{"id":3217,"date":"2024-05-22T14:55:00","date_gmt":"2024-05-22T14:55:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3217"},"modified":"2025-10-01T11:39:33","modified_gmt":"2025-10-01T19:39:33","slug":"usmle-step-1-question-of-the-day-hepatosplenomegaly","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-hepatosplenomegaly","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day: Hepatosplenomegaly"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-hepatosplenomegaly\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-hepatosplenomegaly\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-hepatosplenomegaly\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-hepatosplenomegaly\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-hepatosplenomegaly\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for USMLE Step 1 with this case! Learn about a USMLE Step 1 question involving a 62-year-old man with headaches, blurry vision, and numbness in his hands. Learn the significance of elevated IgM levels, blood viscosity, and the importance of cold agglutination in this hematologic malignancy.<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 62 year-old man presents to his outpatient provider\u2019s office because of two months of persistent headaches, blurry vision, and numbness in the hands bilaterally. The headache is unresponsive to over the counter pain-killers. He also reports 10 lbs (4.5 kg) weight loss over the same period. Past medical history is notable for hypertension. Family history is significant for multiple sclerosis in his mother. His temperature is 37.1\u00b0C (98.8\u00b0F), pulse is 75\/min and blood pressure is 148\/97 mmHg. Cardiopulmonary examination is noncontributory. Abdominal examination reveals hepatosplenomegaly. On peripheral smear, red blood cells are seen to clump together when placed in a 5\u00b0C (41\u00b0F) refrigerator. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following <em>best <\/em>explains the pathophysiology of the patient\u2019s condition?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Neoplastic proliferation of IgM-secreting plasma cells&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Erythropoietin-independent proliferation of red blood cells<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Autoimmune destruction of myelin in the central nervous system&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Malignant proliferation of cells of myeloid lineage&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Infection by a double-stranded DNA virus<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Neoplastic proliferation of IgM-secreting plasma cells<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let&#8217;s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Erythropoietin-independent proliferation of red blood cells<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;This answer describes polycythemia vera, a myeloproliferative neoplasm characterized by elevated red blood cell mass. Patients with the condition may present with constitutional symptoms (e.g., fatigue, weight loss) and symptoms secondary to increased blood viscosity (e.g., visual disturbances, headaches, thrombosis). While the patient in this vignette has some of the aforementioned symptoms, it would be atypical for polycythemia vera to cause rouleaux formation on peripheral smear.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Autoimmune destruction of myelin in the central nervous system&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;This answer describes multiple sclerosis, which may cause symptoms including vision impairment, incontinence, paresthesia, and impaired coordination. The patient presents with vision changes and has a family history of multiple sclerosis. However, the disease typically affects young adults between 20-40 years-old. Moreover, multiple sclerosis would not explain the cold-agglutination of RBCs.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Malignant proliferation of cells of myeloid lineage&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>Malignant proliferation of cells of myeloid lineage (e.g. acute or chronic myeloid leukemia) can present with constitutional symptoms, lymphadenopathy, and hepatosplenomegaly. However, it would be uncommon for either AML or CML to present with headaches, visual impairments, and peripheral neuropathy. In addition, peripheral smear finding of rouleaux formation cannot be accounted for by AML or CML.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Infection by a double-stranded DNA virus&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Base excision repair plays an important role in the repair of spontaneous or toxic deamination (removal of amino groups from nitrogen bases) that results from chemicals like nitrites or nitrosamine. A defect in base excision repair can increase the risk of developing colorectal cancer but is not associated with xeroderma pigmentosum. &nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"551\" width=\"1024\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_9f69c4.png?w=1024\" alt=\"Presentation &amp; Diagnosis of Different Plasma Cell Disorders\n\nMultiple Myeloma\n\nClinical Symptoms:\n* Hypercalcemia\n* Renal insufficiency\n* Anemia\n* Bone pain \/ lytic lesions\n\nLaboratory Findings:\n* M-spike on serum protein electrophoresis\n* Rouleaux formation seen on peripheral blood smear\n* Bence-Jones proteins on urine protein electrophoresis\n* More than 10% plasma cells in bone marrow biopsy\n\nDiagnostic Criteria:\n1. More than 10% plasma cells in bone marrow biopsy\n2. Clinical symptoms or laboratory findings suggesting organ injury\n\nMonoclonal Gammopathy of Undetermined Significance (MGUS)\n\nClinical Symptoms:\n* Asymptomatic\n\nLaboratory Findings:\n* M-spike on serum protein electrophoresis\n* Fewer than 