Hematology — MCQs
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A 63-year-old man presented with back pain for a few weeks. Blood investigations show anemia, hypercalcemia, and hypoalbuminemia. Serum protein electrophoresis (PEP) demonstrates an M spike. All of the following are minor criteria for the diagnosis of multiple myeloma, EXCEPT?
Basophilic stippling is seen in which condition?
A 47-year-old woman presents with fever, headache, confusion, and jaundice for one week. She underwent a hysterectomy two months ago and recently started estrogen replacement therapy. On admission, her temperature is 38.7 C, blood pressure is 140/90 mm Hg, pulse is 98/min, and respiratory rate is 20/min. She is disoriented to time and place. Physical examination reveals jaundiced sclerae and skin, purpura on the trunk, and bleeding gums. Her platelet count is 25,000/mm3, hematocrit is 24%, and creatinine is 4.9 mg/dL. Lactate dehydrogenase (LDH) and indirect bilirubin are elevated. Coagulation tests are within normal limits, but the bleeding time is increased; fibrin-split products and Coombs test are negative. A peripheral blood smear shows schistocytes, helmet-shaped cells, and cells with a triangular shape. Which of the following is the most likely diagnosis?
All are benefits of repeated phlebotomy in hemochromatosis, EXCEPT:
In Polycythemia vera, all of the following are seen except?
In iron deficiency anemia, what is the typical change in hemoglobin?
Which of the following conditions is typically associated with a normal platelet count?
Pancytopenia with hypocellular bone marrow is seen in which of the following conditions?
All of the following are differential diagnoses in hypochromic microcytic anemia EXCEPT?
Burkitt's lymphoma is:
Hematology Indian Medical PG Practice Questions and MCQs
Question 681: A 63-year-old man presented with back pain for a few weeks. Blood investigations show anemia, hypercalcemia, and hypoalbuminemia. Serum protein electrophoresis (PEP) demonstrates an M spike. All of the following are minor criteria for the diagnosis of multiple myeloma, EXCEPT?
- A. Bone marrow plasmacytosis = 20%
- B. Multiple lytic lesions on skull X-ray
- C. Plasmacytoma on tissue biopsy (Correct Answer)
- D. Monoclonal spike < 3.5 g/dL for IgG and < 2 g/dL for IgA
Explanation: This question tests your knowledge of the **Durie-Salmon Staging and Diagnostic Criteria** for Multiple Myeloma, a high-yield topic for NEET-PG. [1] ### **Explanation of the Correct Answer** The correct answer is **C (Plasmacytoma on tissue biopsy)**. Under the Durie-Salmon criteria, a tissue biopsy showing a plasmacytoma is classified as a **Major Criterion**, not a minor one. [1] The Major Criteria include: 1. **Plasmacytoma** on tissue biopsy. 2. **Bone marrow plasmacytosis > 30%**. 3. **High M-spike:** IgG > 3.5 g/dL, IgA > 2 g/dL, or Bence Jones proteinuria > 1 g/24h. ### **Analysis of Incorrect Options** * **Option A (Bone marrow plasmacytosis 10-30%):** This is a **Minor Criterion**. Note that if it exceeds 30%, it becomes a Major Criterion. * **Option B (Lytic lesions):** The presence of multiple "punched-out" lytic lesions on skeletal survey is a **Minor Criterion**. [1] * **Option D (Low-level M-spike):** Monoclonal spikes that do not meet the "Major" threshold (i.e., IgG < 3.5 g/dL or IgA < 2 g/dL) are classified as **Minor Criteria**. [1] ### **Clinical Pearls for NEET-PG** * **CRAB Features:** Remember the classic tetrad for symptomatic myeloma: **C**alcium elevation, **R**enal insufficiency, **A**nemia, and **B**one lesions. [1] * **Modern Diagnosis:** While Durie-Salmon is historically important for exams, the **IMWG (International Myeloma Working Group)** updated criteria now require ≥10% clonal plasma cells PLUS a CRAB feature or a biomarker of malignancy (e.g., Free Light Chain ratio ≥ 100). * **Peripheral Smear:** Look for **Rouleaux formation** due to increased serum proteins (ESR will also be characteristically high). [1]
Question 682: Basophilic stippling is seen in which condition?
