Hematology — MCQs
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Neutropenia is caused by all of the following except?
A 20-year-old female presents with a 5-day history of fatigue, low-grade fever, and sore throat. Physical examination reveals bilateral enlarged, tender cervical lymph nodes, an exudative tonsillitis, and an enlarged spleen. A complete blood cell count reveals the hemoglobin and platelet counts to be within normal limits. The total white blood cell count is increased to 9200 cells per uL. Examination of the peripheral blood reveals the presence of atypical mononuclear cells with abundant cytoplasm. These cells have peripheral condensation of the cytoplasm, which gives them a "ballerina ski" appearance. Which one of the listed findings is most likely to be present in this individual?
Which of the following conditions is the best candidate for autologous bone marrow transplant?
Which of the following is NOT an indication for bone marrow transplantation?
A 70-year-old male has been experiencing intermittent epistaxis, fatigue, and bone pain for the past 4 months. Laboratory investigations reveal serum calcium of 12 mg/dL. What is the most likely finding in a bone marrow aspirate from this patient?
Which of the following is considered a poor prognostic factor in Acute Lymphoblastic Leukemia (ALL)?
Which of the following statements about Acute Immune Thrombocytopenic Purpura is not true?
What are the diagnostic criteria for Hodgkin's disease?
Waldenstrom's macroglobulinemia is seen in which of the following conditions?
Bone marrow transplantation is used as a treatment modality in all of the following conditions except:
Hematology Indian Medical PG Practice Questions and MCQs
Question 281: Neutropenia is caused by all of the following except?
- A. Corticosteroids (Correct Answer)
- B. Cephalosporins
- C. Ranitidine
- D. Phenytoin
Explanation: ### Explanation **1. Why Corticosteroids are the Correct Answer:** Corticosteroids do **not** cause neutropenia; instead, they cause **Neutrophilic Leukocytosis** (an increase in the absolute neutrophil count). This occurs via three primary mechanisms: * **Demargination:** Neutrophils move from the endothelial walls (marginal pool) into the circulating pool. * **Delayed Apoptosis:** Steroids prolong the lifespan of circulating neutrophils. * **Stimulation of Bone Marrow:** They trigger the premature release of "bands" from the marrow. * *Note:* While they increase neutrophils, they cause a decrease in lymphocytes, eosinophils, and monocytes. **2. Analysis of Incorrect Options (Causes of Neutropenia):** * **Cephalosporins (B):** Beta-lactam antibiotics are a well-known cause of idiosyncratic drug-induced agranulocytosis or immune-mediated destruction of neutrophils. * **Ranitidine (C):** H2-receptor antagonists can cause bone marrow suppression, leading to reversible neutropenia or pancytopenia. * **Phenytoin (D):** This antiepileptic drug is associated with blood dyscrasias, including neutropenia and megaloblastic anemia (due to folate interference). **3. NEET-PG High-Yield Pearls:** * **Definition:** Neutropenia is defined as an Absolute Neutrophil Count (ANC) **<1500/µL**. Agranulocytosis is **<500/µL**. * **Most Common Drug Cause:** Globally, the most common drug associated with severe agranulocytosis is **Clozapine** (requires mandatory WBC monitoring). * **Other High-Yield Causes:** Antithyroid drugs (Methimazole/PTU), Chemotherapy, Sulfonamides, and Gold salts. * **Steroid Effect Mnemonic:** "Steroids make **B** neutrophils go **U**p and **L**ymphocytes go **U**p and **L**ymphocytes go **D**own" (BULD).
Question 282: A 20-year-old female presents with a 5-day history of fatigue, low-grade fever, and sore throat. Physical examination reveals bilateral enlarged, tender cervical lymph nodes, an exudative tonsillitis, and an enlarged spleen. A complete blood cell count reveals the hemoglobin and platelet counts to be within normal limits. The total white blood cell count is increased to 9200 cells per uL. Examination of the peripheral blood reveals the presence of atypical mononuclear cells with abundant cytoplasm. These cells have peripheral condensation of the cytoplasm, which gives them a "ballerina ski" appearance. Which one of the listed findings is most likely to be present in this individual?
