Hematology Practice Questions

Q: 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?

Plasmacytoma on tissue biopsy. 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]

Q: Basophilic stippling is seen in which condition?

Lead poisoning. **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].

Q: In Polycythemia vera, all of the following are seen except?

Thrombocytopenia. **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.

Q: In iron deficiency anemia, what is the typical change in hemoglobin?

Decrease in hemoglobin. **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 IDA. * **Blood Picture:** Microcytic hypochromic anemia with increased **RDW** (Red Cell Distribution Width) [3].

Q: Which of the following conditions is typically associated with a normal platelet count?

Shaken baby syndrome. **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.

Q: All of the following are differential diagnoses in hypochromic microcytic anemia EXCEPT?

Recent blood loss. **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 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.

Q: Burkitt's lymphoma is:

A B cell lymphoma. **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.

Question 1

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?

Accepted Answer

Plasmacytoma on tissue biopsy

Answer

Bone marrow plasmacytosis = 20%

Answer

Multiple lytic lesions on skull X-ray

Answer

Monoclonal spike < 3.5 g/dL for IgG and < 2 g/dL for IgA

Question 2

Basophilic stippling is seen in which condition?

Accepted Answer

Lead poisoning

Answer

Cadmium poisoning

Answer

Chromium poisoning

Answer

Iron poisoning

Question 3

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?

Accepted Answer

Thrombotic thrombocytopenic purpura

Answer

Autoimmune hemolytic anemia

Answer

Disseminated intravascular coagulation

Answer

Hemolytic-uremic syndrome

Question 4

All are benefits of repeated phlebotomy in hemochromatosis, EXCEPT:

Accepted Answer

Reversal of testicular atrophy

Answer

Improved control of diabetes

Answer

Decrease in skin pigmentation

Answer

Normalization of the liver enzymes

Question 5

In Polycythemia vera, all of the following are seen except?

Accepted Answer

Thrombocytopenia

Answer

Increased GI bleed

Answer

Thrombosis

Answer

Transient visual loss

Question 6

In iron deficiency anemia, what is the typical change in hemoglobin?

Accepted Answer

Decrease in hemoglobin

Answer

Increase in hemoglobin

Answer

Increase in platelets

Answer

Decrease in platelets

Question 7

Which of the following conditions is typically associated with a normal platelet count?

Accepted Answer

Shaken baby syndrome

Answer

Disseminated intravascular coagulation (DIC)

Answer

Microangiopathic hemolytic anemia

Answer

Splenomegaly

Question 8

Pancytopenia with hypocellular bone marrow is seen in which of the following conditions?

Accepted Answer

Fanconi's anemia

Answer

Paroxysmal nocturnal hemoglobinuria

Answer

Hairy cell leukemia

Answer

Myelopthisis

Question 9

All of the following are differential diagnoses in hypochromic microcytic anemia EXCEPT?

Accepted Answer

Recent blood loss

Answer

Thalassemia

Answer

Iron deficiency

Answer

Sideroblastic anemia

Question 10

Burkitt's lymphoma is:

Accepted Answer

A B cell lymphoma

Answer

Associated with a 6;14 translocation

Answer

PAS positive in cytochemistry

Answer

Treated with radiotherapy

Hematology — MCQs

Hematology — MCQs

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