- A. Cadmium poisoning
- B. Lead poisoning (Correct Answer)
- C. Chromium poisoning
- D. Iron poisoning
Explanation: **Explanation:** **Basophilic stippling** refers to the presence of numerous blue-purple granules (representing aggregated ribosomes/RNA) distributed throughout the cytoplasm of red blood cells on a peripheral smear [1], [2]. **Why Lead Poisoning is Correct:** In lead poisoning (Plumbism), lead inhibits the enzyme **Pyrimidine 5'-nucleotidase**. Under normal conditions, this enzyme degrades residual ribosomal RNA in reticulocytes. When inhibited, the undegraded RNA aggregates, resulting in the characteristic coarse basophilic stippling [2]. Lead also inhibits **ALAD (Aminolevulinic acid dehydratase)** and **Ferrochelatase**, leading to microcytic anemia and elevated free erythrocyte protoporphyrin [3]. **Analysis of Incorrect Options:** * **A & C (Cadmium/Chromium):** While these are heavy metals that cause systemic toxicity (e.g., Cadmium causes Itai-itai disease and renal damage), they do not specifically inhibit pyrimidine 5'-nucleotidase or cause ribosomal aggregation in RBCs. * **D (Iron Poisoning):** Acute iron toxicity primarily presents with gastrointestinal hemorrhage, metabolic acidosis, and hepatic failure. It does not manifest with basophilic stippling; rather, iron *deficiency* is a more common hematological concern. **NEET-PG High-Yield Pearls:** * **Differential Diagnosis for Basophilic Stippling:** Remember the mnemonic **"TAAL"**: **T**halassemia, **A**rsenic poisoning, **A**nemia of chronic disease (rarely), and **L**ead poisoning (most common association). * **Coarse vs. Fine:** Coarse stippling is highly suggestive of Lead poisoning or Sideroblastic anemia, while fine stippling is often seen in increased erythropoiesis (Reticulocytosis). * **Burton’s Line:** Look for a bluish-purple line on the gums in lead poisoning cases [2], [4]. * **Treatment:** For lead poisoning, the drug of choice is **Succimer** (oral) or **Ca-EDTA/Dimercaprol** (parenteral) [1], [4].
Question 683: A 47-year-old woman presents with fever, headache, confusion, and jaundice for one week. She underwent a hysterectomy two months ago and recently started estrogen replacement therapy. On admission, her temperature is 38.7 C, blood pressure is 140/90 mm Hg, pulse is 98/min, and respiratory rate is 20/min. She is disoriented to time and place. Physical examination reveals jaundiced sclerae and skin, purpura on the trunk, and bleeding gums. Her platelet count is 25,000/mm3, hematocrit is 24%, and creatinine is 4.9 mg/dL. Lactate dehydrogenase (LDH) and indirect bilirubin are elevated. Coagulation tests are within normal limits, but the bleeding time is increased; fibrin-split products and Coombs test are negative. A peripheral blood smear shows schistocytes, helmet-shaped cells, and cells with a triangular shape. Which of the following is the most likely diagnosis?