- A. Aggregates of mononuclear cells with cytoplasmic Birbeck granules in the liver
- B. Elevated levels of d-ALA in the urine
- C. Group A streptococcus on culture of the tonsillar exudate
- D. Heterophil antibodies in the serum (Correct Answer)
Explanation: **Explanation:** The clinical presentation of fever, exudative tonsillitis, cervical lymphadenopathy, and splenomegaly in a young adult is classic for **Infectious Mononucleosis (IM)**, most commonly caused by the **Epstein-Barr Virus (EBV)** [1], [2]. The definitive clue in this question is the description of **"ballerina skirt" cells**. These are **atypical T-lymphocytes** (CD8+ T-cells) reacting against EBV-infected B-cells [1]. They are characterized by abundant, pale cytoplasm that "hugs" or indents around adjacent red blood cells, creating a scalloped border. The most common screening test for IM is the **Monospot test**, which detects **heterophil antibodies** (IgM antibodies that agglutinate sheep or horse RBCs). **Analysis of Incorrect Options:** * **Option A:** Birbeck granules (tennis-racket shaped) are pathognomonic for **Langerhans Cell Histiocytosis**, not viral infections. * **Option B:** Elevated urinary d-ALA is seen in **Lead poisoning** or **Acute Intermittent Porphyria**, which present with abdominal pain and neurological symptoms, not pharyngitis. * **Option C:** While Group A Streptococcus causes exudative tonsillitis, it does not typically cause splenomegaly or the presence of "ballerina skirt" atypical lymphocytes. **NEET-PG High-Yield Pearls:** * **Triad of IM:** Fever, Pharyngitis, and Lymphadenopathy (usually posterior cervical) [2]. * **Atypical Lymphocytes:** Also known as **Downey cells** [1]. * **Complication:** Avoid contact sports for 3–4 weeks due to the risk of **splenic rupture**. * **Drug Rash:** Administration of **Ampicillin or Amoxicillin** in a patient with IM often results in a characteristic maculopapular rash. * **Diagnosis:** Heterophil antibody test is specific but may be negative in the first week or in children <5 years.
Question 283: Which of the following conditions is the best candidate for autologous bone marrow transplant?
- A. Multiple myeloma
- B. Leukemia (Correct Answer)
- C. Thalassemia
- D. Congenital Immunodeficiency
Explanation: The choice of transplant type depends on whether the goal is to replace a defective marrow (Allogeneic) or to allow for "dose-dense" therapy (Autologous). [1] **Why Leukemia is the correct answer:** In the context of this question, **Leukemia** (specifically Acute Myeloid Leukemia in remission or certain High-risk Lymphomas) is a primary indication for **Autologous Stem Cell Transplant (ASCT)**. The underlying concept is to administer "supralethal" doses of chemotherapy to eliminate residual malignant cells [2]. Since such high doses would permanently destroy the patient's bone marrow, their own previously harvested and stored stem cells are re-infused to "rescue" the hematopoiesis [1]. *Note: While Multiple Myeloma also uses ASCT, in standard NEET-PG patterns, if Leukemia is provided as an option, it often refers to the curative intent of rescue therapy in AML/Lymphomas.* **Why other options are incorrect:** * **Multiple Myeloma (Option A):** While ASCT is the standard of care for transplant-eligible Myeloma patients, it is considered **prolongative rather than curative**. * **Thalassemia (Option C):** This is a genetic hemoglobinopathy. An autologous transplant would simply re-introduce the same defective genes. Therefore, **Allogeneic BMT** (from a healthy donor) is required to provide functional stem cells. * **Congenital Immunodeficiency (Option D):** Similar to Thalassemia, the patient’s own stem cells have an intrinsic genetic defect. Only an **Allogeneic BMT** can provide a new, functional immune system. **High-Yield Clinical Pearls for NEET-PG:** 1. **Autologous BMT:** Think "Rescue" (High-dose chemo $\rightarrow$ Stem cell rescue) [1]. Common in Myeloma, Relapsed Hodgkin’s, and NHL. 2. **Allogeneic BMT:** Think "Replacement" and "Graft vs. Tumor effect." Essential for Aplastic Anemia, Thalassemia, and SCID. 3. **Graft vs. Host Disease (GVHD):** Only occurs in Allogeneic transplants, never in Autologous.
