Hematology Practice Questions

Q: Which of the following does not cause megaloblastic anemia?

Chloroquine. Megaloblastic anemia is characterized by impaired DNA synthesis, leading to a maturation delay between the nucleus and cytoplasm (nuclear-cytoplasmic asynchrony) [1]. This is most commonly caused by deficiencies or interference with the metabolism of Vitamin B12 and Folic acid [3]. **Why Chloroquine is the correct answer:** Chloroquine is an antimalarial and amebicidal drug. It does not interfere with DNA synthesis or folate/B12 metabolism. Therefore, it is **not** a cause of megaloblastic anemia. **Analysis of incorrect options:** * **Phenytoin:** This antiepileptic drug causes megaloblastic anemia by inhibiting the intestinal enzyme (folate conjugase), thereby reducing the absorption of dietary folates. * **Sulfasalazine:** Used in inflammatory bowel disease, it acts as a competitive inhibitor of the enzyme dihydrofolate reductase (DHFR) [2] and also impairs folate absorption. * **Alcohol:** Alcoholism is a common cause of macrocytosis. It has a direct toxic effect on the bone marrow and interferes with folate metabolism and enterohepatic circulation of folate. **High-Yield Clinical Pearls for NEET-PG:** * **Drug-induced Megaloblastic Anemia:** * **DHFR Inhibitors:** Methotrexate, Pyrimethamine, Trimethoprim [2]. * **DNA Synthesis Inhibitors:** 6-Mercaptopurine, 5-Fluorouracil, Hydroxyurea, Zidovudine (AZT). * **Absorption Interference:** Metformin, Oral Contraceptive Pills (OCPs), Phenobarbital. * **Key Finding:** The presence of **hypersegmented neutrophils** (>5 lobes) on a peripheral smear is the earliest sign of megaloblastic changes. * **Differentiation:** Unlike Vitamin B12 deficiency, Folate deficiency does **not** cause neurological symptoms (like Subacute Combined Degeneration of the spinal cord).

Q: All of the following are true about Chronic Lymphocytic Leukemia, except?

T lymphocyte CLL is more common. Explanation: **Why Option D is the Correct Answer (The Exception):** Chronic Lymphocytic Leukemia (CLL) is almost exclusively a **B-cell malignancy** (over 95% of cases). The malignant cells express B-cell markers such as CD19, CD20, and CD23, along with the characteristic aberrant expression of **CD5** (a T-cell marker). True "T-cell CLL" is an outdated term; most such cases are now classified as T-cell Prolymphocytic Leukemia (T-PLL), which is rare and clinically distinct [1]. Therefore, the statement that T-lymphocyte CLL is more common is false. **Analysis of Incorrect Options:** * **Option A:** CLL is often asymptomatic in its early stages. It is frequently **diagnosed incidentally** on routine complete blood counts (CBC) performed for other reasons, showing an isolated increase in absolute lymphocyte count [1]. * **Option B:** **Leukocytosis** (specifically lymphocytosis) is the hallmark of CLL. The diagnosis requires a sustained absolute lymphocyte count of **>5,000/µL** in the peripheral blood. * **Option C:** While CLL is an indolent "chronic" disease, it can undergo a sudden transformation into an aggressive high-grade lymphoma (usually Diffuse Large B-cell Lymphoma), a phenomenon known as **Richter’s Transformation** [1]. This presents clinically like an acute, rapidly progressing malignancy. **NEET-PG High-Yield Pearls:** * **Smudge Cells:** Characteristically seen on peripheral smears due to the fragility of the neoplastic lymphocytes. * **Immunophenotype:** CD5+, CD19+, CD20+ (weak), CD23+, and surface Ig (weak). * **Staging:** Uses the **Rai** (USA) or **Binet** (Europe) systems, primarily based on lymphadenopathy, organomegaly, and cytopenias [1]. * **Hypogammaglobulinemia:** Common in late stages, leading to recurrent bacterial infections (most common cause of death) [1].

Q: A 30-year-old man presents with anemia, clinical jaundice, and splenomegaly. He has an autosomal dominant disorder for which splenectomy is the only treatment. What is the most likely diagnosis?

