Hematology Practice Questions

Q: Which antibody is commonly elevated in Waldenstrom macroglobulinemia?

IgM. **Explanation:** **Waldenström Macroglobulinemia (WM)** is a low-grade B-cell lymphoma characterized by the infiltration of the bone marrow by **lymphoplasmacytic cells** that secrete a monoclonal **IgM** protein [1]. 1. **Why IgM is Correct:** The defining feature of WM is the presence of a monoclonal IgM paraprotein (M-spike) in the serum [1]. Because IgM is the largest immunoglobulin (a pentamer), its elevation significantly increases blood viscosity, leading to the classic **Hyperviscosity Syndrome** (headache, visual disturbances, and mucosal bleeding) [1]. 2. **Why Other Options are Incorrect:** * **IgG and IgA:** These are typically elevated in **Multiple Myeloma (MM)**. While MM involves plasma cells, WM involves lymphoplasmacytoid cells. IgG is the most common subtype in MM, followed by IgA. * **IgD:** This is a very rare subtype of Multiple Myeloma and is not associated with Waldenström Macroglobulinemia. **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Marker:** Over 90% of patients with WM harbor the **MYD88 L265P mutation**, which is a crucial diagnostic marker. * **Clinical Triad:** Anemia, hepatosplenomegaly/lymphadenopathy (unlike Multiple Myeloma), and hyperviscosity symptoms [1]. * **Diagnosis:** Bone marrow biopsy showing >10% infiltration by lymphoplasmacytic cells + IgM monoclonal protein (any size). * **Fundoscopy:** May show "sausage-link" or "box-car" appearance of retinal veins due to hyperviscosity. * **Treatment:** Plasmapheresis is the immediate treatment for symptomatic hyperviscosity; Rituximab-based regimens are used for definitive therapy [1].

Q: Macrocytic anemia occurs in all except?

Copper deficiency. **Explanation:** The correct answer is **Copper deficiency**. In hematology, macrocytic anemia (MCV >100 fL) is broadly divided into megaloblastic and non-megaloblastic causes. **1. Why Copper Deficiency is the correct answer:** Copper is an essential cofactor for **hephaestin** and **ceruloplasmin**, which are required for iron transport and utilization. Copper deficiency typically presents as **Microcytic Hypochromic Anemia** (due to defective iron mobilization) or **Normocytic Anemia**. A classic high-yield finding in copper deficiency is **sideroblastic changes** and **neutropenia**, often mimicking Myelodysplastic Syndrome (MDS). **2. Analysis of Incorrect Options:** * **Thiamine (B1) Deficiency:** Specifically, **Thiamine-Responsive Megaloblastic Anemia (TRMA)** or Rogers Syndrome is a rare genetic disorder characterized by megaloblastic anemia, non-type 1 diabetes, and sensorineural deafness. * **Liver Disease:** This is a classic cause of **non-megaloblastic macrocytosis**. Increased cholesterol deposition on the RBC membrane leads to increased surface area (target cells) and macrocytosis. * **Orotic Aciduria:** This is an autosomal recessive disorder of pyrimidine synthesis. It presents with **megaloblastic anemia** [1] that does not respond to B12 or Folate [2], along with failure to thrive and orotic acid crystals in the urine. **Clinical Pearls for NEET-PG:** * **Megaloblastic Macrocytosis:** B12/Folate deficiency [2], Drugs (Methotrexate, Phenytoin, Hydroxyurea), Orotic aciduria. * **Non-Megaloblastic Macrocytosis:** Alcoholism (most common), Liver disease, Hypothyroidism, Pregnancy, and Reticulocytosis. * **Copper Deficiency Clue:** Look for a history of gastric bypass surgery or excessive zinc ingestion (zinc induces metallothionein which sequesters copper).

Q: Which of the following is NOT true about multiple myeloma?

Increased alkaline phosphatase. In Multiple Myeloma (MM), the characteristic bone lesions are purely **osteolytic**. This is due to the activation of osteoclasts (via RANKL) and the simultaneous inhibition of osteoblasts [1]. Since **Alkaline Phosphatase (ALP)** is a marker of osteoblastic activity (bone formation), its levels typically remain **normal** in MM, despite extensive bone destruction [1]. This is a classic "trap" in NEET-PG questions, as most other bone-destroying pathologies (like bony metastases or Paget’s disease) show elevated ALP. **Explanation of Options:** * **Option D (Correct):** ALP is not increased because there is no compensatory osteoblastic activity in MM. If ALP is elevated in a myeloma patient, one should suspect a pathological fracture or an alternative diagnosis. * **Option A (Incorrect):** Hyperuricemia is common due to high cell turnover and increased nucleic acid breakdown, especially during treatment (Tumor Lysis Syndrome). * **Option B (Incorrect):** Increased urea (Azotemia) occurs due to **Myeloma Kidney**. Renal failure is caused by Bence-Jones proteinuria (cast nephropathy), hypercalcemia, and amyloidosis [1]. * **Option C (Incorrect):** Hypercalcemia is a hallmark of MM (part of the **CRAB** criteria), resulting from massive osteoclast-mediated bone resorption. **High-Yield Clinical Pearls for NEET-PG:** 1. **CRAB Criteria:** **C**alcium (↑), **R**enal failure, **A**nemia, **B**one lesions [1]. 2. **Radiology:** "Punched-out" lytic lesions on a skeletal survey; **Technetium-99m bone scans are often negative** (as they detect osteoblastic activity) [1]. 3. **Diagnosis:** M-spike on Serum Protein Electrophoresis (SPEP) and >10% clonal plasma cells on bone marrow biopsy [1]. 4. **Blood Film:** Rouleaux formation due to high globulin levels [1].

