A 45-year-old man with heavy alcohol use is operated on for suspected perforation and is found to have acute pancreatitis. The omentum and mesentery show many chalky white spots. His serum calcium is 7.4 mg/dL. Which process best explains the white spots?

Fat necrosis with calcium soaps

Metastatic calcification of fat

Coagulative necrosis from ischaemia

Caseous necrosis from tuberculosis

A 58-year-old man has painless generalised lymphadenopathy. A node biopsy shows back-to-back neoplastic follicles, and cytogenetics shows t(14;18). How does the protein over-expressed from this translocation help the tumour cells survive?

It blocks release of cytochrome c from mitochondria

It increases transcription of the p53 gene

It binds and inactivates the Fas death receptor

It directly cleaves and inactivates caspase 8

During a deceased-donor kidney transplant, a time-zero biopsy of the graft, which had been cold-stored for 14 hours, shows tubular cells that are swollen, with pale, clear, finely vacuolated cytoplasm; the nuclei are normal. What is the first cause of this change?

Failure of the ATP-dependent sodium pump

Activation of caspases by cytochrome c

Fusion of lysosomes with the cell membrane

Accumulation of triglyceride in vacuoles

A 47-year-old man on maintenance haemodialysis for six years has serum calcium 9.6 mg/dL, phosphate 8.9 mg/dL and a raised PTH. A chest CT shows calcification of the alveolar walls in both lungs, and gastroscopy shows calcified gastric mucosa. How is this calcification best explained?

Metastatic calcification from a high calcium-phosphate product

Psammoma bodies from an occult papillary tumour

Calcium soap formation in necrotic fat

Dystrophic calcification of previously damaged tissue

A 19-year-old student is brought to casualty 30 hours after swallowing 40 tablets of paracetamol 500 mg after a quarrel. ALT is 6,800 U/L and INR 3.2. Which mechanism and zone of injury best describe her liver damage?

