INI-CET 2017 Practice Questions

Q: Comment on the diagnosis of the image shown below. (AIIMS Nov 2017)

Hypothyroidism. ***Hypothyroidism*** - The image depicts **myxoedema**, characterized by localized, non-pitting edema and thickened skin, typically on the shins, which is a classic manifestation of severe **hypothyroidism**. - This condition results from the accumulation of **hyaluronic acid** and chondroitin sulfate in the dermis, causing a characteristic doughy texture. *Hyperthyroidism* - While hyperthyroidism (specifically Graves' disease) can cause **pretibial myxoedema**, the image alone showing generalized myxoedematous changes is more indicative of **hypothyroidism**. - Pretibial myxoedema associated with hyperthyroidism typically presents as elevated, firm, non-pitting plaques, whereas the image shows a more widespread thickening. *Sarcoidosis* - Sarcoidosis involves the formation of **non-caseating granulomas** in various organs, including the skin. - Skin manifestations of sarcoidosis can include **erythema nodosum**, plaques, or lupus pernio, which do not match the generalized thickening seen in the image. *Diabetes* - Diabetes mellitus can cause various skin manifestations such as **diabetic dermopathy**, necrobiosis lipoidica diabeticorum, and acanthosis nigricans. - These conditions present with different visual characteristics, like hyperpigmented atrophic macules or waxy yellow plaques, unlike the diffuse thickening shown.

Q: A middle-aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? (AIIMS Nov 2017)

Decompressive surgery. ***Decompressive surgery*** - The NCCT image shows a **large, well-demarcated hypodensity in the right cerebral hemisphere**, characteristic of a **subacute to chronic ischemic infarct with significant edema and mass effect**. This is evidenced by the effaced sulci, compressed ventricles on the right, and likely midline shift, causing the patient's **drowsiness** and **left-sided weakness**. - Given the patient's **drowsiness** (indicating rising intracranial pressure) and significant mass effect from the large infarct, **decompressive craniectomy** is often a life-saving measure to reduce intractable intracranial pressure and prevent further herniation in cases of malignant middle cerebral artery (MCA) infarction. *Aspirin/Clopidogrel* - These are **antiplatelet medications used for secondary stroke prevention** after an acute ischemic event. - They are not the primary treatment for an **existing large infarct with mass effect and neurological deterioration** (drowsiness), as they do not address the acute intracranial pressure. *Mechanical thrombectomy* - This procedure is indicated for **acute ischemic stroke due to large vessel occlusion**, typically performed within a very narrow time window (usually up to 6-24 hours) from symptom onset. - The patient presents two days after symptom onset, and the CT findings suggest a **subacute to chronic infarct that has completed evolution**, making thrombectomy ineffective and potentially harmful. *Mannitol* - Mannitol is an **osmotic diuretic used to acutely reduce intracranial pressure (ICP)** in situations like cerebral edema. - While it can provide temporary relief, it is often insufficient for profound edema and mass effect from a **large, evolving infarct** that is causing significant neurological decline (drowsiness), and it does not treat the underlying structural issue.

Q: Which causative organism is responsible for this disease?

Coxsackie virus. ***Coxsackie virus*** - The images show typical lesions of **Hand-Foot-and-Mouth Disease (HFMD)**, characterized by **oral ulcers** (herpangina) and a vesiculopapular rash on the **palms, soles**, and sometimes buttocks. - HFMD is most commonly caused by **Coxsackie virus A16** and other enteroviruses. *Human herpes virus 7* - This virus is primarily associated with **roseola infantum (exanthem subitum)**, characterized by rapid onset of high fever followed by a rash after the fever breaks. - The rash is typically maculopapular and found on the trunk, not primarily on the palms, soles, and mouth as seen in the image. *Pox virus* - Poxviruses cause diseases like **smallpox** and **molluscum contagiosum**, which present with different types of lesions. - **Smallpox** lesions are deep-seated, painful pustules that evolve synchronously, and **molluscum contagiosum** manifests as pearly, umbilicated papules, neither matching the depicted oral and acral rash. *Molluscum contagiosum virus* - Molluscum contagiosum virus (MCV) is a type of **poxvirus** that causes the skin infection **molluscum contagiosum**. - Its characteristic lesions are **dome-shaped, pearly papules with central umbilication**, which are not consistent with the vesicular lesions and oral ulcers shown in the image.