- A. Autoimmune hemolytic anemia
- B. Disseminated intravascular coagulation
- C. Hemolytic-uremic syndrome
- D. Thrombotic thrombocytopenic purpura (Correct Answer)
Explanation: ### Explanation The patient presents with the classic **Pentad of Thrombotic Thrombocytopenic Purpura (TTP)**: 1. **Microangiopathic Hemolytic Anemia (MAHA):** Indicated by schistocytes (helmet cells), jaundice, elevated LDH, and indirect bilirubin [3]. 2. **Thrombocytopenia:** Low platelet count (25,000/mm³) and purpura [2]. 3. **Neurological symptoms:** Confusion and disorientation. 4. **Renal dysfunction:** Elevated creatinine (4.9 mg/dL). 5. **Fever:** 38.7°C. **Pathophysiology:** TTP is caused by a deficiency of the **ADAMTS13** enzyme (a von Willebrand factor-cleaving protease). This leads to ultra-large vWF multimers that cause spontaneous platelet aggregation and microthrombi, shearing RBCs as they pass through narrowed vessels (creating schistocytes). #### Why the other options are incorrect: * **Autoimmune Hemolytic Anemia (AIHA):** While it causes jaundice and anemia, the **Coombs test is negative** here, and AIHA does not typically cause schistocytes or severe thrombocytopenia (unless it's Evans Syndrome, which lacks the renal/neuro components). * **Disseminated Intravascular Coagulation (DIC):** DIC also shows schistocytes and low platelets, but **coagulation profiles (PT/aPTT) are normal** in this patient [1]. In DIC, PT/aPTT would be prolonged, and fibrin-split products (D-dimer) would be elevated. * **Hemolytic-Uremic Syndrome (HUS):** HUS shares the triad of MAHA, thrombocytopenia, and renal failure [3]. However, it is more common in children (often post-diarrheal) and **neurological symptoms/fever** are much more characteristic of TTP. #### NEET-PG High-Yield Pearls: * **Treatment of Choice:** Emergent **Plasmapheresis (Plasma Exchange)**. Never delay treatment for ADAMTS13 levels if TTP is suspected. * **Contraindication:** Platelet transfusion is generally contraindicated as it may "fuel the fire" of microthrombi. * **Mnemonic (FAT RN):** **F**ever, **A**nemia (MAHA), **T**hrombocytopenia, **R**enal failure, **N**eurological symptoms.
Question 684: All are benefits of repeated phlebotomy in hemochromatosis, EXCEPT:
- A. Improved control of diabetes
- B. Decrease in skin pigmentation
- C. Normalization of the liver enzymes
- D. Reversal of testicular atrophy (Correct Answer)
Explanation: Hereditary Hemochromatosis is a disorder of iron overload where excess iron is deposited in various organs, leading to tissue damage [1]. Therapeutic phlebotomy is the mainstay of treatment, aimed at removing iron to prevent further injury and improve organ function. **Why Option D is the correct answer:** Iron deposition in the pituitary gland (specifically the gonadotrophs) leads to hypogonadotropic hypogonadism, which manifests as **testicular atrophy** [1], loss of libido, and impotence. Unfortunately, once structural damage to the pituitary-gonadal axis occurs, it is generally **irreversible**. Phlebotomy does not restore testicular size or function; these patients often require testosterone replacement therapy. **Analysis of Incorrect Options:** * **A. Improved control of diabetes:** Iron deposition in the pancreas (Bronze Diabetes) causes beta-cell dysfunction [1]. Early phlebotomy improves insulin sensitivity and glycemic control, though it may not completely reverse established type 1-like diabetes. * **B. Decrease in skin pigmentation:** The "bronze" appearance is due to both iron deposition and increased melanin production [1]. This is one of the earliest signs to improve or disappear with iron depletion. * **C. Normalization of liver enzymes:** Phlebotomy effectively reduces hepatic iron concentration, leading to a decrease in transaminases and a reduction in the rate of progression to cirrhosis [1]. **NEET-PG High-Yield Pearls:** * **Most common cause of death:** Decompensated Cirrhosis or **Hepatocellular Carcinoma (HCC)** [1]. Note: Phlebotomy reduces the risk of cirrhosis but does *not* eliminate the risk of HCC once cirrhosis is established. * **Arthropathy:** Like testicular atrophy, the **arthropathy** (typically involving the 2nd and 3rd MCP joints) is usually **not reversed** by phlebotomy. * **Cardiac involvement:** Restrictive cardiomyopathy and arrhythmias often show significant improvement with treatment.
Question 685: In Polycythemia vera, all of the following are seen except?
