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 a feature of Chronic Myeloid Leukemia (CML)?

Autoimmune hemolytic anemia. **Explanation:** Chronic Myeloid Leukemia (CML) is a myeloproliferative neoplasm characterized by the uncontrolled proliferation of the myeloid lineage, driven by the **Philadelphia chromosome t(9;22)** and the resulting **BCR-ABL1** fusion gene [1]. **Why Option D is the Correct Answer:** **Autoimmune Hemolytic Anemia (AIHA)** is a classic feature of **Chronic Lymphocytic Leukemia (CLL)**, not CML [2]. In CML, anemia is typically normocytic normochromic due to bone marrow overcrowding (myelophthisis) or splenic sequestration, rather than immune-mediated destruction. **Analysis of Incorrect Options:** * **A. Pruritus:** This is a common feature in myeloproliferative neoplasms. It occurs due to **basophilia** and the subsequent release of histamine. * **B. Infections:** While CML presents with a high white cell count, these cells are often dysfunctional [1]. Furthermore, as the disease progresses to the Accelerated Phase or Blast Crisis, neutropenia can occur, leading to opportunistic infections. * **C. Shift to left:** This is a hallmark of CML. The peripheral blood smear shows the entire spectrum of myeloid differentiation, including myeloblasts, promyelocytes, myelocytes (the "myelocyte bulge"), and metamyelocytes. **High-Yield Clinical Pearls for NEET-PG:** * **Leukocyte Alkaline Phosphatase (LAP) Score:** Characteristically **decreased** in CML (helps differentiate it from a Leukemoid Reaction, where LAP is increased). * **Splenomegaly:** The most common physical finding; often "massive" [2]. * **Drug of Choice:** Imatinib (a Tyrosine Kinase Inhibitor) [1]. * **Cytogenetics:** Presence of t(9;22) is essential for diagnosis [1].

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: All of the following are inherited thrombocytopenia syndromes, EXCEPT:

Pelger-Huet anomaly. **Explanation:** The correct answer is **D. Pelger-Huet anomaly**. The core medical concept here is distinguishing between **disorders of platelet number/size** and **disorders of leukocyte morphology**. 1. **Why Pelger-Huet anomaly is the correct answer:** Pelger-Huet anomaly is an autosomal dominant condition characterized by a failure of normal neutrophil segmentation. This results in "pince-nez" nuclei (bilobed) or non-segmented nuclei. Crucially, it is a **benign white blood cell morphology variant** and does not involve thrombocytopenia or platelet abnormalities. 2. **Why the other options are incorrect:** Options A, B, and C are all part of the **MYH9-related disorders (MYH9-RD)** spectrum. These are inherited as autosomal dominant conditions caused by mutations in the *MYH9* gene, which encodes the non-muscle myosin heavy chain IIA. * **May-Hegglin Anomaly:** Characterized by the triad of macrothrombocytopenia (large platelets), thrombocytopenia, and blue-staining cytoplasmic inclusions in neutrophils (Döhle-like bodies). * **Epstein’s Syndrome:** Features macrothrombocytopenia along with hereditary nephritis and sensorineural hearing loss. * **Fechtner Syndrome:** Includes all features of Epstein’s syndrome plus the presence of leukocyte inclusions (similar to May-Hegglin). **High-Yield Clinical Pearls for NEET-PG:** * **MYH9-RD Triad:** Macrothrombocytopenia + Leukocyte inclusions + Variable systemic involvement (renal/hearing). * **Wiskott-Aldrich Syndrome:** Another high-yield inherited thrombocytopenia, but unlike MYH9-RD, it features **microthrombocytes** (very small platelets). * **Pseudo-Pelger-Huet:** If seen in an older patient, it is often an acquired sign of **Myelodysplastic Syndrome (MDS)** or acute myeloid leukemia, rather than the benign inherited form.

Question 1

Leukocytosis is seen in all conditions except?

Accepted Answer

Typhoid Fever

Answer

Brucellosis

Answer

Acute Myocardial Infarction

Answer

Diphtheria

Question 2

Which antibody is commonly elevated in Waldenstrom macroglobulinemia?

Accepted Answer

IgM

Answer

IgG

Answer

IgA

Answer

IgD

Question 3

Which disorder is most likely associated with erythroid hyperplasia in the bone marrow?

Accepted Answer

7 to 10 days after a gastrointestinal bleed

Answer

Anemia of chronic disease

Answer

Thalassemia minor

Answer

Iron deficiency

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 a feature of Chronic Myeloid Leukemia (CML)?

Accepted Answer

Autoimmune hemolytic anemia

Answer

Pruritus

Answer

Infections

Answer

Shift to left

Question 7

Which blood indices most accurately reflect iron deficiency?

Accepted Answer

MCHC

Answer

MCV

Answer

MCH

Answer

PCV

Question 8

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 9

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 10

All of the following are inherited thrombocytopenia syndromes, EXCEPT:

Accepted Answer

Pelger-Huet anomaly

Answer

May Hegglin anomaly

Answer

Epstein's syndrome

Answer

Fechtner syndrome

Hematology — MCQs

Hematology — MCQs

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