Hereditary spherocytosis. ### Explanation **Correct Option: B. Hereditary Spherocytosis (HS)** The clinical triad of **anemia, jaundice, and splenomegaly** in a young patient suggests chronic hemolysis. Hereditary Spherocytosis is an **autosomal dominant** disorder (most common inheritance) caused by defects in red blood cell membrane proteins (Ankyrin, Spectrin, or Band 3). This leads to the formation of spherical RBCs that are prematurely destroyed in the splenic cords. **Splenectomy** is considered the definitive treatment for HS as it stops the site of hemolysis, corrects the anemia, and prevents gallstone formation. **Why other options are incorrect:** * **A. Thalassemia:** This is an **autosomal recessive** disorder. While splenectomy may be performed for hypersplenism or to reduce transfusion requirements, it is not the "only" or definitive treatment; the mainstay is blood transfusion and iron chelation. * **C. Sickle Cell Disease:** This is also **autosomal recessive**. Splenectomy is rarely indicated because these patients usually undergo "autosplenectomy" (splenic infarction) by early childhood. * **D. Idiopathic Autoimmune Hemolytic Anemia (AIHA):** This is an **acquired** condition, not an autosomal dominant genetic disorder. The first-line treatment is typically corticosteroids, not surgery. **NEET-PG High-Yield Pearls:** * **Diagnosis of HS:** Increased MCHC (highly specific), positive Osmotic Fragility Test, and Eosin-5-maleimide (EMA) binding test (Gold Standard). * **Surgical Timing:** Splenectomy is ideally delayed until after age 5–6 to reduce the risk of OPSI (Overwhelming Post-Splenectomy Infection). * **Prophylaxis:** Post-splenectomy patients must receive vaccinations against *S. pneumoniae*, *H. influenzae*, and *N. meningitidis* (ideally 2 weeks before elective surgery). * **Associated Finding:** Pigmented (calcium bilirubinate) gallstones are common in HS; always check the gallbladder before splenectomy.

Q: All are true about thrombotic thrombocytopenic purpura except?

Grossly abnormal coagulation tests. Thrombotic Thrombocytopenic Purpura (TTP) is a microangiopathic disorder caused by a deficiency in the **ADAMTS13** enzyme (a vWF-cleaving protease). This leads to large von Willebrand factor (vWF) multimers that cause spontaneous platelet aggregation and microthrombi formation. **1. Why Option D is the Correct Answer:** In TTP, the primary pathology is **platelet consumption**, not a failure of the coagulation cascade [1]. Therefore, **coagulation tests (PT, aPTT, and Fibrinogen) remain normal**. If these tests were grossly abnormal (prolonged PT/aPTT and low fibrinogen), the diagnosis would shift toward **Disseminated Intravascular Coagulation (DIC)** [1]. This distinction is a classic high-yield differentiator in hematology. **2. Why other options are incorrect:** * **A & B (MAHA and Thrombocytopenia):** These are the two mandatory components of the TTP diagnosis [1]. Microangiopathic Hemolytic Anemia (MAHA) is characterized by schistocytes on a peripheral smear, while thrombocytopenia results from the consumption of platelets in microthrombi [1]. * **C (Normal complement level):** TTP is not an immune-complex-mediated consumption disorder like SLE or certain glomerulonephritides; thus, complement levels (C3, C4) are typically normal. **High-Yield Clinical Pearls for NEET-PG:** * **The Classic Pentad:** (1) Microangiopathic Hemolytic Anemia (MAHA), (2) Thrombocytopenia, (3) Fever, (4) Renal failure, and (5) Neurological symptoms. (Note: Only the first two are required for a presumptive diagnosis). * **Treatment:** The treatment of choice is **Plasmapheresis (Plasma Exchange)**. * **Contraindication:** Platelet transfusion is generally **contraindicated** as it may "fuel the fire" of microthrombi formation. * **Peripheral Smear:** Always look for **Schistocytes** (fragmented RBCs).

Q: A patient presents with a hemoglobin of 5 g%, total leukocyte count of 9000/cc, differential leukocyte count showing 3% neutrophils and 75% lymphoblasts, and has had a fever for 1 month. Which of the following management options would be appropriate?

