Hematology Practice Questions

Q: All of the following are features of thrombotic thrombocytopenic purpura, EXCEPT:

Splenomegaly. Thrombotic Thrombocytopenic Purpura (TTP) is a life-threatening microangiopathy caused by a deficiency in the **ADAMTS13** enzyme (a von Willebrand factor-cleaving protease). This deficiency leads to large vWF multimers that cause spontaneous platelet aggregation and microthrombi formation. **Why Splenomegaly is the Correct Answer:** Splenomegaly is **not** a characteristic feature of TTP [1]. While TTP involves significant platelet consumption and red cell destruction, the pathology occurs within the microvasculature (systemic microthrombi) rather than via splenic sequestration or congestion. If a patient presents with thrombocytopenia and a significantly enlarged spleen, alternative diagnoses like hypersplenism, portal hypertension, or certain hematologic malignancies should be considered [1]. **Analysis of Incorrect Options:** * **Microangiopathic Hemolytic Anemia (MAHA):** A hallmark of TTP. Fragmentation of RBCs as they pass through fibrin/platelet meshworks results in **schistocytes** on peripheral smear [2]. * **Neurologic findings:** Common due to microthrombi in the cerebral vasculature. Symptoms range from fluctuating headaches and confusion to seizures and coma. * **Fever:** Part of the classic pentad, likely due to tissue ischemia and inflammation, though it is present in only about 25% of cases. **Clinical Pearls for NEET-PG:** * **The Classic Pentad (FAT RN):** **F**ever, **A**nemia (MAHA), **T**hrombocytopenia, **R**enal failure, and **N**eurological deficits [2]. * **Diagnosis:** Decreased ADAMTS13 activity (<10%). * **Treatment:** **Emergency Plasmapheresis (Plasma Exchange)** is the gold standard. Never delay treatment for lab confirmation. * **Contraindication:** Platelet transfusion is generally contraindicated as it may "fuel the fire" by promoting further thrombosis.

Q: Splenomegaly is least likely associated with which of the following conditions?

Primary Thrombocytosis. **Explanation:** The correct answer is **Primary Thrombocytosis** (also known as Essential Thrombocythemia). **1. Why Primary Thrombocytosis is the correct answer:** In the spectrum of Chronic Myeloproliferative Neoplasms (MPNs), **Essential Thrombocythemia (ET)** is the condition least likely to present with significant splenomegaly. In ET, the primary pathology is the overproduction of platelets. While mild splenomegaly can occur in about 25–40% of cases, it is often absent. If a patient with suspected ET has massive splenomegaly, clinicians should look for an alternative diagnosis like Myelofibrosis or CML. **2. Analysis of Incorrect Options:** * **Chronic Myeloid Leukemia (CML):** Splenomegaly is a hallmark feature, present in over 50–70% of cases. It occurs due to the massive infiltration of the spleen by leukemic cells. * **Polycythemia Rubra Vera (PRV):** Splenomegaly is common (approx. 70% of patients) due to extramedullary hematopoiesis and increased red cell mass. * **Idiopathic Myelofibrosis (Primary Myelofibrosis):** This condition is associated with the **most massive splenomegaly** among all MPNs [1]. As the bone marrow becomes fibrotic, the spleen takes over hematopoiesis (extramedullary hematopoiesis), leading to giant enlargement [1]. **3. NEET-PG High-Yield Pearls:** * **Massive Splenomegaly (Spleen crossing midline/reaching iliac fossa):** Remember the mnemonic **"M-C-I"** — **M**yelofibrosis, **C**hronic Myeloid Leukemia, and **I**ndian Kala-azar (Visceral Leishmaniasis). Other causes include Malaria and Gaucher’s disease. * **Essential Thrombocythemia:** The most common clinical presentation is actually vasomotor symptoms (headaches, erythromelalgia) or thrombohemorrhagic events, rather than organomegaly. * **Diagnostic Clue:** If a question mentions "Tear-drop RBCs" (Dacrocytes) and massive splenomegaly, always think of Myelofibrosis [1].

Q: For what procedure is the instrument depicted in the diagram used?

Bone marrow biopsy. ***Bone marrow biopsy*** - The **Jamshidi needle** depicted has a distinctive **tapered bore** that is wider at the tip with a **cutting edge**, specifically designed to obtain bone marrow core samples from the **iliac crest** or sternum. - Features a **removable stylet** and sturdy construction to penetrate cortical bone and extract intact marrow specimens for histological examination. *Pleural biopsy* - Requires specialized needles like the **Abrams needle** or **Cope needle** with a **notched cutting mechanism** to sample pleural tissue. - These instruments have a **hook-like design** with a cutting chamber, completely different from the straight, tapered Jamshidi needle. *Kidney biopsy* - Utilizes **Tru-Cut needles** or **automated core biopsy guns** with spring-loaded mechanisms for precise tissue sampling. - These needles have **smaller gauge** (14-18G) and **automated firing systems**, unlike the manual, larger-bore Jamshidi needle. *Liver biopsy* - Performed with **Menghini needles** or **Vim-Silverman needles** that have **suction capability** and thinner profiles. - These instruments feature **aspiration mechanisms** and are designed for softer tissue penetration, not the bone-cutting capability of the Jamshidi needle.

