Hematology Practice Questions

Q: In the evaluation of a newly diagnosed case of acute lymphoid leukemia (ALL), which of the following tests is not routinely included?

Plasma viscosity. ### Plasma viscosity - **Plasma viscosity** measurement is not a standard diagnostic or staging test for **acute lymphoid leukemia (ALL)**. [1] - While it can be elevated in conditions with high protein levels or hypergammaglobulinemia, it does not provide specific information relevant to ALL diagnosis or treatment planning. [1] *Bone marrow biopsy* - A **bone marrow biopsy** is crucial for diagnosing ALL, confirming the presence of **lymphoblasts**, and assessing disease burden. [2] - It also helps in identifying cytogenetic and molecular abnormalities. [2] *Cell surface phenotyping* - **Cell surface phenotyping** (immunophenotyping) via **flow cytometry** is essential for classifying the subtype of ALL (e.g., B-ALL, T-ALL) and identifying specific markers. [2] - This information guides treatment protocols and predicts prognosis. [2] *Complete metabolic panel* - A **complete metabolic panel (CMP)** assesses organ function (e.g., kidney, liver), **electrolyte balance**, and levels of substances like **uric acid** and **lactate dehydrogenase (LDH)**. - These measurements are vital for identifying complications, assessing baseline health, and monitoring for **tumor lysis syndrome** which can be seen in ALL.

Q: Which of the following does not cause deep venous thrombosis (DVT)?

Subungual hematoma. ***Subungual hematoma*** - A **subungual hematoma** is a collection of blood under the fingernail or toenail, usually caused by trauma. - It is a localized injury that **does not affect systemic coagulation** or venous blood flow, thus not increasing DVT risk. *Lower limb trauma* - **Trauma to the lower limb**, especially involving fractures or significant soft tissue damage, can lead to **venous stasis** due to immobility and direct vessel injury [1]. - This immobility and vessel damage activate the **coagulation cascade**, significantly increasing the risk of DVT [1]. *Cushing's syndrome* - **Cushing's syndrome** is characterized by **hypercortisolism**, which leads to a **hypercoagulable state**. - **Elevated cortisol levels** increase circulating procoagulant factors and decrease fibrinolytic activity, predisposing patients to DVT. *Hip & pelvic surgeries* - **Major surgeries**, particularly those involving the **hip and pelvis**, frequently cause **endothelial injury**, blood stasis, and activate the coagulation system [1]. - Patients undergoing these procedures are at a **very high risk for DVT** due to prolonged immobility and surgical trauma [1].

Q: Which is not seen in Polycythemia Vera?

Increased erythropoietin level. ***Increased erythropoietin level*** - In polycythemia vera, there is typically a **decrease in erythropoietin levels** due to the autonomous production of red blood cells. - The overproduction of red cells occurs independently of erythropoietin stimulation, distinguishing this condition from secondary causes of erythrocytosis. *Ocular congestion* - Ocular congestion can occur due to **increased blood volume** and vascular stasis associated with polycythemia vera. - It is often a result of elevated hematocrit levels leading to **erythromelalgia** and **hyperviscosity symptoms**. *Increase RBC count* - A hallmark of polycythemia vera is a **significant increase in red blood cell (RBC) count**, which is diagnostic for the condition. - This increase in RBCs contributes to symptoms such as **headaches, dizziness**, and ruddy complexion. *Increased Vit B12 binding capacity* - Polycythemia vera is associated with **increased vitamin B12 levels** due to elevated levels of transcobalamin, resulting in high binding capacity. - This phenomenon helps differentiate polycythemia vera from other forms of polycythemia. [1]

Q: Multiple myeloma has been seen commonly after exposure to which of the following substances?

Radioactive isotopes. ***Radioactive isotopes*** - Exposure to **ionizing radiation** from radioactive isotopes is a known risk factor for developing multiple myeloma due to its damaging effects on DNA and cells, potentially leading to malignant transformation [2]. - Studies have shown an increased incidence of **plasma cell dyscrasias**, including multiple myeloma, in populations exposed to significant levels of radiation [1]. *Gold* - **Gold compounds** were historically used in the treatment of rheumatoid arthritis, but there is no established association between gold exposure and the development of multiple myeloma. - While gold can cause side effects like **nephrotoxicity** or **dermatitis**, it is not considered a carcinogen for plasma cell disorders. *Asbestos* - **Asbestos exposure** is primarily linked to respiratory diseases such as **asbestosis**, **lung cancer**, and **mesothelioma**. - There is no direct causal link between asbestos exposure and the development of multiple myeloma. *Organic dyes* - Exposure to **certain organic dyes** and chemicals used in industries like textiles and rubber manufacturing has been associated with an increased risk of **bladder cancer** and some **hematological malignancies**. - However, the evidence specifically linking exposure to organic dyes to multiple myeloma is not well-established or consistent.