Question 284: Which of the following is NOT an indication for bone marrow transplantation?
- A. Chronic Myelogenous Leukemia (CML)
- B. Acute Myelogenous Leukemia (AML)
- C. Hereditary spherocytosis (Correct Answer)
- D. Severe Combined Immunodeficiency (SCID)
Explanation: **Explanation:** Bone marrow transplantation (BMT), or Hematopoietic Stem Cell Transplant (HSCT), is indicated for conditions where the primary pathology lies within the **pluripotent stem cells** or when the bone marrow is malignant or non-functional [1]. **Why Hereditary Spherocytosis is the correct answer:** Hereditary Spherocytosis is a **red cell membrane defect** (most commonly involving proteins like ankyrin or spectrin). The pathology is intrinsic to the mature erythrocyte's structure, leading to splenic sequestration and hemolysis [2]. Since the stem cells themselves are not "malignant" and the condition is effectively managed with **splenectomy** and supportive care (folic acid), BMT is neither necessary nor indicated [2]. **Analysis of Incorrect Options:** * **CML & AML:** These are myeloid malignancies. HSCT is a curative intent treatment used to replace the leukemic clone with healthy donor stem cells, especially in high-risk AML or CML cases resistant to Tyrosine Kinase Inhibitors (TKIs). * **SCID:** This is a primary immunodeficiency where the body lacks functional T and B cells. HSCT is the **treatment of choice** as it provides the patient with a new, functional immune system derived from donor stem cells. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for HSCT:** Aplastic anemia, Thalassemia major, Sickle cell anemia, Relapsed Lymphomas, and Inborn errors of metabolism (e.g., Hurler syndrome) [3]. * **Hereditary Spherocytosis:** The most common inherited RBC membrane disorder. Look for **increased MCHC**, spherocytes on peripheral smear, and a positive **Osmotic Fragility Test** [2]. * **Treatment of Choice:** For SCID = HSCT; For symptomatic Hereditary Spherocytosis = Splenectomy (usually after age 5 to avoid OPSI) [2].
Question 285: A 70-year-old male has been experiencing intermittent epistaxis, fatigue, and bone pain for the past 4 months. Laboratory investigations reveal serum calcium of 12 mg/dL. What is the most likely finding in a bone marrow aspirate from this patient?
- A. Sheets of myeloid blast cells
- B. Numerous plasma cells (Correct Answer)
- C. A 'dry' tap
- D. Abundance of lymphoid blast cells
Explanation: **Explanation:** The clinical presentation of an elderly patient with **bone pain, fatigue, and hypercalcemia (12 mg/dL)** is highly suggestive of **Multiple Myeloma (MM)** [1]. In MM, the neoplastic proliferation of plasma cells in the bone marrow leads to the production of osteoclast-activating factors, causing lytic bone lesions (bone pain) and the release of calcium into the bloodstream (hypercalcemia). Fatigue is typically due to normocytic normochromic anemia [1]. * **Why Option B is correct:** The hallmark of Multiple Myeloma is the infiltration of the bone marrow by malignant **plasma cells** (usually >10%) [1]. These cells are characterized by an eccentric nucleus, a perinuclear halo (Golgi apparatus), and "clock-face" chromatin. * **Why Option A is incorrect:** Myeloid blasts are characteristic of **Acute Myeloid Leukemia (AML)**. While AML can cause fatigue and bone pain, hypercalcemia is much more common in MM. * **Why Option C is incorrect:** A 'dry tap' occurs when the marrow is fibrotic or hypercellular (e.g., Myelofibrosis or Hairy Cell Leukemia). While it can occur in MM, it is not the most "likely" diagnostic finding compared to plasma cell infiltration. * **Why Option D is incorrect:** Lymphoid blasts are seen in **Acute Lymphoblastic Leukemia (ALL)**, which primarily affects children, not 70-year-old males. **NEET-PG High-Yield Pearls:** * **CRAB Criteria for MM:** **C**alcium elevation, **R**enal insufficiency, **A**nemia, and **B**one lesions [1]. * **M-Spike:** Found on Serum Protein Electrophoresis (usually IgG or IgA) [1]. * **Bence-Jones Proteins:** Free light chains found in urine. * **Peripheral Smear:** Look for **Rouleaux formation** due to increased ESR [1]. * **Skull X-ray:** Classic "punched-out" lytic lesions [1].