Reactive metabolite after glutathione depletion; centrilobular

Direct ischaemic injury from hypotension; periportal

Immune-mediated hepatocyte apoptosis; periportal

Bile acid toxicity from cholestasis; centrilobular

Cell injury, necrosis and apoptosis

20 NEET-PG practice questions on Cell injury, necrosis and apoptosis, part of Pathology. The first 20 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 45-year-old man with heavy alcohol use is operated on for suspected perforation and is found to have acute pancreatitis. The omentum and mesentery show many chalky white spots. His serum calcium is 7.4 mg/dL. Which process best explains the white spots?
1. AMetastatic calcification of fat
2. BFat necrosis with calcium soaps
3. CCoagulative necrosis from ischaemia
4. DCaseous necrosis from tuberculosis
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Answer: B · Fat necrosis with calcium soaps
Lipase released from injured acinar cells breaks down triglyceride in peripancreatic and omental fat. The free fatty acids combine with calcium to form chalky white calcium soaps (saponification), which is enzymatic fat necrosis. Deposition of calcium in these soaps is one reason for the hypocalcaemia of severe pancreatitis. Low calcium is also a marker of severity in pancreatitis scoring systems.
- A: Metastatic calcification needs high serum calcium; this patient's calcium is low.
- C: Coagulative necrosis follows ischaemia in solid organs and does not form chalky soaps.
- D: Caseous necrosis is cheesy necrosis within granulomas, as in tuberculosis.
Question 2 · Medium
A 58-year-old man has painless generalised lymphadenopathy. A node biopsy shows back-to-back neoplastic follicles, and cytogenetics shows t(14;18). How does the protein over-expressed from this translocation help the tumour cells survive?
1. AIt blocks release of cytochrome c from mitochondria
2. BIt increases transcription of the p53 gene
3. CIt binds and inactivates the Fas death receptor
4. DIt directly cleaves and inactivates caspase 8
Show answerHide answer
Answer: A · It blocks release of cytochrome c from mitochondria
The t(14;18) of follicular lymphoma places BCL2 next to the immunoglobulin heavy chain enhancer, so BCL2 is over-expressed. BCL2 is an anti-apoptotic protein of the mitochondrial (intrinsic) pathway: it restrains BAX and BAK, keeping the outer mitochondrial membrane intact, so cytochrome c is not released and caspase 9 is not activated. The lymphoma cells therefore accumulate because they live too long, not because they divide fast, which is why the disease is indolent. Venetoclax is a drug that inhibits BCL2.
- B: p53 promotes apoptosis, so increasing it would not help tumour survival.
- C: The Fas pathway is the extrinsic pathway and is inhibited by FLIP, not BCL2.
- D: BCL2 does not cleave caspases; caspase 8 is regulated by FLIP.
Question 3 · Medium
During a deceased-donor kidney transplant, a time-zero biopsy of the graft, which had been cold-stored for 14 hours, shows tubular cells that are swollen, with pale, clear, finely vacuolated cytoplasm; the nuclei are normal. What is the first cause of this change?
1. AFailure of the ATP-dependent sodium pump
2. BActivation of caspases by cytochrome c
3. CFusion of lysosomes with the cell membrane
4. DAccumulation of triglyceride in vacuoles
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Answer: A · Failure of the ATP-dependent sodium pump
Cellular swelling (hydropic change) is the earliest light microscopic change of reversible injury. Hypoxia reduces oxidative phosphorylation, ATP falls and the plasma membrane sodium-potassium ATPase fails, so sodium and water enter the cell. The cell becomes swollen and pale, with small clear vacuoles of distended ER. If oxygen and perfusion are restored in time, as when the graft is reperfused, the change reverses fully.
- B: Caspase activation leads to apoptosis, in which the cell shrinks rather than swells.
- C: Lysosome fusion is not the cause of hydropic swelling.
- D: Triglyceride vacuoles are fatty change, which takes longer to appear.
Question 4 · Medium
A 47-year-old man on maintenance haemodialysis for six years has serum calcium 9.6 mg/dL, phosphate 8.9 mg/dL and a raised PTH. A chest CT shows calcification of the alveolar walls in both lungs, and gastroscopy shows calcified gastric mucosa. How is this calcification best explained?
1. APsammoma bodies from an occult papillary tumour
2. BMetastatic calcification from a high calcium-phosphate product
3. CCalcium soap formation in necrotic fat
4. DDystrophic calcification of previously damaged tissue
Show answerHide answer
Answer: B · Metastatic calcification from a high calcium-phosphate product
In chronic kidney disease, phosphate retention and secondary hyperparathyroidism give a high calcium-phosphate product, so calcium salts precipitate in normal tissues: metastatic calcification. It favours tissues that excrete acid and so have an alkaline internal compartment: the gastric mucosa, kidneys, lungs, systemic arteries and pulmonary veins. Lung deposits can impair gas exchange. Control of phosphate with diet, binders and adequate dialysis is the main prevention.
- A: Psammoma bodies are tiny calcified bodies in tumours, not diffuse calcification of lung and stomach.
- C: Calcium soaps form in enzymatic fat necrosis, as in pancreatitis.
- D: Dystrophic calcification affects dead tissue; these tissues were healthy.
Question 5 · Medium
A 19-year-old student is brought to casualty 30 hours after swallowing 40 tablets of paracetamol 500 mg after a quarrel. ALT is 6,800 U/L and INR 3.2. Which mechanism and zone of injury best describe her liver damage?
1. ADirect ischaemic injury from hypotension; periportal
2. BImmune-mediated hepatocyte apoptosis; periportal
3. CReactive metabolite after glutathione depletion; centrilobular
4. DBile acid toxicity from cholestasis; centrilobular
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Answer: C · Reactive metabolite after glutathione depletion; centrilobular
Most paracetamol is conjugated, but a fraction is oxidised by cytochrome P450 (mainly CYP2E1) to the reactive metabolite NAPQI. Normally glutathione neutralises it; after an overdose glutathione is used up, and NAPQI binds cell proteins and causes free radical injury. The damage is greatest in the centrilobular zone (zone 3), where P450 enzymes are richest. N-acetylcysteine replenishes glutathione and should be given even when the patient presents late.
- A: Ischaemic hepatitis is also centrilobular, and this patient had an overdose, not shock.
- B: Paracetamol injury is a dose-related toxic injury, not immune-mediated, and is centrilobular.
- D: Cholestatic injury raises ALP and bilirubin more than ALT and is not the mechanism here.
Question 6 · Medium
A 36-year-old woman with rheumatic mitral stenosis has had breathlessness on exertion for years. Her sputum contains many macrophages with coarse golden-brown cytoplasmic granules that stain blue with Perls' stain. Which pigment are these cells carrying?
1. AMelanin taken up from damaged skin
2. BLipofuscin from lipid peroxidation
3. CHaemosiderin from extravasated red cells
4. DAnthracotic carbon from inhaled smoke
