycolysis and lactic acidosis.
(B) Incorrect. Patients with hypercholesterolemia are at increased risk for accelerated atherosclerosis and peripheral vascular disease.
Grandma falls down the steps leading to the entrance of the house of a relative hosting a family reunion, who is heard to remark, "I've been meaning to get that loose step fixed." Grandma is hospitalized for surgery to replace the broken hip she sustains and is then moved to a nursing home, but she is unable to ambulate until about a month later, when she dies suddenly. Which of the following is most likely to be the immediate cause of death found at autopsy?
C. Pulmonary embolism
(C) CORRECT. Immobilization following fracture, particularly in the elderly, is a significant risk for development of deep venous thrombosis, followed by pulmonary embolism.
(D) Incorrect. The elderly are at risk for pneumonia when in hospital, but the course is marked by signs and symptoms of an infection.
(E) Incorrect. CHF is a possibility in the elderly, but in the setting given is unlikely to be the cause of the sudden death.
A 53-year-old woman is found on a routine physical examination to have vital signs with T 36.9 C, P 77/minute, R 15/minute, and BP 165/110 mm Hg. There are no other significant findings. She has an abdominal ultrasound examination that shows the right kidney to be atrophic. Angiography reveals markedly reduced blood flow to the right renal artery from an occlusion at the orifice in the abdominal aorta. Which of the following laboratory findings is she most likely to have?
D. Plasma renin activity of 4.8 ng/mL/hr supine
(D) CORRECT. She has renal artery stenosis that is reducing renal blood flow on the right and simulating the JG cells to secrete renin to try and raise blood pressure to increase renal blood flow.
(A) Incorrect. Marked dehydration or free water loss could lead to this degree of hypernatremia. Many persons with essential hypertension may have increased retention of sodium, but it is not marked by significant hypernatremia.
(B) Incorrect. Anti-cardiolipin antibody is seen with the antiphospholipid syndrome, which is a cause for thrombosis. It is unlikely that the selective renal artery occlusion represents a hypercoagulable state.
(C) Incorrect. An elevated prothrombin time predisposes to bleeding.
(E) Incorrect. The decreased perfusion of the right kidney occurs over a long period of time, without a significant rise in lactate that would accompany more global hypoperfusion.
A study of pathologic findings in the islets of Langerhans is performed. It is observed that insulitis may occur in the islets. The inflammatory infiltrate is predominantly composed of T lymphocytes. Which of the following is most likely to occur as a consequence of insulitis?
(C) CORRECT. An insulitis is seen with type I diabetes mellitus. Actually, it is rare to see it because by the time the patients present with overt diabetes mellitus, the islets are long gone.
(A) Incorrect. An insulitis is typical for type I diabetes mellitus; there is no increased risk for neoplasia.
(B) Incorrect. The insulitis involves just the endocrine portion of the pancreas, not the exocrine portion, so there is no loss of pancreatic enzymes for digestion.
(D) Incorrect. Obesity is typically associated with type II diabetes mellitus; with type I diabetes mellitus, there is a catabolic state with weight loss.
(E) Incorrect. The lymphocytes in the islets are part of an autoimmune phenomenon, not an infectious process.
A 20-year-old man incurs blunt trauma to his upper outer arm. On physical examination, there is a 2 x 3 cm contusion. The initial soft tissue bleeding stops in a few minutes and the size of the bruise does not increase. Which of the following chemical mediators is most important in this episode of hemostasis?
(E) CORRECT. Thromboxane is released by platelets to promote formation of a stable 'secondary plug' to achieve hemostasis.
(A) Incorrect. Leukotrienes are generated by the lipo-oxygenase pathway of arachidonic acid metabolism and can cause some vasoconstriction.
(B) Incorrect. Prostaglandins promote vasodilation.
(C) Incorrect. Prostacyclin release causes vasodilation and inhibits platelet aggregation, the opposite of what is needed for hemostasis.
(D) Incorrect. Activation of plasminogen leads to clot lysis.
A 45-year-old man feels some crushing chest pain along with numbness in his left arm after shoveling 15 cm of snow off his driveway. Three hours later he collapses and is taken to the emergency room. Which of the following laboratory tests run on a blood specimen is most useful in this situation?