Intravenous Ciprofloxacin. This question tests the clinical management of **Febrile Neutropenia** in the context of Acute Lymphoblastic Leukemia (ALL). ### **Explanation** The patient presents with **Febrile Neutropenia**. * **Neutropenia** is defined as an Absolute Neutrophil Count (ANC) < 1500 cells/mm³. * **Severe Neutropenia** is ANC < 500 cells/mm³. * In this patient, ANC = Total Leukocyte Count × % of Neutrophils = $9000 \times 0.03 = \mathbf{270\ cells/mm^3}$. Since the patient has severe neutropenia and a fever lasting one month, this is a medical emergency. The standard of care is the immediate administration of **Intravenous (IV) broad-spectrum antibiotics** to prevent life-threatening sepsis. ### **Why other options are incorrect:** * **B. Colony stimulating factor (G-CSF):** While G-CSF can shorten the duration of neutropenia, it is not the primary treatment for an active infection/fever. Antibiotics take precedence. * **C. Packed cell transfusion:** Although the patient is anemic (Hb 5 g%), the immediate life-threatening issue is the infection [2]. Transfusion is supportive, but the "management of choice" for the febrile component is antibiotics. * **D. Oral Ciprofloxacin:** Oral antibiotics are only reserved for "Low-Risk" patients (MASCC score ≥ 21). A patient with leukemia and prolonged fever is "High-Risk" and requires IV therapy [3]. ### **Clinical Pearls for NEET-PG:** 1. **ANC Calculation:** Always calculate the ANC (TLC × % Neutrophils + % Bands). 2. **Empiric Choice:** Monotherapy with an antipseudomonal beta-lactam (e.g., Piperacillin-Tazobactam, Cefepime, or Meropenem) is usually the first line. 3. **High-Risk Criteria:** Patients with ANC < 100, hemodynamic instability, or significant comorbidities must be admitted for IV antibiotics [1]. 4. **Blast Cells:** The presence of 75% lymphoblasts confirms a diagnosis of Acute Leukemia [1].

Q: In which condition is the following finding in the tongue commonly seen?

Iron deficiency anemia. ***Iron deficiency anemia*** - **Atrophic glossitis** is the classic tongue finding, presenting as a **smooth, pale, and depapillated tongue** due to loss of filiform papillae. - This finding occurs due to **iron's role in epithelial cell renewal** and is often accompanied by **angular cheilitis** and **koilonychia** (spoon-shaped nails). *Sickle cell anemia* - Primarily causes **vaso-occlusive crises** and **hemolytic anemia** but does not typically present with atrophic glossitis. - Tongue findings are uncommon; patients more often develop **leg ulcers**, **priapism**, and **acute chest syndrome**. *Acute myeloid leukemia (AML)* - Commonly presents with **gingival hyperplasia** and **bleeding gums** due to thrombocytopenia, not atrophic glossitis. - Oral manifestations include **petechiae**, **ecchymoses**, and **oral infections** due to neutropenia. *Myelodysplastic syndrome (MDS)* - Primarily causes **pancytopenia** with **dysplastic changes** in bone marrow cells, not specific tongue abnormalities. - Oral manifestations are usually related to **thrombocytopenia** (bleeding) and **neutropenia** (infections), not atrophic glossitis.

Q: Which of the following parameters will fall the earliest in iron deficiency?

MCV. In iron deficiency anemia (IDA), the depletion of iron stores occurs in a predictable sequence. Understanding the kinetics of red cell indices is crucial for NEET-PG. **Why MCV is the correct answer:** As iron stores are exhausted, the bone marrow begins to produce smaller red cells (microcytosis) before the hemoglobin concentration within those cells significantly drops [1]. **Mean Corpuscular Volume (MCV)** measures the average size of the RBC. In the progression of IDA, microcytosis (low MCV) typically precedes hypochromia (low MCH/MCHC) [1]. Therefore, MCV is the first of the standard indices (MCV, MCH, MCHC) to fall below the reference range. **Analysis of Incorrect Options:** * **B. MCH (Mean Corpuscular Hemoglobin):** This measures the average amount of hemoglobin per RBC. While it falls early, it generally follows the decrease in MCV. * **C. MCHC (Mean Corpuscular Hemoglobin Concentration):** This is the last index to decrease. It reflects the "concentration" of hemoglobin; cells become smaller first to maintain concentration before eventually becoming pale (hypochromic). * **D. Red Cell Distribution Width (RDW):** RDW actually **increases** (not falls) in iron deficiency. It is often the very first sign of IDA on a CBC, representing anisocytosis (variation in cell size) as new small cells mix with older normal-sized cells. **High-Yield Clinical Pearls for NEET-PG:** 1. **Earliest Biochemical Marker:** Serum Ferritin (reflects storage iron). 2. **Earliest Hematological Change:** Increased RDW (Red Cell Distribution Width). 3. **Earliest Index to Fall:** MCV. 4. **Gold Standard Diagnosis:** Bone marrow aspiration (Perl’s Prussian Blue stain) showing absent haemosiderin [1]. 5. **Mentzer Index:** MCV/RBC count. If 13, suggests Iron Deficiency Anemia.