Q: Elevated serum ferritin, decreased serum iron, and decreased % transferrin saturation are most consistent with which diagnosis?

Anemia of chronic disease. **Explanation:** The laboratory profile described is the classic presentation of **Anemia of Chronic Disease (ACD)**, also known as Anemia of Inflammation [1]. **1. Why Anemia of Chronic Disease is Correct:** The pathophysiology of ACD is driven by **Hepcidin**, an acute-phase reactant [1]. In chronic inflammatory states (infections, malignancy, autoimmune diseases), cytokines like IL-6 stimulate the liver to produce hepcidin. Hepcidin degrades **ferroportin** (the iron export channel), leading to [2]: * **Sequestration of iron** within macrophages and hepatocytes (reflected by **elevated serum ferritin**) [2]. * **Decreased serum iron** because iron cannot be released into the plasma [2]. * **Decreased % Transferrin Saturation** because there is less iron available to bind to transferrin. **2. Why the other options are incorrect:** * **Iron Deficiency Anemia (IDA):** Characterized by **decreased ferritin** (the most sensitive marker) and increased Total Iron Binding Capacity (TIBC) [3]. * **Thalassemia:** Typically presents with **normal to elevated serum iron and ferritin** because the defect is in globin chain synthesis, not iron metabolism. * **Sideroblastic Anemia:** Characterized by iron overload. You would see **elevated serum iron, elevated ferritin,** and increased transferrin saturation, along with ringed sideroblasts in the bone marrow. **High-Yield Clinical Pearls for NEET-PG:** * **Ferritin** is the key differentiator: It is **low** in IDA and **normal/high** in ACD [3]. * **TIBC** (Total Iron Binding Capacity) is **increased** in IDA but **decreased** in ACD [3]. * **Soluble Transferrin Receptor (sTfR) assay:** This is the most reliable test to distinguish IDA from ACD when both coexist; sTfR is **elevated in IDA** but **normal in ACD** [3].

Q: A 30-year-old male, undergoing platelet apheresis for the first time, experiences tingling around the mouth and numbness in his arm. An ECG shows ST segment elevation. What is the most likely cause of these symptoms?

Citrate toxicity. The correct answer is **Citrate toxicity**. During platelet apheresis, **sodium citrate** is used as an anticoagulant. When returned to the donor's circulation, citrate chelates free ionized calcium, leading to **hypocalcemia**. The classic presentation of hypocalcemia includes neuromuscular irritability, such as perioral tingling (paresthesia) and numbness [1]. Crucially, hypocalcemia affects cardiac conduction. While it typically causes QT interval prolongation, severe electrolyte imbalances during apheresis can lead to coronary vasospasm or conduction abnormalities that manifest as **ST-segment changes** on an ECG. **Analysis of Incorrect Options:** * **A & B (Blood phobia/Anxiety):** While common in first-time donors, these typically present with vasovagal symptoms (bradycardia, hypotension, syncope) or hyperventilation. While hyperventilation can cause tingling due to respiratory alkalosis, it does not typically cause the specific ECG changes associated with electrolyte shifts. * **D (Hypothermia):** Though large volume exchanges can lower body temperature, the primary symptoms would be shivering and "J" waves (Osborn waves) on ECG, not acute perioral numbness. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Citrate binds to ionized Calcium ($Ca^{2+}$) $\rightarrow$ Hypocalcemia. * **Management:** Slowing the infusion rate or administering oral/IV calcium gluconate. * **ECG Hallmark:** The most common ECG finding in hypocalcemia is **prolonged QT interval** (specifically the ST segment). * **Apheresis vs. Whole Blood:** Citrate toxicity is significantly more common in apheresis and massive blood transfusions because of the high volume of citrate-anticoagulated plasma involved.

Q: What is the most common subtype of adult acute lymphoblastic leukemia (ALL)?