D. Creatine kinase
(D) CORRECT. Elevations in CK enzymes are going to be seen acutely with myocardial infarction beginning within hours and remaining for days.
(A) Incorrect. An elevation in WBC count is not a specific indicator for myocardial infarction.
(B) Incorrect. Though he may have diabetes mellitus as an underlying cause for the atherosclerosis leading to myocardial infarction, serum glucose will not help to diagnose the infarction.
(C) Incorrect. Platelet counts are of no value in diagnosing infarctions, even though platelets play a role in formation of thrombi that can lead to infarction.
(E) Incorrect. Amylase is increased with pancreatitis, which is not related to cardiovascular disease.
A 68-year-old woman has survived multiple episodes of pulmonary thromboembolism during the past three months. Which of the following is the most likely underlying condition leading to this patient's recurrent pulmonary thromboembolism?
B. Adenocarcinoma of the pancreas
(B) CORRECT. The recurrent episodes suggest a hypercoagulable state, and carcinomas can do this (Trousseau syndrome).
(A) Incorrect. Liver disease leads to a coagulopathy marked by a tendency to bleeding, not thrombosis.
(D) Incorrect. Hypercholesterolemia could accelerate atherosclerosis and thrombosis, but in arteries, not veins.
(E) Incorrect. An endocarditis could lead to to embolization, but into the systemic circulation from the mitral valve.
(F) Incorrect. Diabetes mellitus increases the risk for atherosclerosis, but atherosclerosis does not involve veins.
A 77-year-old woman has experienced abdominal pain for the past month. On physical examination, she has a pulsatile lower abdominal mass. An abdominal CT scan reveals an abdominal aorta dilated to 7 cm in diameter, with calcification of the aortic wall. While awaiting surgery, she has an episode of severe abdominal pain and a repeat CT scan shows marked retroperitoneal hemorrhage. Which of the following laboratory test findings is she most likely to have?
(D) CORRECT. An elevated plasma homocysteine is a risk for atherosclerosis as well as thrombosis. Her findings point to an abdominal aortic aneurysm which ruptured. Such aneurysms are invariably the result of atherosclerosis.
(A) Incorrect. The factor V Leiden mutation is a risk for a hypercoagulable state with venous thrombosis, typically manifested at a young age.
(B) Incorrect. Factor VIII deficiency is one cause for hemophilia with risk for bleeding into soft tissues, manifested early in life.
(C) Incorrect. An increased CEA can be seen with some malignancies, such as adenocarcinoma of the colon. In this case, the mass is an aortic aneurysm caused by atherosclerosis.
A 70-year-old man has noted coldness and numbness of his lower left leg, increasing over the past 4 months. He also experiences pain in this extremity when he tries walking more than the distance of half a city block. On physical examination, his dorsalis pedis, posterior tibial, and popliteal artery pulses are not palpable. Which of the following laboratory test findings is he most likely to have?
(D) CORRECT. This is peripheral arterial vascular disease from severe atherosclerosis, which is promoted by diabetes mellitus. The absence of pulses defines this as an arterial process, as does the claudication (pain with exercise). Thrombophlebitis is a venous process and leads to swelling and pain in the leg, but not loss of pulses..
(A) Incorrect. Coagulopathies with thrombosis may be due to a congenital anticoagulant factor deficiency, but thrombotic events are usually sudden.
(B) Incorrect. Septic thrombosis and mycotic aneurysms may be the result of septicemia, but this is an acute illness.
(C) Incorrect. Oxygen saturation is typically dependent more upon pulmonary function and is not related to focal events, as in the lower extremities.
(E) Incorrect. Calcium levels have little to do with vascular problems in general (except for the rare condition in persons with renal failure called calciphylaxis).
A 72-year-old man suffered a myocardial infarction involving half the left ventricular free wall 3 months ago. He now has increasing dyspnea and orthopnea. On echocardiography his ejection fraction is 29%. On examination he has poor capillary filling in hands and feet. A chest x-ray shows pulmonary edema. Which of the following laboratory test analytes is most likely to be increased in this man at this point in time?