Question 1

Which of the following does not cause megaloblastic anemia?

Accepted Answer

Chloroquine

Answer

Phenytoin

Answer

Sulfasalazine

Answer

Alcohol

Question 2

A 43-year-old woman complains of constant tiredness, light-headedness, and occasional palpitations and shortness of breath. Physical examination shows pallor of the oral mucosa and glossitis. Neurologic examination reveals paresthesias, numbness, decreased vibration sensation, and loss of deep tendon reflexes. Laboratory studies include hemoglobin of 7.2 g/dL, WBC of 4,500/mL, platelets of 140,000/mL, erythrocyte folate of 220 ng/mL, serum vitamin B12 of 40 pg/mL, serum anti-intrinsic factor of 1:128, and serum anti-parietal cell antibody of 1:64. Peripheral blood shows macrocytic anemia with poikilocytosis of RBCs and hypersegmented neutrophils. Atrophic gastritis is diagnosed by gastric biopsy. What is the expected bone marrow examination finding in this patient?

Accepted Answer

Hypercellularity with megaloblastic erythroid maturation

Answer

Absent stainable bone marrow iron

Answer

Atypical megakaryocytes with fibrosis

Answer

Hypocellularity with absence of erythroid precursors

Question 3

All of the following are true about Chronic Lymphocytic Leukemia, except?

Accepted Answer

T lymphocyte CLL is more common

Answer

Diagnosed on routine blood tests

Answer

Leukocytosis is prominent

Answer

Can present as acute leukemia

Question 4

A 30-year-old man presents with anemia, clinical jaundice, and splenomegaly. He has an autosomal dominant disorder for which splenectomy is the only treatment. What is the most likely diagnosis?

Accepted Answer

Hereditary spherocytosis

Answer

Thalassemia

Answer

Sickle cell disease

Answer

Idiopathic autoimmune hemolytic anemia

Question 5

What is the primary abnormality in the sequence of events leading to Disseminated Intravascular Coagulation (DIC)?

Accepted Answer

Uncontrolled thrombin generation

Answer

Fibrin deposits in multiple sites

Answer

Abnormal adhesion and consumption of platelets

Answer

Destruction of red cells

Question 6

All are true about thrombotic thrombocytopenic purpura except?

Accepted Answer

Grossly abnormal coagulation tests

Answer

Microangiopathic hemolytic anemia

Answer

Thrombocytopenia

Answer

Normal complement level

Question 7

A 63-year-old woman experiences a burning sensation in her hands and feet. Two months prior, she had an episode of swelling with tenderness in the right leg, followed by dyspnea and right-sided chest pain. Physical examination reveals splenomegaly and hepatomegaly. CBC shows hemoglobin, 13.3 g/dL; hematocrit, 40.1%; MCV, 91 mm3; platelet count, 657,000/mm3; and WBC count, 17,400/mm3. The peripheral blood smear shows abnormally large platelets. Which of the following is the most likely diagnosis?

Accepted Answer

Essential thrombocytosis

Answer

Acute myelogenous leukemia

Answer

Chronic myelogenous leukemia

Answer

Myelofibrosis with myeloid metaplasia

Question 8

A patient presents with a hemoglobin of 5 g%, total leukocyte count of 9000/cc, differential leukocyte count showing 3% neutrophils and 75% lymphoblasts, and has had a fever for 1 month. Which of the following management options would be appropriate?

Accepted Answer

Intravenous Ciprofloxacin

Answer

Colony stimulating factor

Answer

Packed cell transfusion

Answer

Oral Ciprofloxacin

Question 9

In which condition is the following finding in the tongue commonly seen?

Accepted Answer

Iron deficiency anemia

Answer

Sickle cell anemia

Answer

Acute myeloid leukemia (AML)

Answer

Myelodysplastic syndrome (MDS)

Question 10

Which of the following parameters will fall the earliest in iron deficiency?

Accepted Answer

MCV

Answer

MCH

Answer

MCHC

Answer

Red cell distribution width

Hematology — MCQs

Hematology — MCQs

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