- A. Thrombocytopenia (Correct Answer)
- B. Increased GI bleed
- C. Thrombosis
- D. Transient visual loss
Explanation: **Explanation:** Polycythemia Vera (PV) is a chronic myeloproliferative neoplasm characterized by the autonomous overproduction of all three myeloid cell lines (panmyelosis). **1. Why Thrombocytopenia is the Correct Answer:** In PV, the bone marrow is hypercellular, leading to an **increase** in red blood cells, white blood cells, and platelets. Therefore, **Thrombocytosis** (elevated platelet count) is a hallmark feature, not thrombocytopenia. If a patient with suspected PV presents with thrombocytopenia, one must consider alternative diagnoses or progression to the "spent phase" (myelofibrosis) [1]. **2. Analysis of Incorrect Options:** * **Thrombosis (Option C):** This is the most common complication and a major cause of morbidity [2]. Increased blood viscosity (due to high hematocrit) and qualitative platelet defects lead to both arterial and venous thrombosis (e.g., Budd-Chiari syndrome) [2]. * **Transient Visual Loss (Option D):** Known as *Amaurosis fugax*, this occurs due to microvascular ocular ischemia caused by hyperviscosity and platelet aggregation in the retinal vessels. * **Increased GI Bleed (Option B):** Paradoxically, despite the risk of thrombosis, PV patients have an increased risk of bleeding (especially GI bleeds). This is often due to dysfunctional platelets or "acquired von Willebrand syndrome" when platelet counts are extremely high. **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Marker:** >95% of cases are associated with the **JAK2 V617F mutation** [2]. * **Classic Symptom:** **Aquagenic pruritus** (itching after a warm bath) due to mast cell degranulation [2]. * **Lab Findings:** Low serum Erythropoietin (EPO) levels and increased Vitamin B12 levels. * **Treatment of Choice:** Phlebotomy (to keep Hematocrit <45%) and low-dose Aspirin. Hydroxyurea is used for high-risk patients.
Question 686: In iron deficiency anemia, what is the typical change in hemoglobin?
- A. Decrease in hemoglobin (Correct Answer)
- B. Increase in hemoglobin
- C. Increase in platelets
- D. Decrease in platelets
Explanation: **Iron Deficiency Anemia (IDA)** is the most common cause of anemia worldwide [1][2]. The hallmark of any anemia is a reduction in the total circulating red blood cell (RBC) mass, which clinically manifests as a **decrease in hemoglobin (Hb)** concentration [4]. **1. Why Option A is correct:** Hemoglobin is a protein composed of heme and globin. Iron is a central component of the heme molecule. In IDA, the depletion of iron stores leads to impaired heme synthesis [4]. Consequently, the bone marrow cannot produce sufficient hemoglobin, leading to a drop in Hb levels, a decrease in Mean Corpuscular Volume (MCV - microcytosis), and a decrease in Mean Corpuscular Hemoglobin (MCH - hypochromia) [3]. **2. Why other options are incorrect:** * **Option B:** An increase in hemoglobin (polycythemia) occurs in conditions like Polycythemia Vera or chronic hypoxia, not in nutrient deficiencies. * **Options C & D:** While IDA is often associated with **reactive thrombocytosis** (mildly increased platelets) due to shared precursor pathways (EPO and TPO) or as a compensatory response to chronic bleeding, it is not the *typical change in hemoglobin* requested by the question. Platelet counts can be variable and are not used to define anemia. **NEET-PG High-Yield Pearls:** * **Earliest Sign:** The first laboratory sign of iron deficiency is a **decrease in Serum Ferritin** (most sensitive marker). * **Gold Standard:** Bone marrow aspiration (Prussian blue staining) is the gold standard for assessing iron stores, though rarely performed. * **Mentzer Index:** (MCV/RBC count) < 13 suggests Thalassemia trait; > 13 suggests IDA. * **Blood Picture:** Microcytic hypochromic anemia with increased **RDW** (Red Cell Distribution Width) [3].
Question 687: Which of the following conditions is typically associated with a normal platelet count?