C. Lactic acid
(C) CORRECT. Under conditions of poor tissue perfusion, there will be more anaerobic glycolysis and more acidosis. The blood lactate rises in this condition.
(A) Incorrect. The serum sodium may give an indication of the degree of hydration, not tissue perfusion.
(B) Incorrect. Poor perfusion leading to myocardial infarction would increase the creatine kinase.
(D) Incorrect. The hematocrit suggests the ability of the blood to carry oxygen and prevent ischemia, but does not predict whether there is poor perfusion with ischemia.
(E) Incorrect. The sed rate gives an indication of the presence of inflammation, a consequence of an ischemic event.
A 44-year-old African-American man has had elevated blood pressure for years which has not been treated. He now has severe headaches. On physical examination his blood pressure is 275/150 mm Hg. Laboratory studies show Hgb 13.8 g/dL, serum glucose 76 mg/dL, and creatinine 3.5 mg/dL. These findings are most likely to be associated with which of the following pathologic lesions involving his kidneys?
A. Hyperplastic arteriolosclerosis
(A) CORRECT. Hyperplastic arteriolosclerosis is seen in the setting of malignant hypertension, and renal failure is common.
(B) Incorrect. These are complications typically seen in association with diabetes mellitus.
(C) Incorrect. This is a histologic curiosity with no major clinical importance.
(D) Incorrect. Hypertension is a risk for coronary artery disease, but malignant hypertension is not specifically linked to coronary thrombosis.
(E) Incorrect. Venous thrombosis is most often a result of stasis from immobilization.
A 60-year-old woman has become increasingly obtunded over the past day. She was found by her daughter in a stuporous condition and brought to the emergency department. On physical examination, she has poor skin turgor. She is afebrile. Her vital signs reveal a blood pressure of 90/40 mm Hg, respirations 15 and shallow, pulse 95, and temperature 36 C. Laboratory studies show a hemoglobin A1C of 10%. Her serum electrolytes show sodium 144 mmol/L, potassium 5 mmol/L, chloride 95 mmol/L, CO2 22 mmol/L, and glucose 940 mg/dL. Which of the following is the most likely diagnosis?
B. Hyperosmolar coma
(B) CORRECT. This is an extremely elevated serum glucose that would increase the serum osmolality markedly.
(A) Incorrect. An overdose of insulin would lead to hypoglycemia.
(D) Incorrect. Diabetics with ketoacidosis may have a serum glucose around 500 to 600 mg/dl, but generally not over 1000 mg/dl.
A study is performed involving persons who have a history of diabetes mellitus type 1 or type 2. These patients are found to have cellular injury that results from glycosylation end products and from sorbitol accumulation within cells. The same patients are also shown to have ischemic tissue damage from accelerated and advanced atherosclerosis. Which of the following complications is most likely to result from atherosclerosis in these patients?
(C) CORRECT. Stroke from cerebral atherosclerosis or from embolization of mural thrombi from a heart involved with ischemic injury as a consequence of atherosclerosis....
(A) Incorrect. A variety of conditions occur with diabetes mellitus, including nodular glomerulosclerosis and pyelonephritis, can lead to renal failure.
(B) Incorrect. The neuropathy that occurs with diabetes mellitus can affect penile erection in men.
(D) Incorrect. Cataracts involving the crystalline lens of the eye are seen more frequently in diabetics.
(E) Incorrect. Blindness from diabetic retinopathy is a frequent long term complication of diabetes mellitus.
A 30-year-old man goes to his physician for a routine health checkup. On physical examination there are no abnormal findings. Laboratory test findings include serum glucose 80 mg/dL, hemoglobin A1C 4%, total cholesterol 240 mg/dL, LDL cholesterol 180 mg/dL, and HDL cholesterol 20 mg/dL. Through which of the following mechanisms is endothelial vascular injury in this patient most likely to occur?
B. Insudation of lipid in foam cells
(B) CORRECT. He has hypercholesterolemia with more of the 'bad' LDL cholesterol that can become oxidized and taken up by modified arterial wall LDL receptors. The lipid collects in macrophages and becomes a lipid lesion--the precursor to more serious atheromatous plaques.
(A) Incorrect. The accumulation of sorbitol in tissues not requiring insulin for glucose uptake is a feature of diabetes mellitus with hyperglycemia.