Q: A patient with HIV develops fever weight loss and diarrhea. Fecal examination shows isospora belli. He was given treatment with TMP - SMX. Diarrhea subsided but fever persisted. Bone marrow examination showed the following picture with intracellular fungi. Which of the following statements is wrong? (AIIMS Nov 2017)

It cannot be grown in SDA. ***It cannot be grown in SDA*** - The image shows **intracellular budding yeast** consistent with *Histoplasma capsulatum*. - *Histoplasma capsulatum* **can be cultured** on Sabouraud Dextrose Agar (SDA) as a mold at room temperature, making the statement that it cannot be grown in SDA incorrect. *Spores are infective form* - The infective form of *Histoplasma capsulatum* is indeed **microconidia (spores)**, which are inhaled into the lungs. - These spores convert to yeast forms in the host's body. *It is intracellular budding yeast* - The image clearly depicts **intracellular yeast cells within a macrophage**, a hallmark of *Histoplasma capsulatum* infection. - These yeast cells reproduce by **budding**, which is visible as smaller structures emerging from the main yeast cell. *It can cause systemic disease* - *Histoplasma capsulatum* is known to cause **histoplasmosis**, which can range from asymptomatic to severe disseminated disease, especially in **immunocompromised individuals like HIV patients**. - Systemic disease involves the spread of the fungus to organs beyond the lungs, such as the **bone marrow, liver, and spleen**, as evidenced by the bone marrow examination in the question.

Q: A patient presented with mitral valve stenosis, identify the diagnosis from the mitral valve histopathology depicted below. (AIIMS Nov 2017)

Rheumatic heart disease. ***Rheumatic heart disease*** - **Rheumatic heart disease** is the most common cause of **mitral valve stenosis** and is characterized by **fibrosis** and **calcification** of the valve leaflets, often with **commissural fusion** [1]. - Histopathology would show features like **Aschoff bodies** (granulomas with Anitschkow cells) in the acute phase [3], and later **fibrous thickening** and **neovascularization** of the valve [1]. *Tuberculosis* - While tuberculosis can affect the heart (tuberculous pericarditis or myocarditis), it is an **extremely rare cause of isolated valvular stenosis**. - Histopathology would show **caseating granulomas** with **Langhans giant cells**, which are not typical findings in primary valvular stenosis. *Myxomatous degeneration* - **Myxomatous degeneration** primarily affects the **mitral valve**, leading to **mitral valve prolapse** and **regurgitation**, not stenosis. - Histopathology shows **accumulation of proteoglycans** and **disruption of collagen fibers** within the valve, making it floppy. *Viral myocarditis* - **Viral myocarditis** is an inflammation of the **myocardium** (heart muscle) and typically leads to **dilated cardiomyopathy** and **heart failure**, not primary valvular stenosis. - Histopathology would reveal **inflammatory infiltrates** (lymphocytes) and **myocyte necrosis**, not changes specific to valve stenosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 566-567. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 293-294. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, p. 566.

Q: The digital subtraction angiography given below shows? (AIIMS Nov 2017)

Carotid-cavernous fistula. ***Carotid-cavernous fistula*** - The image shows early opacification of the **cavernous sinus** and cerebral veins (indicated by the arrow) directly from the internal carotid artery, which is characteristic of a carotid-cavernous fistula. - This high-flow shunt between the arterial and venous systems leads to venous congestion and often presents with **pulsatile exophthalmos**, chemosis, and ophthalmoplegia. *Intra-cranial pseudo-aneurysm* - A pseudo-aneurysm typically appears as a sac-like outpouching from an artery, lacking a true vessel wall, and would not show direct early venous filling. - Pseudo-aneurysms are often caused by **trauma** or infection and may present with signs of hemorrhage if ruptured. *Angiofibroma tumor blush* - An angiofibroma would appear as a **hypervascular mass** with a dense, persistent tumor blush on angiography, but it would not show early direct shunting into veins. - These tumors are typically found in the nasopharynx and present with symptoms like **epistaxis** and nasal obstruction. *Vein of Galen malformation* - A **Vein of Galen malformation** is a developmental anomaly involving an arteriovenous fistula that drains into a dilated median prosencephalic vein, often presenting in infants with high-output heart failure. - While it is an arteriovenous malformation, its typical location and presentation are different from the findings shown in this image, which demonstrates shunting in the region of the cavernous sinus.

Q: Comment on the diagnosis from the thyroid scan shown below. (AIIMS May 2017)

Hypersecreting adenoma. ***Hypersecreting adenoma*** - The thyroid scan shows a **single, intensely "hot" nodule**, indicating increased uptake of the radioactive tracer in a localized area. - This pattern is characteristic of a **hyperfunctioning thyroid adenoma**, where the adenoma produces hormones independently, leading to suppression of the rest of the normal thyroid tissue (which appears "cold" or has reduced uptake). *Papillary cancer thyroid* - Papillary thyroid cancer typically appears as a **"cold" nodule** on a thyroid scan, meaning it has reduced or no tracer uptake. - Malignant nodules generally do **not accumulate iodine** as efficiently as normal thyroid tissue or hyperfunctioning benign nodules. *Grave's disease* - Grave's disease presents with **diffuse uptake of the tracer** throughout the entire thyroid gland, not a single localized hot nodule. - The entire gland is generally enlarged and hyperactive, showing **symmetrically increased uptake**. *Lateral aberrant thyroid* - A lateral aberrant thyroid refers to **ectopic thyroid tissue** usually found in the neck, often in lymph nodes due to metastatic papillary carcinoma. - While it involves thyroid tissue outside the normal gland, it wouldn't typically manifest as a single hyperfunctioning nodule within the main thyroid gland, and most ectopic thyroid tissue would show varying uptake depending on its function or if it's metastatic cancer.

