Hematology — MCQs

Hematology Indian Medical PG Practice Questions and MCQs

Question 1011: A 63-year-old female with rheumatoid arthritis and renal impairment presents with anemia. A bone marrow biopsy shows increased cellularity with all cell lines present. What is the most likely cause of her anemia?

A. Anemia of chronic disease (Correct Answer)
B. Iron deficiency anemia
C. Vitamin B12 deficiency
D. Acute blood loss

Explanation: ***Anemia of chronic disease*** - This patient has **rheumatoid arthritis** and **renal impairment**, both chronic inflammatory conditions that reduce **erythropoietin** production and iron utilization, leading to anemia [2]. Interleukin-6 (IL-6) plays a critical role in regulating the systemic effects of RA by inducing the acute phase response and anemia of chronic disease [1]. - The bone marrow biopsy demonstrating **increased cellularity with all cell lines present** is consistent with anemia of chronic disease, indicating adequate marrow response but impaired red blood cell maturation and release. *Iron deficiency anemia* - While iron deficiency can occur in this patient population, the bone marrow biopsy showing **increased cellularity** and **all cell lines present** argues against the typical picture of iron deficiency, which often involves a hypoplastic or less active marrow in terms of red cell precursors [2]. - **Iron studies** (ferritin, transferrin saturation) would be crucial to rule this out [3], and the absence of specific findings like microcytosis and hypochromia on peripheral smear makes it less likely as the primary cause here. *Vitamin B12 deficiency* - **Vitamin B12 deficiency** typically leads to **megaloblastic anemia**, characterized by **hypersegmented neutrophils** and **macrocytic red blood cells**, which is not indicated by the provided information [2]. - A bone marrow biopsy in B12 deficiency would often show **megaloblastic changes** in erythroid and myeloid precursors, which is not described as "all cell lines present" in a normal context. *Acute blood loss* - **Acute blood loss** would typically present with signs of hypovolemia and an **elevated reticulocyte count** due to compensatory marrow response, none of which are mentioned [2]. - Furthermore, a bone marrow biopsy after acute blood loss often shows erythroid hyperplasia, but "increased cellularity with all cell lines present" is less specific and more aligned with chronic conditions.

Question 1012: In a patient with severe anemia and fatigue, which laboratory test is crucial to differentiate between iron deficiency anemia and anemia of chronic disease?

A. Serum ferritin (Correct Answer)
B. Complete blood count
C. Hemoglobin electrophoresis
D. Reticulocyte count

Explanation: ***Serum ferritin*** - Serum ferritin levels are a key indicator of **iron stores** in the body, allowing differentiation between iron deficiency anemia (low ferritin) and anemia of chronic disease (normal or increased ferritin) [2]. - In iron deficiency anemia, **ferritin** is usually significantly decreased, whereas in anemia of chronic disease, ferritin can be normal or even elevated due to chronic inflammation [1], [2]. *Complete blood count* - While a complete blood count (CBC) provides overall information on hemoglobin, hematocrit, and RBC indices, it does not specifically indicate the cause of anemia [3]. - Both types of anemia can present with similar CBC findings, making it insufficient for differentiation. *Hemoglobin electrophoresis* - This test is primarily used to identify **hemoglobinopathies** such as sickle cell disease and thalassemia, not to distinguish between types of anemia due to iron deficiency or chronic disease. - It would not provide relevant information for the iron metabolism status necessary for this differentiation. *Reticulocyte count* - A reticulocyte count measures the bone marrow's response to anemia but does not specifically indicate whether the anemia is due to iron deficiency or chronic disease. - Both conditions can result in a low reticulocyte count, making it an inadequate test for this purpose.

Question 1013: A 45-year-old male presents with fatigue, arthralgia, and darkening of the skin. Laboratory tests show elevated serum iron and transferrin saturation. What is the most likely diagnosis?