- A. Disseminated intravascular coagulation (DIC)
- B. Shaken baby syndrome (Correct Answer)
- C. Microangiopathic hemolytic anemia
- D. Splenomegaly
Explanation: **Explanation:** The correct answer is **Shaken baby syndrome (B)**. This condition is characterized by the clinical triad of subdural hemorrhage, retinal hemorrhage, and encephalopathy. Unlike the other options, it is a mechanical injury caused by physical abuse (acceleration-deceleration forces), which does not inherently involve a consumption or sequestration of platelets. Therefore, the platelet count remains **normal**. **Analysis of Incorrect Options:** * **Disseminated Intravascular Coagulation (DIC):** This is a consumptive coagulopathy. Widespread activation of the coagulation cascade leads to the formation of microthrombi, which consumes platelets and clotting factors, resulting in **thrombocytopenia**. * **Microangiopathic Hemolytic Anemia (MAHA):** Conditions like TTP or HUS involve the formation of platelet-rich thrombi in small vessels. These thrombi mechanically shear RBCs (schistocytes) and consume platelets, leading to **thrombocytopenia**. * **Splenomegaly:** The spleen normally stores about one-third of the body's platelets. In splenomegaly (congestive or infiltrative), the spleen sequesters a significantly higher percentage of platelets, leading to **sequestration-induced thrombocytopenia**. **NEET-PG High-Yield Pearls:** * **Shaken Baby Syndrome:** Always look for the "triad" in forensic/pediatric questions. A normal coagulation profile and platelet count help rule out bleeding diathesis as a cause of the intracranial bleed. * **Pseudothrombocytopenia:** Always remember that EDTA-induced platelet clumping can cause a falsely low count on automated analyzers; check a peripheral smear. * **Isolated Thrombocytopenia:** In a patient with a low platelet count but otherwise normal CBC and no organomegaly, **ITP (Immune Thrombocytopenic Purpura)** is the most likely diagnosis.
Question 688: Pancytopenia with hypocellular bone marrow is seen in which of the following conditions?
- A. Fanconi's anemia (Correct Answer)
- B. Paroxysmal nocturnal hemoglobinuria
- C. Hairy cell leukemia
- D. Myelopthisis
Explanation: The core concept tested here is the differentiation between **Aplastic Anemia (Hypocellular marrow)** and **Infiltrative/Ineffective disorders (Hyper/Normocellular marrow)** presenting with pancytopenia. **1. Why Fanconi’s Anemia (FA) is correct:** Fanconi’s Anemia is the most common **inherited aplastic anemia**. It is an autosomal recessive DNA repair defect (FANC gene mutations) leading to progressive bone marrow failure. By definition, aplastic anemia presents with **pancytopenia and a hypocellular bone marrow** where hematopoietic tissue is replaced by fat cells. **2. Why the other options are incorrect:** * **Paroxysmal Nocturnal Hemoglobinuria (PNH):** While PNH is closely associated with aplastic anemia, the classic presentation involves intravascular hemolysis. In PNH, the marrow is typically **normocellular or hypercellular** (due to erythroid hyperplasia) unless it evolves from or into aplastic anemia. * **Hairy Cell Leukemia (HCL):** This presents with pancytopenia and massive splenomegaly. However, the bone marrow is usually **hypercellular** or involved with a diffuse infiltration of "hairy cells." It often results in a "dry tap" due to increased reticulin fibrosis. * **Myelophthisis:** This refers to the displacement of hemopoietic tissue by fibrosis, tumors, or granulomas. While it causes pancytopenia, the marrow is **infiltrated (hypercellular/fibrotic)**, not hypocellular. A classic feature is a leucoerythroblastic blood picture (teardrop RBCs). **High-Yield Clinical Pearls for NEET-PG:** * **Fanconi’s Anemia Triad:** Pancytopenia + Short stature + Skeletal anomalies (absent/hypoplastic thumb or radius). * **Gold Standard Test for FA:** Chromosomal breakage analysis (using Mitomycin C or Diepoxybutane). * **Marrow Cellularity:** In Aplastic Anemia, marrow cellularity must be **<25%** to meet the diagnostic criteria. * **Hairy Cell Leukemia:** Look for "TRAP" positivity and "fried egg appearance" on marrow biopsy.
Question 689: All of the following are differential diagnoses in hypochromic microcytic anemia EXCEPT?
