NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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June 3, 2025
MKSAP 19 Hematology, Question 26
A 32-year-old man is evaluated in the emergency department for a 1-week history of fatigue, low- grade fever, bruising, and epistaxis. He has no other medical problems, and he takes no medications.
On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 120/65 mm Hg, pulse rate is 108/min, and respiration rate is 22/min. Pallor is noted. Dried blood is present in the nares. Multiple bruises are seen on his extremities, and he has petechiae at his ankles.
Which of the following is the most likely diagnosis?
A. Aplastic anemia
B. Coagulopathy of liver disease
C. Disseminated intravascular coagulation
D. Thrombotic thrombocytopenic purpura
Responses Received from Members (700 member responses):
The Correct Answer is: C. Disseminated intravascular coagulation
Educational Objective:
Diagnose disseminated intravascular coagulation.
The most likely diagnosis is disseminated intravascular coagulation (DIC) (Option C). DIC results from the simultaneous activation of coagulation and fibrinolysis. It is associated with severe sepsis, usually with septic shock; with disseminated malignancy, most classically with mucin-secreting pancreatic adenocarcinoma; and in pregnancy, with complications of placental abruption and eclampsia. The initial pathogenesis involves widespread endothelial injury and circulating procoagulants that lead to disseminated microvascular thrombi, with consumption of platelets and clotting factors, and erythrocyte shearing injury leading to hemolysis. Fibrinolysis is accelerated, resulting in dissolution of the microvascular thrombus, usually before thrombotic complications are noted. Classic laboratory findings include thrombocytopenia, prolonged activated partial thromboplastin and prothrombin times (aPTT, PT), elevated INR, hypofibrinogenemia, and elevated D-dimer level. Management is directed primarily at the inciting cause of DIC and supported with platelet transfusions, cryoprecipitate, and fresh frozen plasma as needed. In this previously well, young patient with DIC associated with pancytopenia, an underlying leukemia should be suspected. A characteristic feature of acute promyelocytic leukemia is presentation with DIC at the time of diagnosis.
coagulopathy that are present (Option A).
Liver disease results in procoagulant and anticoagulant factor reduction and in mild to moderate thrombocytopenia. Reduced procoagulant factors can result in prolongation of PT and aPTT; however, these results do not correlate with bleeding risk because they do not reflect the parallel reduction in anticoagulant factors. Distinguishing between liver disease and DIC may be challenging because patients, not uncommonly, have components of both disorders. However, this previously well patient with normal liver function tests and severe pancytopenia is not likely to have coagulopathy of liver disease (Option B).
Thrombocytopenia and microangiopathic hemolysis are the hallmarks of thrombotic thrombocytopenic purpura (TTP) (Option D). However, TTP is not associated with coagulation abnormalities or severe hypofibrinogenemia as seen in this patient.
Key Point
Typical findings of disseminated intravascular coagulation include thrombocytopenia, prolonged coagulation measures, hypofibrinogenemia, and elevated D-dimer level.
Bibliography
Levi M, Sivapalaratnam S. Disseminated intravascular coagulation: An update on pathogenesis and diagnosis. Expert Rev Hematol. 2018;11:663-672. PMID:
29999440 doi:10.1080/17474086.2018.1500173
Copyright 2019, American College of Physicians.
May 20, 2025
MKSAP 19 MKSAP Quick Q's, Question 215
A 32-year-old man is evaluated for a 4-month history of right-lower-quadrant pain and occasional diarrhea.
Examination is remarkable only for tenderness to palpation over the right lower quadrant. Stool is negative for Clostridioides difficile and enteropathogens. Colonoscopy shows superficial serpiginous ulcers and cobblestoning in the ileum and right colon. Histology shows nongranulomatous inflammation.
Which of the following is the most appropriate initial treatment?
A. Adalimumab
B. Azathioprine
C. Controlled ileal release budesonide
D. Mesalamine
Responses Received from Members (737 Responses):
The Correct Answer is: C. Controlled ileal release budesonide
Educational Objective:
Treat mild Crohn disease.
The patient has clinical and endoscopic features of mild Crohn disease and should be treated with controlled ileal release (CIR) budesonide (Option C) to induce and maintain remission. Crohn disease is an inflammatory disease that can affect any part of the gastrointestinal system and can also cause extraintestinal manifestations. Diagnosis is based on clinical features, laboratory studies (complete blood count, C-reactive protein, fecal calprotectin), and ileocolonoscopic findings. Histology reveals patchy superficial ulcerations; unlike in ulcerative colitis, the rectum is usually unaffected.
Microscopic granulomas support the diagnosis but are absent in most patients. More severe forms involve deeper layers of the bowel wall and lead to complications such as strictures and fistulas.
Treatment of Crohn disease depends on its severity, location, and complications. Induction of remission in mild disease, particularly in the ileum and right colon, may be achieved with CIR budesonide, but maintenance therapy should be limited to 4 months. In more severe and extensive forms of Crohn disease, particularly those involving the left colon, systemic glucocorticoids may be used to induce remission but not to maintain it.
The tumor necrosis factor (TNF) inhibitors adalimumab (Option A), infliximab, and certolizumab, either alone or in combination with a thiopurine (e.g., azathioprine, mercaptopurine), are recommended for the induction and maintenance of remission in moderate to severe forms of Crohn disease and for patients who have not responded to glucocorticoids. However, it is usually unnecessary in the treatment of mild disease.
The thiopurines azathioprine (Option B) and mercaptopurine are also used in Crohn disease as glucocorticoid-sparing therapy but are not effective in inducing remission.
Aminosalicylates such as mesalamine (Option D) are effective in the treatment of mild ulcerative colitis but not Crohn disease.
Key Point
Induction of remission in mild Crohn disease, particularly in the ileum and right colon, may be achieved with controlled ileal release budesonide.
The tumor necrosis factor inhibitors adalimumab, infliximab, and certolizumab, either alone or in combination with a thiopurine, are recommended for the induction and maintenance of remission in moderate to severe forms of Crohn disease and for patients who have not responded to glucocorticoids.
Bibliography
Lichtenstein GR, Loftus EV, Isaacs KL, et al. ACG clinical guideline: management of Crohn's disease in adults. Am J Gastroenterol. 2018;113:481-517. PMID: 29610508 doi:10.1038/ajg.2018.27
Copyright 2019, American College of Physicians.