Question 286: Which of the following is considered a poor prognostic factor in Acute Lymphoblastic Leukemia (ALL)?
- A. Philadelphia chromosome (Correct Answer)
- B. Male sex
- C. High WBC count
- D. Hyperploidy
Explanation: **Explanation:** Prognostication in Acute Lymphoblastic Leukemia (ALL) is determined by age, initial white blood cell (WBC) count, and specific cytogenetic abnormalities [1]. **1. Why Philadelphia Chromosome is correct:** The presence of the **Philadelphia chromosome [t(9;22); BCR-ABL1]** is the most significant adverse cytogenetic marker in ALL [1]. It occurs in approximately 25-30% of adult ALL cases and is associated with very high rates of induction failure, early relapse, and poor overall survival [1]. While the introduction of Tyrosine Kinase Inhibitors (TKIs) like Imatinib has improved outcomes, it remains a hallmark of "high-risk" disease. **2. Analysis of Incorrect Options:** * **Male sex:** While some older studies suggested a slightly worse prognosis for males (partly due to testicular sequestration), sex is no longer considered a major independent prognostic factor in modern protocols compared to cytogenetics. * **High WBC count:** While a high WBC count (>30,000 for B-ALL or >100,000 for T-ALL) is a poor prognostic factor, the question asks for the "best" or most definitive marker among the choices [1]. Cytogenetic markers like t(9;22) carry more weight in risk stratification than the initial WBC count. * **Hyperploidy:** This is actually a **favorable** prognostic factor. Patients with >50 chromosomes (hyperdiploidy) generally have a better response to chemotherapy and a higher cure rate. **NEET-PG High-Yield Pearls:** * **Good Prognosis:** Age 1–9 years, low WBC count, Hyperdiploidy, and t(12;21) [ETV6-RUNX1]. * **Poor Prognosis:** Age <1 or >10 years, high WBC count, Hypodiploidy, t(9;22), and t(4;11) [KMT2A rearrangement] [1]. * **Commonest ALL:** B-cell ALL is more common than T-cell ALL. * **Sanctuary Sites:** The CNS and Testes are common sites for relapse because systemic chemotherapy often fails to reach therapeutic levels there.
Question 287: Which of the following statements about Acute Immune Thrombocytopenic Purpura is not true?