Q: A 67-year-old male presents with severe pain in the right foot and paleness of the right toe. He received unfractionated heparin 7 days prior. His hemogram shows: Hb – 13.2 g/dL, WBC – 10000/mm³, Platelet – 50000/mm³. Which of the following should be used to treat this condition?

Argatroban. **Explanation:** The clinical presentation of a patient developing thrombocytopenia and arterial thrombosis (the "white clot" syndrome causing foot pain and paleness) approximately 7 days after starting heparin is classic for **Heparin-Induced Thrombocytopenia (HIT) Type II**. **1. Why Argatroban is correct:** HIT is caused by IgG antibodies against the **Heparin-Platelet Factor 4 (PF4) complex**, leading to massive platelet activation and a paradoxical prothrombotic state. The first step in management is the immediate cessation of all heparin products. To maintain anticoagulation and prevent further thrombosis, a **Direct Thrombin Inhibitor (DTI)** like **Argatroban** (or Lepirudin/Danaparoid) must be started [1]. Argatroban is preferred in patients with renal impairment as it is hepatically cleared. **2. Why the other options are incorrect:** * **High dose Heparin:** This would be catastrophic, as it provides more substrate for the antibody-mediated reaction, worsening the thrombosis. * **Platelet infusions:** Generally contraindicated in HIT. Adding more platelets is like "adding fuel to the fire," potentially increasing the risk of thrombotic events. * **Warfarin:** Should **never** be used as monotherapy in the acute phase of HIT. It can cause a rapid drop in Protein C levels, leading to **venous limb gangrene** or skin necrosis. It should only be started once the platelet count has recovered to >150,000/mm³. **Clinical Pearls for NEET-PG:** * **The 4T Score:** Used clinically to assess the probability of HIT (Thrombocytopenia, Timing, Thrombosis, and oTher causes). * **Timing:** HIT typically occurs **5–10 days** after heparin exposure [1]. * **Diagnosis:** Initial screening with **ELISA (anti-PF4)**; Gold standard confirmatory test is the **Serotonin Release Assay (SRA)**. * **Management Rule:** Stop Heparin → Start DTI (Argatroban) → Delay Warfarin.

Q: Which of the following is NOT true about Idiopathic Thrombocytopenic Purpura (ITP)?

Splenomegaly is not essential for the diagnosis of ITP.. ### Explanation **Understanding the Correct Answer (Option C)** In Immune Thrombocytopenic Purpura (ITP), the pathophysiology involves the peripheral destruction of platelets by anti-platelet antibodies (IgG) [1]. While this destruction occurs primarily in the spleen, the spleen itself is **not typically enlarged**. In fact, the presence of significant splenomegaly should prompt a clinician to look for alternative diagnoses, such as leukemia, lymphoma, or portal hypertension. Therefore, the statement "Splenomegaly is not essential for the diagnosis" is medically accurate, making it the correct choice in the context of this question. **Analysis of Other Options** * **Option A:** This statement is **False**. In pediatric ITP, the majority of cases (approx. 80%) are acute and self-limiting, often following a viral infection. Conservative management or short-term steroids/IVIG are preferred; splenectomy is reserved only for chronic, refractory cases. * **Option B:** This statement is **True**. Splenectomy is a second-line treatment that produces complete remission in about 70% of patients [2]. Many patients respond well to corticosteroids (first-line), Rituximab, or TPO-receptor agonists (Eltrombopag/Romiplostim) [2]. * **Option D:** This statement is **False**. IVIG is highly effective in adults, especially when a rapid rise in platelet count is required (e.g., life-threatening bleed or emergency surgery). **NEET-PG High-Yield Pearls** * **First-line treatment:** Corticosteroids (Prednisolone or high-dose Dexamethasone). * **Bone Marrow Finding:** Increased or normal megakaryocytes (compensatory response to peripheral destruction). * **Diagnosis of Exclusion:** ITP is diagnosed only after ruling out other causes of thrombocytopenia [1]. * **Indication for treatment:** Generally started when platelets are <20,000–30,000/µL or if there is significant mucosal bleeding [1].

Q: A patient presents with renal failure and bone pain. X-rays show evidence of skeletal destruction. Laboratory evaluation reveals hypercalcemia. Serum electrophoresis shows a prominent M spike. Tissue biopsy shows plasmacytoma. Bone marrow shows plasmacytosis with 35 percent plasma cells. What is the most likely diagnosis?