(C) Incorrect. Neutrophilic inflammation can be the result of infection and is unusual in arteries. It is not related to atherosclerosis.
(D) Incorrect. Mutations can result in neoplastic transformation, but atherosclerosis is not a neoplastic process.
(E) Incorrect. The process of atherogenesis proceeds slowly, without significant inflammation and activation of complement.
A 65-year-old man has had increasing lower leg swelling along with reduced exercise tolerance for the past 5 years. He sometimes has chest pain on exertion. He has not experienced dyspnea. He has experienced 4 episodes of transient ischemic attacks in the past year. He has experienced abdominal pain in the past 2 months. Vital signs show T 36.9 C, P 82/min, RR 15/min, and BP 130/85 mm Hg. He has pitting edema to the knees bilaterally. The lower extremities have palpable pulses, no tenderness, and no erythema. An abdominal CT scan shows dilation of the abdominal aorta to 5 cm, filled with mural thrombus. Other family members have had similar problems. Which of the following underlying conditions is most likely to produce these findings:
E. Diabetes mellitus
(E) CORRECT. He has findings associated with atherosclerosis, including coronary and aortic disease at least, with congestive heart failure and evidence for an aortic aneurysm. Diabetes mellitus causes advanced atherosclerosis. There is a genetic component, with a family history often present, particularly for type II diabetes mellitus.
(A) Incorrect. This is a cause for hypercoagulability, usually manifesting at an early age, with a risk mainly for venous thrombosis, not atherosclerosis.
(B) Incorrect. Malignancies can be associated with a hypercoagulable state with thrombosis, but not manifestations of atherosclerosis. In fact, persons with malignancies typically have a regression of atherosclerotic lesions.
(D) Incorrect. Vasculitis does not typically lead to findings in a distribution associated with atherosclerosis. Some forms of vasculitis favor thrombosis, others occlusion.
A 45-year-old woman who has been bedridden for several weeks has the onset of left sided chest pain along with dyspnea. She has some tenderness in her left leg, which has a slightly greater circumference in the thigh than the right. A ventilation/perfusion scan shows evidence for a left lower lobe perfusion defect. Which of the following vascular diseases is most likely to cause these findings
(E) CORRECT. A pulmonary infarction is due to a thromboembolus that arose in a vein (usually legs or pelvic region) and travelled to the lungs. Immobilization with vascular stasis predisposes to phlebothrombosis to form thrombi that can then dislodge and become thromboemboli.
(D) Incorrect. An arterial mural thrombus can become an embolus in the systemic arterial circulation and produce an infarct (but not in lung, which is supplied by the pulmonary circulation).
(C) Incorrect. This would lead to ischemia and/or infarction of the myocardium.
(A) Incorrect. This is the type of vascular change that is typical with hypertension and/or diabetes mellitus.
(B) Incorrect. Monckeberg sclerosis is not generally associated with any complications
A 27-year-old woman had a hemoglobin A1C of 7.9% noted during a prenatal visit. She gives birth to a 4350 gm baby at 37 weeks gestation. Just after the delivery, the baby becomes irritable and displays seizure activity. Which of the following laboratory findings is most likely to be found in the baby:
D. Blood glucose of 20 mg/dl
(D) CORRECT. Infants of diabetic mothers are at risk for hypoglycemia following delivery, because they have islet hypertrophy and hyperplasia, and the increased islet production of insulin carries into the immediate postpartum period.
(A) Incorrect. The hemoglobin A1C is typically increased in diabetics with poor control.
(B) Incorrect. Monckeberg sclerosis is not generally associated with any complications.
(C) Incorrect. An 'islitis' that precedes type I diabetes probably occurs in children and is hardly ever observed, because the diabetes is treated.
(E) Incorrect. Ketoacidosis is typical for type I diabetes in which there is an absolute insulin lack.
Which of the following chemical components of the blood is mainly responsible for transporting exogenous (dietary) triglyceride from the intestine following a meal.
(B) CORRECT. Chylomicrons formed in intestinal epithelial cells contain apoproteins, triglyceride and cholesterol.
(A) Incorrect. There are a number of apoproteins involved in transport of lipids in the blood.