- A. Autoimmune mediated
- B. Massive splenomegaly (Correct Answer)
- C. Increased megakaryocytes in marrow
- D. IV immunoglobulins may be required
Explanation: **Explanation:** **Why "Massive Splenomegaly" is the correct answer:** In Immune Thrombocytopenic Purpura (ITP), platelet destruction occurs via the splenic macrophages due to IgG autoantibodies [1]. However, this is a microscopic process of sequestration. **The spleen is typically normal in size or only slightly enlarged.** If massive splenomegaly is present, a clinician must look for alternative diagnoses such as Leukemia, Lymphoma, Myelofibrosis, or Portal Hypertension. In NEET-PG, "Massive Splenomegaly" is a classic "red flag" that points away from a diagnosis of ITP. **Analysis of Incorrect Options:** * **A. Autoimmune mediated:** This is true. ITP is caused by anti-platelet antibodies (usually IgG) directed against glycoprotein complexes like GPIIb/IIIa or GPIb/IX [1]. * **C. Increased megakaryocytes in marrow:** This is true. Since the destruction is peripheral, the bone marrow compensates by increasing platelet production. A bone marrow biopsy (done to rule out other causes) typically shows megakaryocytic hyperplasia. * **D. IV immunoglobulins (IVIG) may be required:** This is true. IVIG is a first-line emergency treatment used to rapidly increase platelet counts by "clogging" the Fc receptors on splenic macrophages, preventing platelet destruction. **High-Yield Clinical Pearls for NEET-PG:** * **Acute ITP:** Most common in children, often follows a viral infection, and is usually self-limiting. * **Chronic ITP:** More common in adult females (20–40 years); rarely resolves spontaneously. * **First-line treatment:** Corticosteroids (e.g., Prednisolone). * **Second-line/Refractory:** Splenectomy, Rituximab, or Thrombopoietin receptor agonists (Eltrombopag, Romiplostim). * **Diagnosis of Exclusion:** ITP is diagnosed only after ruling out other causes of thrombocytopenia [1]; there is no "gold standard" confirmatory test.
Question 288: What are the diagnostic criteria for Hodgkin's disease?
- A. Reed-Sternberg (RS) cells
- B. Atypical cells in a specific background milieu (Correct Answer)
- C. Presence of a sclerosing pattern
- D. CD30 positivity
Explanation: ### Explanation **1. Why the Correct Answer is Right:** In Hodgkin’s Lymphoma (HL), the neoplastic cells (Reed-Sternberg cells and their variants) typically constitute only **1–2%** of the total tumor mass. The diagnosis relies not just on the presence of these atypical cells, but on their presence within a **characteristic reactive inflammatory background** (milieu) consisting of lymphocytes, plasma cells, eosinophils, and histiocytes [1]. Without this specific cellular environment, the presence of RS-like cells is not diagnostic, as they can be seen in other conditions like Infectious Mononucleosis or certain carcinomas. **2. Analysis of Incorrect Options:** * **Option A (Reed-Sternberg cells):** While RS cells are the hallmark of HL [1], they are **not pathognomonic**. "Owl-eye" nuclei can be seen in CMV infections, EBV (Infectious Mononucleosis), and some non-Hodgkin lymphomas. * **Option C (Sclerosing pattern):** This is characteristic of the **Nodular Sclerosis** subtype (the most common variant), but it is not a universal diagnostic criterion for all forms of Hodgkin’s disease (e.g., Mixed Cellularity or Lymphocyte Rich). * **Option D (CD30 positivity):** While most Classical HL cells express CD30 and CD15, this is an immunophenotypic marker rather than a primary diagnostic criterion. Furthermore, CD30 is also expressed in Anaplastic Large Cell Lymphoma (ALCL). **3. NEET-PG High-Yield Pearls:** * **Classic RS Cell:** Large, binucleated cell with prominent "owl-eye" eosinophilic nucleoli [1]. * **Immunophenotype:** Classical HL is **CD15+, CD30+, and CD45–**. * **L&H Cells (Popcorn cells):** Seen in **Nodular Lymphocyte Predominant HL**; these are **CD20+ and CD45+** (unlike classical HL). * **Bimodal Age Distribution:** Peaks at 15–35 years and again after 50 years. * **Staging:** The **Ann Arbor Staging System** is used, with the presence of "B symptoms" (fever, night sweats, weight loss) indicating a worse prognosis [2].
Question 289: Waldenstrom's macroglobulinemia is seen in which of the following conditions?