Answer and explanation in LearnFree account
Question 7 · Easy
A 25-year-old man has jaundice and an ALT of 1,400 U/L; IgM anti-HAV is positive. A liver biopsy done to exclude another cause shows scattered shrunken, intensely eosinophilic hepatocytes with dense nuclear fragments, without surrounding neutrophils. What process do these cells represent?
1. AHydropic swelling
2. BApoptosis of hepatocytes
3. CFatty change of hepatocytes
4. DCoagulative necrosis
Answer and explanation in LearnFree account
Question 8 · Hard
A 49-year-old man has diabetes, bronzed skin, hepatomegaly and loss of libido. Transferrin saturation is 82%, serum ferritin 2,400 ng/mL and liver enzymes are mildly raised. Liver biopsy shows golden-brown granules in periportal hepatocytes that stain blue with Perls' stain, and he is homozygous for HFE C282Y. Which mechanism best explains the iron overload?
1. ALow hepcidin allowing excess ferroportin activity
2. BHigh hepcidin trapping iron in macrophages
3. CExcess absorption of iron caused by haemolysis
4. DLoss of transferrin from the circulation
Answer and explanation in LearnFree account
Question 9 · Medium
A 22-year-old woman from Kanpur has a firm, matted cervical lymph node mass for three months. FNAC shows clusters of epithelioid cells, occasional Langhans giant cells and abundant granular, amorphous, pinkish debris with no cell outlines. Which type of necrosis is present?
1. ALiquefactive necrosis
2. BGangrenous necrosis
3. CCoagulative necrosis
4. DCaseous necrosis
Answer and explanation in LearnFree account
Question 10 · Easy
A 67-year-old hypertensive man dies six weeks after a large left middle cerebral artery stroke. At autopsy the infarcted area of the brain is a cystic cavity filled with fluid and lined by foamy macrophages. Which pattern of necrosis does this show?
1. AFibrinoid necrosis
2. BCaseous necrosis
3. CLiquefactive necrosis
4. DCoagulative necrosis
Answer and explanation in LearnFree account
Question 11 · Hard
A 26-year-old woman has a massive postpartum haemorrhage after a home delivery and reaches the district hospital in shock. After transfusion her blood pressure recovers, but urine output stays at 200 mL/day for four days, creatinine rises to 6.2 mg/dL and the urine sediment shows muddy brown granular casts. Which parts of the nephron are most vulnerable to the injury she has suffered?
1. AThin descending limb and vasa recta
2. BDistal convoluted tubule and collecting duct
3. CGlomerular capillaries and Bowman capsule
4. DStraight proximal tubule and thick ascending limb
Answer and explanation in LearnFree account
Question 12 · Medium
A 55-year-old diabetic smoker has a black, shrivelled, mummified right great toe with a sharp line of demarcation from the healthy skin. The foot is cold and the dorsalis pedis pulse is absent; there is no pus or foul smell. Which pattern of necrosis underlies this lesion?
1. ALiquefactive necrosis
2. BEnzymatic fat necrosis
3. CCoagulative necrosis
4. DCaseous necrosis
Answer and explanation in LearnFree account
Question 13 · Medium
A 38-year-old man is brought to casualty with headache and blurred vision. BP is 240/140 mmHg, the fundi show papilloedema and flame haemorrhages, and serum creatinine is 3.6 mg/dL. A renal biopsy shows bright pink, smudgy, fibrin-like material in the walls of arterioles. What is this change called?
1. AAmyloid deposition
2. BFibrinoid necrosis
3. CHyaline arteriolosclerosis
4. DCaseous necrosis
Answer and explanation in LearnFree account
Question 14 · Medium
A 6-year-old boy has had massive non-tender lymphadenopathy and splenomegaly since infancy, with autoimmune haemolytic anaemia and thrombocytopenia. Flow cytometry shows an increase of CD4-negative, CD8-negative T cells bearing the alpha-beta T-cell receptor. A defect in which apoptotic pathway is most likely?
1. Ap53-mediated DNA damage pathway
2. BFas-Fas ligand death receptor pathway
3. CMitochondrial cytochrome c pathway
4. DPerforin-granzyme pathway
Answer and explanation in LearnFree account
Question 15 · Medium
A 50-year-old man dies on the second day after an anterior wall myocardial infarction. A pathology postgraduate examining the left ventricle by electron microscopy notes four findings: 1. Large amorphous densities in mitochondria. 2. Breaks in the plasma membrane. 3. Swollen endoplasmic reticulum with detached ribosomes. 4. Small blebs on the cell surface. Which findings indicate irreversible injury?
1. A1, 2, 3 and 4
2. B3 and 4 only
3. C1 and 2 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 16 · Medium
A 61-year-old man with an acute inferior wall myocardial infarction undergoes primary PCI four hours after the onset of pain, and the occluded artery is opened. He dies of an arrhythmia on the second day, and sections of the reperfused myocardium show hypercontracted myocytes with dense transverse bands. Which process mainly causes this additional injury?
1. AComplement-mediated lysis by autoantibodies
2. BCalcium overload and free radicals on reperfusion
3. CContinued ATP depletion from persistent ischaemia
4. DCaspase-mediated apoptosis triggered by Fas
Answer and explanation in LearnFree account
Question 17 · Easy
An 84-year-old woman dies of pneumonia in a geriatric ward. At autopsy her heart is small and dark brown, and the myocardial fibres contain fine yellow-brown granules clustered at the poles of the nuclei. The granules do not stain with Perls' Prussian blue. What is the pigment?
1. AHaemosiderin
2. BBilirubin
3. CMelanin
4. DLipofuscin
Answer and explanation in LearnFree account
Question 18 · Easy
A 76-year-old man has exertional syncope and an ejection systolic murmur. Echocardiography shows a heavily calcified tricuspid aortic valve with severe stenosis. Serum calcium, phosphate and PTH are normal. How is this calcification best classified?
1. AMetastatic calcification
2. BDystrophic calcification
3. CCalcinosis cutis
4. DCalciphylaxis
Answer and explanation in LearnFree account
Question 19 · Hard
A 54-year-old woman receiving pelvic radiotherapy for carcinoma cervix develops diarrhoea. A rectal biopsy shows many single shrunken crypt cells with fragmented nuclei and no inflammation around them. Her oncologist explains four points about this process: 1. DNA damage stabilises p53. 2. p53 induces pro-apoptotic proteins such as PUMA and NOXA. 3. BAX and BAK form channels in the outer mitochondrial membrane. 4. Tumours that have lost p53 are more sensitive to radiation-induced apoptosis. Which points are correct?
1. A1 and 2 only
2. B2, 3 and 4 only
3. C1 and 3 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 20 · Hard
A 44-year-old man who drinks about 150 g of alcohol daily presents with fever, jaundice and a tender liver. AST is 240 U/L, ALT 95 U/L, GGT 680 U/L, and TLC 16,000/µL with neutrophilia. Liver biopsy shows ballooned hepatocytes containing ropy, eosinophilic cytoplasmic inclusions, with neutrophils around them. What are these inclusions made of?
1. AAggregated keratin intermediate filaments
2. BAccumulated apolipoprotein and triglyceride
3. CMisfolded alpha-1 antitrypsin protein
4. DCondensed copper-binding metallothionein
Answer and explanation in LearnFree account