A. Hemochromatosis (Correct Answer)
B. Wilson's disease
C. Addison's disease
D. Cushing's syndrome

Explanation: ***Hemochromatosis*** - **Hemochromatosis** is characterized by excessive iron absorption and deposition, leading to symptoms like **fatigue**, **arthralgia**, and **bronze skin pigmentation** (darkening of the skin) [1]. - Elevated **serum iron** and **transferrin saturation** are key laboratory findings that confirm the diagnosis [2]. *Wilson's disease* - **Wilson's disease** involves excessive copper accumulation, primarily affecting the liver, brain, and eyes (**Kayser-Fleischer rings**). - Symptoms include neurological and psychiatric disturbances, and liver disease, with laboratory findings showing decreased **serum ceruloplasmin** and increased urinary copper, not elevated iron. *Addison's disease* - **Addison's disease** is caused by adrenal insufficiency, leading to symptoms such as fatigue, weight loss, and **hyperpigmentation** (darkening of the skin) due to increased ACTH. - However, it is characterized by electrolyte imbalances (hyponatremia, hyperkalemia) and low cortisol levels, not elevated iron. *Cushing's syndrome* - **Cushing's syndrome** results from prolonged exposure to high levels of cortisol, presenting with symptoms like truncal obesity, moon facies, and purple striae. - While it can cause fatigue, skin changes typically involve easy bruising and thin skin, not generalized darkening, and iron metabolism is not primarily affected.

Question 1014: A 45-year-old woman presents with severe fatigue, pallor, and a sore tongue. Her hemoglobin level is 8 g/dL, and her mean corpuscular volume is 105 fL. What is the most likely cause of her anemia?

A. Vitamin B12 deficiency (Correct Answer)
B. Iron deficiency
C. Sickle cell disease
D. Thalassemia

Explanation: ***Vitamin B12 deficiency*** - The combination of severe fatigue, pallor, **sore tongue** (glossitis), **macrocytic anemia** (MCV > 100 fL), and low hemoglobin strongly suggests **vitamin B12 deficiency** [1]. - **Pernicious anemia**, an autoimmune condition affecting intrinsic factor, is a common cause of B12 deficiency in this age group, leading to impaired B12 absorption [1]. *Iron deficiency* - This typically presents with **microcytic anemia** (low MCV), not macrocytic anemia as seen in this patient (MCV 105 fL) [2]. - While fatigue and pallor are common, iron deficiency does not typically cause a **sore tongue** as a prominent symptom. *Sickle cell disease* - This is a **hereditary hemolytic anemia** characterized by sickled red blood cells and recurrent pain crises, usually diagnosed in childhood [2]. - It would present with specific features like **hemolysis** and often **normocytic anemia**, not the macrocytic anemia seen in this case [2]. *Thalassemia* - Thalassemia is a **genetic disorder** causing abnormal hemoglobin production, leading to **microcytic hypochromic anemia**. - Its presentation is typically characterized by a **low MCV** and is often diagnosed earlier in life, unlike the macrocytic anemia in this scenario.

Question 1015: A 35-year-old female presents with fatigue, palpitations, and pallor. Laboratory tests reveal a hemoglobin level of 8 g/dL, low serum iron, and high TIBC. Which additional test would best guide the next step in management?

A. Reticulocyte count
B. Bone marrow biopsy
C. Serum ferritin level (Correct Answer)
D. Serum vitamin B12 level

Explanation: ***Serum ferritin level*** - The **serum ferritin level** directly reflects the body's **iron stores**, essential for confirming iron deficiency anemia in this patient [2]. - Low ferritin would confirm iron deficiency, guiding management towards **iron supplementation** [1]. *Reticulocyte count* - A **reticulocyte count** measures the bone marrow's response to anemia; however, it does not determine the underlying cause. - In iron deficiency anemia, the reticulocyte count may be **low** due to inadequate iron for erythropoiesis. *Serum vitamin B12 level* - A **serum vitamin B12 level** is relevant for diagnosing macrocytic anemias, not microcytic anemia featured here due to low **serum iron** [3]. - This test would not clarify the cause of the anemia since the lab results suggest iron deficiency [4]. *Bone marrow biopsy* - A **bone marrow biopsy** is an invasive procedure typically reserved for cases of unexplained anemia or suspected malignancy. - It is not necessary here since the clinical picture and lab findings strongly indicate iron deficiency anemia [4].

Question 1016: A 7-year-old male presents with persistent epistaxis, easy bruising, and joint swelling. There is a family history of hemophilia. Laboratory results show an increased PTT, normal PT, and decreased factor VIII activity. Evaluate the treatment options considering the risk and benefit.