Multiple Myeloma. The patient presents with the classic triad of **Multiple Myeloma (MM)**: bone destruction, renal insufficiency, and monoclonal protein proliferation. [1] **1. Why Multiple Myeloma is correct:** According to the International Myeloma Working Group (IMWG) criteria, a diagnosis of MM requires: * **Clonal bone marrow plasma cells ≥10%** (Patient has 35%) OR biopsy-proven extramedullary plasmacytoma. * **CRAB features** (Evidence of end-organ damage): **C**alcium elevation, **R**enal insufficiency, **A**nemia, or **B**one lesions. [1] This patient satisfies both criteria with hypercalcemia, renal failure, skeletal destruction, and 35% plasma cells. **2. Why other options are incorrect:** * **Plasmacytoma:** This refers to a solitary mass of neoplastic plasma cells. While the patient has a plasmacytoma, the presence of systemic involvement (bone marrow >10% and CRAB features) upgrades the diagnosis to Multiple Myeloma. * **MGUS (Monoclonal Gammopathy of Undetermined Significance):** Characterized by M-protein <3 g/dL, bone marrow plasma cells <10%, and **no** CRAB features. * **Smoldering Myeloma:** Characterized by M-protein ≥3 g/dL or bone marrow plasma cells 10–60%, but crucially, there is **no** end-organ damage (CRAB features). **Clinical Pearls for NEET-PG:** * **M-Spike:** Usually IgG (most common) or IgA. [1] * **Peripheral Smear:** Look for **Rouleaux formation** due to high protein levels. * **Bence-Jones Proteins:** Free light chains in urine (not detected by routine dipstick). * **Radiology:** "Punched-out" lytic lesions; Bone scans are often negative (as there is no osteoblastic activity). [1] * **Renal Failure:** Most commonly due to "Myeloma Kidney" (cast nephropathy).

Question 1

Which of the following statements is false regarding Multiple Myeloma?

Accepted Answer

It is a plasma cell malignancy characterized by the overproduction of a monoclonal immunoglobulin.

Answer

Bence Jones proteins are typically found in the urine.

Answer

Lytic bone lesions are a common radiological finding.

Answer

Rouleaux formation of red blood cells may be observed on peripheral blood smear.

Question 2

Leukocytosis is seen in all conditions except?

Accepted Answer

Typhoid Fever

Answer

Brucellosis

Answer

Acute Myocardial Infarction

Answer

Diphtheria

Question 3

Which antibody is commonly elevated in Waldenstrom macroglobulinemia?

Accepted Answer

IgM

Answer

IgG

Answer

IgA

Answer

IgD

Question 4

Macrocytic anemia occurs in all except?

Accepted Answer

Copper deficiency

Answer

Thiamine deficiency

Answer

Liver disease

Answer

Orotic aciduria

Question 5

A 72-year-old woman is admitted to the hospital with an acute illness. Her platelet count is incidentally noted to be 800,000/mL. For this patient with a blood-count anomaly, select the corresponding clinical situation and/or laboratory finding.

Accepted Answer

Acute hemorrhage

Answer

Post-splenectomy

Answer

Increased numbers of reticulocytes

Answer

Thiamine deficiency

Question 6

Which of the following is NOT true about multiple myeloma?

Accepted Answer

Increased alkaline phosphatase

Answer

Increased uric acid

Answer

Increased urea

Answer

Increased calcium

Question 7

Which of the following patients would LEAST likely require a bone marrow examination?

Accepted Answer

Adult with fever and a WBC of 20,000 cells/l with a left shift

Answer

Adult with pancytopenia and a normal mean corpuscular volume

Answer

Adult with a myeloproliferative disease

Answer

Adult with a monoclonal spike on a serum protein electrophoresis

Question 8

A 67-year-old male presents with severe pain in the right foot and paleness of the right toe. He received unfractionated heparin 7 days prior. His hemogram shows: Hb – 13.2 g/dL, WBC – 10000/mm³, Platelet – 50000/mm³. Which of the following should be used to treat this condition?

Accepted Answer

Argatroban

Answer

High dose of Heparin

Answer

Platelet infusions

Answer

Warfarin

Question 9

Which of the following is NOT true about Idiopathic Thrombocytopenic Purpura (ITP)?

Accepted Answer

Splenomegaly is not essential for the diagnosis of ITP.

Answer

Splenectomy is the treatment of choice in pediatric patients.

Answer

Splenectomy is not performed in all cases.

Answer

Intravenous immunoglobulin (IVIG) is not useful in adults.

Question 10

A patient presents with renal failure and bone pain. X-rays show evidence of skeletal destruction. Laboratory evaluation reveals hypercalcemia. Serum electrophoresis shows a prominent M spike. Tissue biopsy shows plasmacytoma. Bone marrow shows plasmacytosis with 35 percent plasma cells. What is the most likely diagnosis?

Accepted Answer

Multiple Myeloma

Answer

Plasmacytoma

Answer

MGUS

Answer

Smoldering Myeloma

Hematology — MCQs

Hematology — MCQs

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