(C) Incorrect. Lipoprotein lipase in endothelium hydrolyzes chylomicrons, liberating fatty acids for use by fat and muscle. The cholesterol-rich chylomicron remnants go to the liver.
(D) Incorrect. Such LDL is injurious to endothelium and is more avidly taken up by macrophages and smooth muscle, thus promoting atherogenesis in vessels.
(E) Incorrect. HDL is 'good' because it transports cholesterol back to the liver.
Some cells demonstrate glucose uptake regardless of the plasma insulin level. In a person who has had persistent hyperglycemia for years, cellular injury can occur. Which of the following cell types is most likely to show injury from hyperglycemia:
D) CORRECT. Neurons do not require insulin for glucose uptake. The excess glucose diffusing into the cells is shunted into the sorbitol pathway and can lead to osmotic injury, resulting in neuropathy.
(A) Incorrect. Cardiac muscle cells require insulin for glucose uptake.
(B) Incorrect. Fibroblasts require insulin for glucose uptake.
(C) Incorrect. Fat cells require insulin for glucose uptake. Steatocytes also are part of the endogenous pathway of lipoprotein transport and convert VLDL to LDL.
(E) Incorrect. Smooth muscle requires insulin for glucose
During hospitalization, a 40-year-old woman develops thrombophlebitis. She recovers and is discharged. She returns to her job as an electrician. A couple of months later, which of the following terms would best describe the process seen in a femoral vein after recovery from her thrombophlebitis:
(D) CORRECT. Thrombi will organize over time, with much of the clot eventually removed and the vascular lumen restored.
(A) Incorrect. Some inflammation, possibly acute, may have been present at the time of the original episode of thrombophlebitis.
(B) Incorrect. Thrombophlebitis is a process best known for thrombus formation, and rupture of a vein wall would be an extreme rarity.
(C) Incorrect. After she is mobile again and months pass, any thrombus capable of embolizing is long gone.
(E) Incorrect. Propagation of a thrombus is most likely to occur at the time it originally forms, or soon thereafter.
A 52-year-old man has an ulcerated area on the sole of his foot that has not healed for 2 months. He is 180 cm tall, weighs 126 kg, and has continued to gain weight gradually. He has not had any major illnesses. His blood pressure is normal. Which of the following laboratory tests performed on serum from a blood sample would be most useful in elucidating the underlying cause for his problem:
(D) CORRECT. The history suggests diabetes mellitus, most likely type II, and persistent hyperglycemia would confirm the diagnosis.
(B) Incorrect. Cortisol may be decreased with adrenal failure. Increased cortisol with Cushing syndrome may result in weight gain, but signs of severe peripheral atherosclerosis are lacking
(A) Incorrect. ATIII may be diminished in some cases of recurrent thrombosis.
A 57-year-old man has had blood pressure measurements in the range of 160/95 to 180/110 mm Hg for many years. He has taken no medications. A renal scan reveals kidneys of normal size for age. These findings with benign nephrosclerosis are most likely to occur with which of the following vascular changes:
A. Hyaline arteriolosclerosis
(A) CORRECT. Hyaline arteriolosclerosis is a feature of long-standing hypertension and is part of benign nephrosclerosis which may go on for many years with no complications. The small arterioles are thickened.
(E) Incorrect. Hyperplastic arteriolosclerosis is usually seen in the kidneys when there is severe hypertension.
(C) Incorrect. Coronary artery disease is caused by atherosclerosis that can be accelerated by hypertension. Atheromatous plaques occur in medium to large sized arteries and can be complicated by calcification of the plaques.
(D) Incorrect. Mural thrombosis typically occurs in the aorta and its branches when there is severe atherosclerosis.
(B) Incorrect. Medial calcific sclerosis is a form of arteriolosclerosis without significant complications. The vascular lumen is not significantly compromised by the medial calcification.
A 70-year-old woman with a history of type II diabetes mellitus is found comatose at her home. There are no external signs of trauma. When seen a week ago she was depressed, but in no apparent distress. She had not been ingesting much food or drinking much water for several days. Vital signs show T 35.8 C, P 85, R 16, and BP 100/65 mm Hg. Which of the following laboratory test findings is most likely to be present:
B. Markedly increased serum osmolality
(B) CORRECT. There is insulin production in type II diabetes mellitus, but not enough to prevent hyperglycemia, either from abnormal secretion patterns or from peripheral resistance. When dehydration occurs, the glucose can rise significantly.