A. Recombinant factor IX therapy + antifibrinolytics
B. Fresh frozen plasma + supportive measures
C. Gene therapy trial with monitoring
D. Factor VIII replacement therapy + DDAVP for mild cases (Correct Answer)

Explanation: ***Factor VIII replacement therapy + DDAVP for mild cases*** - The patient's presentation with **persistent epistaxis**, **easy bruising**, **joint swelling**, increased **PTT**, normal **PT**, and decreased **factor VIII activity** is characteristic of **hemophilia A** [1]. - **Factor VIII replacement therapy** directly addresses the underlying deficiency, and **desmopressin (DDAVP)** can be used for mild cases as it stimulates the release of endogenous factor VIII and von Willebrand factor [1]. *Recombinant factor IX therapy + antifibrinolytics* - **Recombinant factor IX therapy** is indicated for **hemophilia B**, which involves a deficiency in factor IX, not factor VIII. - While **antifibrinolytics** (e.g., tranexamic acid, epsilon-aminocaproic acid) can be used as adjuncts to prevent clot breakdown, they do not correct the primary coagulation defect. *Fresh frozen plasma + supportive measures* - **Fresh frozen plasma (FFP)** contains all clotting factors, but it requires large volumes to achieve therapeutic levels of factor VIII, carries a risk of **transfusion-related acute lung injury (TRALI)** and viral transmission, and is less effective than targeted factor replacement [1]. - **Supportive measures** alone are insufficient to manage severe bleeding episodes in hemophilia. *Gene therapy trial with monitoring* - **Gene therapy** is an investigational treatment for hemophilia, mainly considered for severe cases and is currently not the first-line treatment. - While promising, it involves potential risks and long-term efficacy and safety are still under evaluation, making it less suitable for initial management compared to established therapies.

Question 1017: A 55-year-old man presents with weakness and lymphadenopathy. A peripheral blood smear shows lymphocytosis with smudge cells. What is the best treatment option for symptomatic chronic lymphocytic leukemia (CLL)?

A. Bone marrow transplant
B. Surgery followed by radiation therapy
C. Observation with routine blood work
D. BTK inhibitor therapy (e.g., ibrutinib) (Correct Answer)

Explanation: ***Chemotherapy with rituximab*** - Rituximab is an effective therapy for **chronic lymphocytic leukemia (CLL)** [1], especially indicated in symptomatic patients with lymphocytosis and **smudge cells**. - It targets **CD20** on B-cells [1], leading to tumor cell apoptosis and depletion, improving symptoms like weakness and lymphadenopathy. *Observation with routine blood work* - This approach may be used for **asymptomatic CLL** [1] but does not address the current symptoms of weakness and lymphadenopathy. - It is inappropriate for symptomatic cases, where treatment is warranted to prevent disease progression. *Surgery followed by radiation therapy* - Surgery is generally not indicated in **CLL**, as it is typically not a solid tumor amenable to surgical resection. - Radiation therapy is also not the primary treatment; it is more relevant in localized lymphomas rather than CLL [1]. *Bone marrow transplant* - Generally considered for **refractory cases** or high-risk leukemias, it is not the first-line treatment for CLL [1]. - This approach carries significant risks and is reserved for cases not responsive to standard therapies like **rituximab**.

Question 1018: A 60-year-old male presents with fatigue, anemia, and splenomegaly. His peripheral blood smear shows teardrop-shaped red blood cells. Which of the following physiological mechanisms is most likely responsible for his anemia?

A. Increased iron absorption in the gut
B. Decreased erythropoietin production in the kidneys
C. Increased erythropoiesis response
D. Decreased red blood cell lifespan due to splenic sequestration (Correct Answer)

Explanation: ***Decreased red blood cell lifespan due to splenic sequestration*** - **Myelofibrosis** often leads to splenomegaly due to **extramedullary hematopoiesis** [3] and an enlarged spleen can sequester and destroy red blood cells prematurely [1]. - The characteristic **teardrop-shaped red blood cells** (poikilocytosis) are a hallmark of myelofibrosis, indicating distorted erythropoiesis [3] and fragmentation, making them more susceptible to splenic removal. *Increased iron absorption in the gut* - This mechanism would lead to **iron overload**, not anemia, and is typically seen in conditions like **hereditary hemochromatosis**. - While iron dysregulation can occur in myelofibrosis, primary increased absorption is not the cause of anemia [4]. *Decreased erythropoietin production in the kidneys* - This is characteristic of **anemia of chronic kidney disease**, where failing kidneys cannot produce adequate **erythropoietin** to stimulate bone marrow [2]. - In myelofibrosis, erythropoietin levels may be normal or even elevated as the body tries to compensate for insufficient red blood cell production. *Increased erythropoiesis response* - An **increased erythropoiesis response** would typically lead to **reticulocytosis** and aim to correct the anemia, not cause it. - While there is often compensatory erythropoiesis (often extramedullary) in myelofibrosis, it is usually ineffective, and the overall result is still anemia [3].