10% plasma cells in bone marrow biopsy\n\nDiagnostic Criteria:\n1. Patient is asymptomatic\n2. Serum electrophoresis shows elevated immunoglobulin levels\n3. Fewer than 10% plasma cells in bone marrow biopsy\n\nWaldenstrom Macroglobulinemia\n\nClinical Symptoms:\n* Mucosal bleeding\n* Hepatosplenomegaly\n* Visual disturbances\n* Peripheral neuropathy\n* Headaches \/ fatigue\n\nLaboratory Findings:\n* M-spike on serum protein electrophoresis\n* Rouleaux formation seen on peripheral blood smear\n* Bence-Jones proteins on urine protein electrophoresis\n* More than 10% plasma cells in bone marrow biopsy\n\nDiagnostic Criteria:\n1. More than 10% plasma cells in bone marrow biopsy\n2. Elevated IgM levels\" class=\"wp-image-3219\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_9f69c4.png 1592w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_9f69c4.png?resize=300,161 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_9f69c4.png?resize=768,413 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_9f69c4.png?resize=1024,551 1024w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_9f69c4.png?resize=1536,826 1536w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This patient most likely has&nbsp;Waldenstrom macroglobulinemia, a malignant proliferation of&nbsp;IgM-producing plasma cells. The elevated serum IgM levels result in increased blood viscosity. Many patients with the condition are asymptomatic, However, symptomatic patients present with constitutional symptoms (e.g., fatigue, fever,&nbsp;weight loss) and symptoms secondary to increased blood viscosity\/decreased blood flow&nbsp;(e.g.,&nbsp;vision impairment, leg cramps,&nbsp;neuropathy).&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Diagnostic workup involves obtaining a complete blood count, peripheral blood smear, serum protein electrophoresis, and bone marrow biopsy.&nbsp;Cold agglutination, the clumping of red blood cells at low temperatures, can be seen on peripheral smears. A diagnosis of Waldenstrom macroglobulinemia can be made if serum protein electrophoresis demonstrates&nbsp;elevated IgM levels&nbsp;and&nbsp;bone marrow biopsy shows&nbsp;greater than 10% plasma cells.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Asymptomatic patients do not need treatment but should be followed closely. Patients with symptoms secondary to elevated blood viscosity should undergo&nbsp;plasmapheresis, which filters out the excess IgM. Chemotherapeutic agents such as&nbsp;rituximab&nbsp;and&nbsp;fludarabine&nbsp;can be utilized to destroy malignant plasma cells.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Waldenstrom macroglobulinemia&nbsp;is the malignant proliferation of&nbsp;IgM-producing plasma cells. Symptomatic individuals present with a mix of&nbsp;constitutional symptoms&nbsp;and&nbsp;symptoms secondary to increased blood viscosity. A diagnosis can be made based on bone marrow biopsy and protein electrophoresis results.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Gertz, M.A. (2017) Waldenstrom macroglobulinemia: 2017 update on diagnosis, risk stratification, and management.&nbsp;Annual Clinical Updates in Hematological Malignancies. 92(2), 209-217. Doi: 10.1002\/ajh.24557.&nbsp;<\/li>\n\n\n\n<li>Michels, T.C., Petersen, K.E. (2017) \u201cMultiple Myeloma: Diagnosis and Treatment.\u201d&nbsp;American Family Physician. Web Address:&nbsp;<a href=\"http:\/\/www.aafp.org\/afp\/2017\/0315\/p373.html#afp20170315p373-t3\" target=\"_blank\" rel=\"noreferrer noopener\">www.aafp.org\/afp\/2017\/0315\/p373.html#afp20170315p373-t3<\/a>.&nbsp;<\/li>\n\n\n\n<li>Smith, T., Wong, M., Goldson, T.M., Forjuoh, S.N. (2019) Diagnosis of Waldenstrom macroglobulinemia.\u00a0Baylor University Medical Center Proceedings. 32(3), 394-396. Doi: 10.1080\/08998280.2019.1596681.\u00a0<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_e88408.png\" alt=\"Osmosis sign up ad\" class=\"wp-image-3220\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_e88408.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_e88408.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><figcaption class=\"wp-element-caption\"><em><sub>The United States Medical Licensing Examination (USMLE\u00ae) is a joint program of the Federation of State Medical Boards (FSMB\u00ae) and National Board of Medical Examiners (NBME\u00ae). Osmosis is not affiliated with NBME nor FSMB.\u00a0<\/sub><\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 1 practice questions? Try Osmosis by Elsevier today! Access your\u00a0<em><a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/em>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Prepare for USMLE Step 1 with this case! Learn about a USMLE Step 1 question involving a 62-year-old man with headaches, blurry vision, and numbness in his hands. Learn the significance of elevated IgM levels, blood viscosity, and the importance of cold agglutination in this hematologic malignancy. A 62 year-old man presents to his outpatient [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":3218,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,1369,44],"tags":[],"class_list":["post-3217","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-1-questions","category-step-1"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 1 Question of the Day: Hepatosplenomegaly - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-hepatosplenomegaly\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 1 Question of the Day: Hepatosplenomegaly - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Prepare for USMLE Step 1 with this case! Learn about a USMLE Step 1 question involving a 62-year-old man with headaches, blurry vision, and numbness in his hands. Learn the significance of elevated IgM levels, blood viscosity, and the importance of cold agglutination in this hematologic malignancy. 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