(E) Incorrect. Ketoacidosis is a complication of type I diabetes mellitus, in which there is an absolute lack of insulin production.
(A) Incorrect. Persons with diabetes mellitus that is not well controlled will have an elevated Hgb A1C. This is a better long-term indicator of control than random glucose measurements.
(C) Incorrect. She is unlikely to have decreased tissue perfusion, as her blood pressure is still fairly good.
(D) Incorrect. Profound hypoglycemia is a complication of too much self-administration of insulin in a person with diabetes mellitus.
A 20-year-old woman was diagnosed last year with pulmonary thromboembolism. In her 6th month of her first pregnancy, she delivered a stillborn baby. Laboratory testing revealed the presence of a normal prothrombin time, normal partial thromboplastin time, platelet count of 250,000/microliter, and presence of lupus anticoagulant. These findings are most characteristic for which of the following hypercoagulable states:
A. Antiphospholipid syndrome
(A) CORRECT. There are circulating antibodies that bind plasma proteins with an affinity for phospholipid surfaces, and this can cause thrombosis and in women stillbirth. This syndrome is most often acquired in adulthood, either from an underlying disease or as an idiopathic condition. The two subsets of this syndrome, as defined by laboratory testing, are: lupus anticoagulant (which may or may not be seen with SLE), and anti-cardiolipin antibody.
(B) Incorrect. This is the most common inherited form of hypercoagulability. The mutation, which leads to activated protein C resistance, is present in 5% of Caucasians but is rare in persons of African and Asian ancestry. Heterozygotes have a mild risk for thrombosis, but the rare homozygotes have a marked risk. A point mutation leads to impaired inactivation of factor V by activated protein C. Recurrent venous thrombosis can occur, starting even in young persons, and in women stillbirth.
(C) Incorrect. Neoplastic cells may elaborate a factor, such as a thromboplastin-like substance, that can increase the risk for thrombosis. This is one form of paraneoplastic syndrome, with the name Trousseau syndrome. There can be venous (more likely) or arterial thrombosis.
(D) Incorrect. This condition is as common as factor V Leiden mutation. There may be genetic and environmental factors causing it. Oral contraceptive use increases factor VIII levels. The result is deep venous thrombosis.
(E) Incorrect. This condition is an autosomal dominant disorder and leads to recurrent venous thrombosis, even starting in young persons. Thrombosis is often spontaneous, without other precipitating events.
A 52-year-old woman has a history of urinary tract infections. Recently, one of these episodes was complicated by acute pyelonephritis involving her kidneys. She became septic, and a blood culture grew Escherichia coli. She developed severe hypotension. She had purpuric areas on her skin. A stool for occult blood was positive. She had a prothrombin time of 50 sec (control 12), partial thromboplastin time of 100 sec (control 25), platelet count of 20,000/microliter, and D-dimer of 4 microgm/mL. These findings are most characteristic for which of the following conditions:
C. Disseminated intravascular coagulation
(C) CORRECT. She has a coagulopathy in which there is consumption of coagulation factors leading to hemorrhage. Conditions such as sepsis, severe trauma, neoplasia, and obstetric complications can set off the coagulation system in a generalized fashion, resulting in DIC.
(A) Incorrect. Hemophilia A is an X-linked disorder that almost always affect males. There is no coagulopathy. Instead, there is bleeding, typically into soft tissues such as joints.
(B) Incorrect. Von Willebrand disease is a condition in which a particular blood coagulation factor (von Willebrand factor) is reduced, and the features resemble thrombocytopenia. Other coagulation factors are not reduced.
(D) Incorrect. The antiphospholipid syndrome can have thrombosis as well as bleeding, but there is a circulating antibody present. There does not tend to be a consumptive coagulopathy.
(E) Incorrect. Severe liver disease can lead to bleeding because the liver makes many coagulation factors. However, a consumptive coagulopathy affecting even platelets is unlikely.