Question 1019: In a 32-year-old female with chronic fatigue, a blood test shows low hemoglobin and elevated mean corpuscular volume (MCV). What is the most appropriate dietary recommendation?

A. Increase intake of green leafy vegetables
B. Increase intake of vitamin B12 rich foods (Correct Answer)
C. Increase intake of protein-rich foods
D. Increase intake of iron supplements

Explanation: ***Increase intake of vitamin B12 rich foods*** - Elevated **mean corpuscular volume (MCV)** with low **hemoglobin** suggests **macrocytic anemia**, most commonly due to **vitamin B12** or **folate deficiency** [1]. - **Vitamin B12** is crucial for **DNA synthesis** in red blood cell production, and deficiency leads to the production of larger, immature red blood cells [1]. *Increase intake of green leafy vegetables* - **Green leafy vegetables** are rich in **folate**, another common cause of **macrocytic anemia** [1]. - While beneficial, **vitamin B12 deficiency** can also cause neurological symptoms, so addressing it is critical. *Increase intake of protein-rich foods* - **Protein** is necessary for overall health and **hemoglobin synthesis**, but directly addressing the specific cause of macrocytic anemia (vitamin B12 deficiency) is more appropriate. - While important for general nutrition, **protein deficiency** does not typically manifest with isolated macrocytic anemia. *Increase intake of iron supplements* - **Iron deficiency** typically causes **microcytic anemia** (low MCV), not **macrocytic anemia** (elevated MCV) [1]. - Administering **iron supplements** in the presence of macrocytic anemia for which it is not indicated can delay proper diagnosis and treatment [1].

Question 1020: A 55-year-old woman presents with fatigue, pallor, and jaundice. Laboratory tests show hemoglobin of 8.5 g/dL, a reticulocyte count of 6%, and an indirect bilirubin level of 3.5 mg/dL. Which test is most likely to confirm the diagnosis?

A. Serum ferritin
B. Direct Coombs test (Correct Answer)
C. Hemoglobin electrophoresis
D. Bone marrow biopsy

Explanation: ***Direct Coombs test*** - The patient's symptoms (fatigue, pallor, jaundice) combined with laboratory findings (**anemia**, **reticulocytosis**, **indirect hyperbilirubinemia**) are highly suggestive of **hemolytic anemia** [1],[2]. - A **Direct Coombs test** (Direct Antiglobulin Test or DAT) is used to detect antibodies or complement components bound to the surface of red blood cells, which is the hallmark of **autoimmune hemolytic anemia** [1]. *Serum ferritin* - **Serum ferritin** measures iron stores and would be relevant for diagnosing **iron deficiency anemia**. - However, the presence of **jaundice** and **reticulocytosis** points away from iron deficiency and towards a hemolytic process. *Hemoglobin electrophoresis* - **Hemoglobin electrophoresis** is used to identify abnormal hemoglobin variants and diagnose conditions like **sickle cell anemia** or **thalassemia**. - While these can cause hemolytic anemia, the acute presentation with clear signs of red blood cell destruction (jaundice, reticulocytosis) in an adult often warrants investigation for an acquired cause like **autoimmune hemolytic anemia** first [1]. *Bone marrow biopsy* - A **bone marrow biopsy** is invasive and typically reserved for investigating disorders of hematopoiesis, such as bone marrow failure syndromes or hematologic malignancies. - While it can assess red blood cell production, it is not the primary diagnostic test for identifying the cause of active **hemolysis**.

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Anemia Evaluation and Management

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Hemoglobinopathies

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Thalassemias

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Platelet Disorders

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Coagulation Disorders

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Thrombotic Disorders

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Leukemias

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Lymphomas

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Multiple Myeloma and Plasma Cell Disorders

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Myeloproliferative Neoplasms

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Transfusion Medicine

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Hematopoietic Stem Cell Transplantation

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Hematology — MCQs

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