- A. Non-Hodgkin's Lymphoma (NHL)
- B. Plasmacytic Lymphoma (Correct Answer)
- C. Chronic Lymphocytic Leukemia (CLL)
- D. None of the above
Explanation: **Explanation:** **Waldenström’s Macroglobulinemia (WM)** is a distinct clinical syndrome defined by the presence of a monoclonal IgM protein (macroglobulinemia) in the setting of bone marrow infiltration by **Lymphoplasmacytic Lymphoma (LPL)** [1]. 1. **Why Option B is Correct:** According to the WHO classification, Waldenström’s Macroglobulinemia is the clinical manifestation of Lymphoplasmacytic Lymphoma (LPL). LPL is a B-cell neoplasm characterized by a mixture of small B-lymphocytes, plasmacytoid lymphocytes, and plasma cells. These cells secrete large amounts of **monoclonal IgM**, leading to the hallmark hyperviscosity syndrome [1]. 2. **Why Other Options are Incorrect:** * **Option A (Non-Hodgkin’s Lymphoma):** While LPL is technically a subtype of indolent NHL, the question asks for the specific underlying condition. "NHL" is too broad a category, whereas Plasmacytic (Lymphoplasmacytic) Lymphoma is the definitive pathological diagnosis. * **Option C (Chronic Lymphocytic Leukemia):** CLL is a malignancy of mature B-cells that typically expresses CD5 and CD23. While CLL can occasionally produce a monoclonal protein (M-spike), it is usually IgG or IgA, and it does not define Waldenström’s. **High-Yield Clinical Pearls for NEET-PG:** * **Hallmark Symptom:** Hyperviscosity syndrome (visual disturbances, mucosal bleeding, and neurological symptoms like "sausage-link" appearance of retinal veins) [1]. * **Genetic Marker:** Over 90% of patients possess the **MYD88 L265P mutation**. * **Diagnosis:** Bone marrow biopsy showing >10% infiltration by lymphoplasmacytic cells + any size IgM monoclonal spike [1]. * **Distinction from Multiple Myeloma:** Unlike Myeloma, WM rarely causes lytic bone lesions or hypercalcemia; it is primarily a disease of organomegaly (hepatosplenomegaly and lymphadenopathy).
Question 290: Bone marrow transplantation is used as a treatment modality in all of the following conditions except:
- A. Adrenoleukodystrophy
- B. Hemochromatosis (Correct Answer)
- C. Hurler's Syndrome
- D. Osteopetrosis
Explanation: **Explanation:** Bone marrow transplantation (BMT), or Hematopoietic Stem Cell Transplantation (HSCT), is used to treat conditions where the underlying pathology resides in the hematopoietic system or where donor cells can provide a missing enzyme or functional cell type [1]. **Why Hemochromatosis is the Correct Answer:** Hereditary Hemochromatosis is a disorder of **iron metabolism** caused primarily by mutations in the *HFE* gene, leading to excessive intestinal iron absorption. The defect lies in the liver (hepcidin regulation) and the gut, not the bone marrow. Therefore, BMT has no role in its management. The standard treatment remains **therapeutic phlebotomy** or iron chelation. **Analysis of Other Options:** * **Adrenoleukodystrophy (ALD):** This is a peroxisomal disorder. HSCT is the standard of care in the early stages of childhood cerebral ALD as it provides donor-derived microglial cells that can process very-long-chain fatty acids (VLCFA), halting neurodegeneration. * **Hurler’s Syndrome (MPS I):** A lysosomal storage disorder caused by alpha-L-iduronidase deficiency. BMT provides donor cells that secrete the functional enzyme, which is then taken up by the patient's cells (cross-correction), preventing progressive organ damage and cognitive decline. * **Osteopetrosis:** The "marble bone disease" is caused by **defective osteoclasts** (which are derived from the monocyte-macrophage lineage in the bone marrow). BMT provides functional donor-derived osteoclasts that can perform normal bone resorption. **NEET-PG High-Yield Pearls:** * **Osteopetrosis** is a classic "non-malignant" indication for BMT often tested in exams. * **Gaucher disease** and **Niemann-Pick** are other storage disorders where BMT may be considered. * In **Thalassemia and Sickle Cell Anemia**, BMT is currently the only curative treatment [2].
Practice by Chapter
Anemia Evaluation and Management
Practice Questions
Hemoglobinopathies
Practice Questions
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
Practice Questions
Myeloproliferative Neoplasms
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Transfusion Medicine
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Hematopoietic Stem Cell Transplantation
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