Cell injury, necrosis and apoptosis

A 45-year-old man with heavy alcohol use is operated on for suspected perforation and is found to have acute pancreatitis. The omentum and mesentery show many chalky white spots. His serum calcium is 7.4 mg/dL. Which process best explains the white spots?

A 58-year-old man has painless generalised lymphadenopathy. A node biopsy shows back-to-back neoplastic follicles, and cytogenetics shows t(14;18). How does the protein over-expressed from this translocation help the tumour cells survive?

During a deceased-donor kidney transplant, a time-zero biopsy of the graft, which had been cold-stored for 14 hours, shows tubular cells that are swollen, with pale, clear, finely vacuolated cytoplasm; the nuclei are normal. What is the first cause of this change?

A 47-year-old man on maintenance haemodialysis for six years has serum calcium 9.6 mg/dL, phosphate 8.9 mg/dL and a raised PTH. A chest CT shows calcification of the alveolar walls in both lungs, and gastroscopy shows calcified gastric mucosa. How is this calcification best explained?

A 19-year-old student is brought to casualty 30 hours after swallowing 40 tablets of paracetamol 500 mg after a quarrel. ALT is 6,800 U/L and INR 3.2. Which mechanism and zone of injury best describe her liver damage?

A 36-year-old woman with rheumatic mitral stenosis has had breathlessness on exertion for years. Her sputum contains many macrophages with coarse golden-brown cytoplasmic granules that stain blue with Perls' stain. Which pigment are these cells carrying?

A 25-year-old man has jaundice and an ALT of 1,400 U/L; IgM anti-HAV is positive. A liver biopsy done to exclude another cause shows scattered shrunken, intensely eosinophilic hepatocytes with dense nuclear fragments, without surrounding neutrophils. What process do these cells represent?

A 22-year-old woman from Kanpur has a firm, matted cervical lymph node mass for three months. FNAC shows clusters of epithelioid cells, occasional Langhans giant cells and abundant granular, amorphous, pinkish debris with no cell outlines. Which type of necrosis is present?

A 67-year-old hypertensive man dies six weeks after a large left middle cerebral artery stroke. At autopsy the infarcted area of the brain is a cystic cavity filled with fluid and lined by foamy macrophages. Which pattern of necrosis does this show?

A 55-year-old diabetic smoker has a black, shrivelled, mummified right great toe with a sharp line of demarcation from the healthy skin. The foot is cold and the dorsalis pedis pulse is absent; there is no pus or foul smell. Which pattern of necrosis underlies this lesion?

An 84-year-old woman dies of pneumonia in a geriatric ward. At autopsy her heart is small and dark brown, and the myocardial fibres contain fine yellow-brown granules clustered at the poles of the nuclei. The granules do not stain with Perls' Prussian blue. What is the pigment?

A 76-year-old man has exertional syncope and an ejection systolic murmur. Echocardiography shows a heavily calcified tricuspid aortic valve with severe stenosis. Serum calcium, phosphate and PTH are normal. How is this calcification best classified?