B-cell lineage ALL. **Explanation:** Acute Lymphoblastic Leukemia (ALL) is a malignant transformation of lymphoid progenitor cells. In adults, the distribution of subtypes differs slightly from children, but the overall predominance remains the same [1]. **1. Why B-cell lineage ALL is correct:** Approximately **75-80% of adult ALL cases** are of B-cell lineage [1]. This category encompasses the entire spectrum of B-cell development, from early pro-B to mature B-cells. Because it represents the vast majority of cases, it is classified as the most common subtype. **2. Why the other options are incorrect:** * **Pre-B-cell ALL:** While this is a specific stage within the B-cell lineage (characterized by cytoplasmic mu chains), it is a *subset* of B-cell ALL. The question asks for the broader lineage subtype. * **T-cell lineage ALL:** This accounts for only about **20-25%** of adult ALL cases [1]. It typically presents in younger males with a high white cell count and a mediastinal mass. * **Cortical T-ALL:** This is a specific immunophenotypic subcategory of T-ALL. While it often carries a slightly better prognosis than other T-cell subtypes, it is far less common than B-cell lineage ALL. **High-Yield Clinical Pearls for NEET-PG:** * **Cytogenetics:** The most common translocation in **adult B-ALL** is **t(9;22)**, the Philadelphia chromosome (BCR-ABL1), which carries a poor prognosis [1]. In contrast, children more commonly show t(12;21). * **Markers:** B-ALL typically expresses **CD19, CD20, and CD22** [1]. T-ALL expresses **CD2, CD3, CD5, and CD7**. * **Commonality:** ALL is the most common cancer in children, but in adults, it is less common than AML (Acute Myeloid Leukemia). * **Prognosis:** Adult ALL generally has a poorer prognosis compared to pediatric ALL [1].

Question 1

All of the following are features of thrombotic thrombocytopenic purpura, EXCEPT:

Accepted Answer

Splenomegaly

Answer

Microangiopathic hemolytic anemia

Answer

Neurologic findings

Answer

Fever

Question 2

Splenomegaly is least likely associated with which of the following conditions?

Accepted Answer

Primary Thrombocytosis

Answer

Chronic Myeloid Leukemia (CML)

Answer

Polycythemia Rubra Vera

Answer

Idiopathic Myelofibrosis

Question 3

For what procedure is the instrument depicted in the diagram used?

Accepted Answer

Bone marrow biopsy

Answer

Pleural biopsy

Answer

Kidney biopsy

Answer

Liver biopsy

Question 4

A 20-year-old male presents with weakness, jaundice, and hematuria. He has a history of similar, self-limiting episodes and unusual substance consumption. Examination reveals mild jaundice and splenomegaly. Lab findings include increased indirect bilirubin, hemoglobinemia, hemoglobinuria, absent haptoglobin, raised LDH, hemosiderinuria, and reticulocytosis. Which peripheral blood smear finding is most likely associated with this condition?

Accepted Answer

Smear showing Pappenheimer bodies.

Answer

Smear showing target cells and bite cells.

Answer

Smear showing schistocytes and helmet cells.

Answer

Smear showing rouleaux formation.

Question 5

Which condition is associated with Coomb's positive hemolytic anemia?

Accepted Answer

Systemic lupus erythematosus (SLE)

Answer

Thrombotic thrombocytopenic purpura (TTP)

Answer

Polyarteritis nodosa (PAN)

Answer

Hemolytic uremic syndrome (HUS)

Question 6

Which of the following will NOT show a dismal prognosis?

Accepted Answer

Age between 1-10 years

Answer

Total Leucocyte Count > 1 lac

Answer

Petechiae

Answer

t(9;22) translocation

Question 7

Elevated serum ferritin, decreased serum iron, and decreased % transferrin saturation are most consistent with which diagnosis?

Accepted Answer

Anemia of chronic disease

Answer

Iron deficiency anemia

Answer

Thalassemia

Answer

Sideroblastic anemia

Question 8

A 30-year-old male, undergoing platelet apheresis for the first time, experiences tingling around the mouth and numbness in his arm. An ECG shows ST segment elevation. What is the most likely cause of these symptoms?

Accepted Answer

Citrate toxicity

Answer

Blood phobia

Answer

Anxiety related to first-time transfusion

Answer

Hypothermia

Question 9

What is the most common subtype of adult acute lymphoblastic leukemia (ALL)?

Accepted Answer

B-cell lineage ALL

Answer

Pre-B-cell ALL

Answer

T-cell lineage ALL

Answer

Cortical T-ALL

Question 10

A 58-year-old woman presents with a gastric ulcer, achlorhydria, loss of vibration sense in her lower extremities, and megaloblastic anemia. What diagnostic test would best support a diagnosis of pernicious anemia?

Accepted Answer

Oral administration of radiolabeled vitamin B12

Answer

Response to injection of radioactive vitamin B12

Answer

Endoscopic retrograde cholangiopancreatography (ERCP)

Answer

Prothrombin time (PT)

Hematology — MCQs

Hematology — MCQs

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