- A. Thalassemia
- B. Iron deficiency
- C. Sideroblastic anemia
- D. Recent blood loss (Correct Answer)
Explanation: **Explanation:** The classification of anemia is primarily based on the **Mean Corpuscular Volume (MCV)**. Hypochromic microcytic anemia (MCV <80 fL) occurs when there is a defect in hemoglobin synthesis, involving either iron metabolism or globin chain production [1], [2]. **Why "Recent Blood Loss" is the correct answer:** Acute or recent blood loss results in **Normochromic Normocytic Anemia** [2]. In the acute phase, the body loses whole blood (both cells and plasma equally); the remaining red cells are normal in size and color. It is only after chronic, long-term blood loss that iron stores become depleted, eventually leading to iron deficiency anemia, which is microcytic [1]. **Analysis of Incorrect Options:** * **Iron Deficiency Anemia (IDA):** The most common cause of microcytic anemia worldwide [1], [2]. Lack of iron leads to decreased heme synthesis. * **Thalassemia:** A genetic defect in globin chain synthesis ($\alpha$ or $\beta$). It characteristically presents with very low MCV but a relatively high RBC count (Mentzer Index <13). * **Sideroblastic Anemia:** Occurs due to impaired protoporphyrin synthesis or iron incorporation into heme, leading to iron accumulation in mitochondria (ringed sideroblasts). **NEET-PG High-Yield Pearls:** * **Differential Mnemonic (TAILS):** **T**halassemia, **A**nemia of chronic disease (some cases) [1], **I**ron deficiency, **L**ead poisoning, **S**ideroblastic anemia. * **Mentzer Index:** MCV/RBC count. If **<13**, suspect Thalassemia trait; if **>13**, suspect Iron Deficiency. * **Serum Ferritin:** The most sensitive and specific initial lab test to diagnose Iron Deficiency Anemia. * **RDW (Red Cell Distribution Width):** Typically increased in IDA (anisocytosis) but normal in uncomplicated Thalassemia trait.
Question 690: Burkitt's lymphoma is:
- A. A B cell lymphoma (Correct Answer)
- B. Associated with a 6;14 translocation
- C. PAS positive in cytochemistry
- D. Treated with radiotherapy
Explanation: **Explanation:** **Burkitt’s Lymphoma (BL)** is a highly aggressive, high-grade B-cell non-Hodgkin lymphoma (NHL) derived from germinal center B-cells [1]. 1. **Why Option A is Correct:** Burkitt’s lymphoma is characterized by the neoplastic proliferation of **mature B-cells**. These cells express B-cell markers such as **CD19, CD20, CD22, and CD10**, along with surface IgM. A hallmark feature is the near 100% proliferation index (Ki-67 fraction), reflecting its status as one of the fastest-growing human tumors [1]. 2. **Why Other Options are Incorrect:** * **Option B:** The characteristic translocation in BL is **t(8;14)**, involving the *c-myc* oncogene on chromosome 8 and the Ig heavy chain locus on chromosome 14. Other variants include t(2;8) and t(8;22). t(6;14) is not associated with BL. * **Option C:** Cytochemically, BL cells are typically **Oil Red O positive** (due to neutral fat in cytoplasmic vacuoles) and **PAS negative**. PAS positivity is more characteristic of Acute Lymphoblastic Leukemia (ALL). * **Option D:** Because BL is a systemic, rapidly doubling disease, the primary treatment is **intensive chemotherapy** (e.g., CODOX-M/IVAC) [1]. Radiotherapy plays a very limited role and is not the standard primary treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Morphology:** "Starry sky" appearance (tingible body macrophages against a sea of cohesive B-cells). * **Variants:** * *Endemic (African):* Associated with EBV; involves the jaw. * *Sporadic:* Involves the ileocecal region/abdomen. * *Immunodeficiency-associated:* Often seen in HIV patients. * **Tumor Lysis Syndrome:** High risk due to rapid cell turnover; requires aggressive hydration and Allopurinol/Rasburicase.
Practice by Chapter
Anemia Evaluation and Management
Practice Questions
Hemoglobinopathies
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Thalassemias
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Platelet Disorders
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Coagulation Disorders
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Thrombotic Disorders
Practice Questions
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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