Q: A patient presented with sudden onset difficulty in breathing with RR 28/min, normal blood pressure. X-ray was taken which is given below. What is the diagnosis?

Hydro-pneumothorax. ***Hydro-pneumothorax*** - The chest X-ray clearly shows a **horizontal air-fluid level** in the right hemithorax, indicating the presence of both air (pneumothorax) and fluid (hydrothorax) within the pleural space. - The patient's sudden onset **difficulty in breathing** and **tachypnea (RR 28/min)** are consistent with significant lung pathology like a hydropneumothorax, which compromises lung function. *Pneumothorax* - A simple pneumothorax would show only **air in the pleural space**, characterized by a visible visceral pleural line and absence of lung markings beyond it. - While there is air present, the prominent **fluid level** rules out a diagnosis of pneumothorax alone. *Pleural effusion* - Pleural effusion presents as a **blunting of the costophrenic angles** and a meniscus sign, where fluid conforms to the shape of the thorax. - This image shows a **straight air-fluid level**, not a typical meniscus, indicating the presence of air in addition to fluid. *Consolidation* - Consolidation refers to the **filling of alveolar spaces with fluid or exudate**, appearing as an opacification within the lung parenchyma. - Consolidations typically do not present with a **horizontal fluid level** in the pleural space; they are intraparenchymal.

Question 1

A 30-year-old male presents with joint pain and NSAIDs were prescribed. After one week, joint pain is persisting and he has developed brownish discoloration over nose as shown in the figure. This was due to: (AIIMS Nov 2017)

Accepted Answer

Fixed drug eruption

Answer

Melasma

Answer

Chikungunya

Answer

Dengue

Question 2

Comment on the diagnosis of the image shown below. (AIIMS Nov 2017)

Accepted Answer

Hypothyroidism

Answer

Hyperthyroidism

Answer

Sarcoidosis

Answer

Diabetes

Question 3

A middle-aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? (AIIMS Nov 2017)

Accepted Answer

Decompressive surgery

Answer

Aspirin/Clopidogrel

Answer

Mechanical thrombectomy

Answer

Mannitol

Question 4

Which causative organism is responsible for this disease?

Accepted Answer

Coxsackie virus

Answer

Human herpes virus 7

Answer

Pox virus

Answer

Molluscum contagiosum virus

Question 5

A patient with HIV develops fever weight loss and diarrhea. Fecal examination shows isospora belli. He was given treatment with TMP - SMX. Diarrhea subsided but fever persisted. Bone marrow examination showed the following picture with intracellular fungi. Which of the following statements is wrong? (AIIMS Nov 2017)

Accepted Answer

It cannot be grown in SDA

Answer

Spores are infective form

Answer

It is intracellular budding yeast

Answer

It can cause systemic disease

Question 6

A patient presented with mitral valve stenosis, identify the diagnosis from the mitral valve histopathology depicted below. (AIIMS Nov 2017)

Accepted Answer

Rheumatic heart disease

Answer

Tuberculosis

Answer

Myxomatous degeneration

Answer

Viral myocarditis

Question 7

The digital subtraction angiography given below shows? (AIIMS Nov 2017)

Accepted Answer

Carotid-cavernous fistula

Answer

Intra-cranial pseudo-aneurysm

Answer

Angiofibroma tumor blush

Answer

Vein of Galen malformation

Question 8

Which is not a finding of the Chest X-ray shown below? (AIIMS May 2017)

Accepted Answer

Narrow vascular pedicle

Answer

Pulmonary venous hypertension

Answer

Increased CT ratio

Answer

Acute cardiophrenic angle

Question 9

Comment on the diagnosis from the thyroid scan shown below. (AIIMS May 2017)

Accepted Answer

Hypersecreting adenoma

Answer

Papillary cancer thyroid

Answer

Grave's disease

Answer

Lateral aberrant thyroid

Question 10

A patient presented with sudden onset difficulty in breathing with RR 28/min, normal blood pressure. X-ray was taken which is given below. What is the diagnosis?

Accepted Answer

Hydro-pneumothorax

Answer

Pneumothorax

Answer

Pleural effusion

Answer

Consolidation

INI-CET 2017

Dermatology

Internal Medicine

Microbiology

Pathology

Radiology