Q: During the treatment of chronic myeloid leukemia, cytogenetic remission is least likely to occur with which one of the following treatment modalities?

Hydroxyurea. ***Hydroxyurea*** - **Hydroxyurea** (hydroxycarbamide) is a cytoreductive agent that can control cell counts in **chronic myeloid leukemia (CML)** but it does not specifically target the **BCR-ABL fusion gene**. [1] - Its mechanism of action involves inhibiting **ribonucleotide reductase**, which prevents DNA synthesis and thus reduces cell proliferation, but it does not lead to **cytogenetic remission**. [1] *imatinib mesylate* - **Imatinib mesylate** is a **tyrosine kinase inhibitor (TKI)** that specifically targets the **BCR-ABL fusion protein**. [1] - It is highly effective in achieving **hematological and cytogenetic remission** in most CML patients. [1] *Interferon-alpha* - **Interferon-alpha** is an immunomodulatory agent that was formerly a standard treatment for **CML** before TKIs. [1] - It can induce **cytogenetic remissions** in a significant proportion of patients, though less frequently and with more side effects than TKIs. [1] *Bone marrow transplantation* - **Allogeneic hematopoietic stem cell transplantation (HSCT)**, or bone marrow transplantation, offers the only potential cure for CML. - It involves replacing the patient's diseased bone marrow with healthy donor cells, leading to sustained **cytogenetic and molecular remission** in a high percentage of patients. [1]

Q: What is the best treatment option for a patient aged 65 years with severe aplastic anemia who has an HLA-compatible sibling available?

Antithymocyte globulin followed by cyclosporine. Antithymocyte globulin followed by cyclosporine - For patients **over 50 years** with severe aplastic anemia and an HLA-compatible sibling, **immunosuppressive therapy** with antithymocyte globulin (ATG) and cyclosporine is generally preferred over transplantation due to increased transplant-related mortality risks in older individuals. [1] - This regimen aims to suppress the immune system's attack on hematopoietic stem cells, allowing for recovery of bone marrow function. *Non-myeloablative bone marrow transplantation from the HLA identical sibling* - While generally preferred for older patients with acute myeloid leukemia, **non-myeloablative transplantation** for severe aplastic anemia is often considered for those who fail initial immunosuppressive therapy, not as a first-line option. - The goal in aplastic anemia is to remove the autoimmune attack on stem cells and foster recovery, which immunosuppression can achieve with less toxicity in older patients. *Cyclosporine monotherapy* - **Cyclosporine monotherapy** is typically less effective than combination therapy with ATG for severe aplastic anemia. - Combination therapy provides a more robust immunosuppressive effect, leading to higher response rates. *Conventional myeloablative bone marrow transplantation from the HLA identical sibling* - **Conventional myeloablative transplantation** carries significant risks, including high treatment-related mortality, particularly in patients **over 50 years**. [1] - While it offers a potential cure, the risks in this age group are generally deemed too high as a first-line therapy compared to immunosuppression.

Q: In which of the following age groups is myelodysplastic syndrome (MDS) most commonly diagnosed?

>50 years. Myelodysplastic syndrome (MDS) is predominantly a disease of the **elderly**, with the median age of diagnosis typically in the **mid-to-late 60s or 70s**. The incidence of MDS significantly **increases with age**, reflecting an accumulation of genetic mutations and bone marrow dysfunction over time. *0-10 years* - While MDS can occur in children, it is **very rare** in this age group and often associated with **inherited bone marrow failure syndromes** or **genetic predispositions**. - The clinical presentation and underlying biology of pediatric MDS can differ significantly from adult-onset MDS. *11-20 years* - MDS is also **uncommon** in adolescents and young adults, largely overshadowed by other hematologic malignancies like acute leukemias or lymphomas. - When it does occur, it may sometimes be linked to prior exposure to **chemotherapy or radiation**. *21-50 years* - Although possible, the diagnosis of MDS in this age range is still relatively **infrequent** compared to older populations. - MDS in younger adults may have different prognostic implications or be more often linked to secondary causes.

Q: Earliest phenotypic manifestation of idiopathic hereditary hemochromatosis is:

Increased transferrin saturation. ***Increased transferrin saturation*** - **Increased transferrin saturation** is the **earliest phenotypic manifestation** of idiopathic hereditary hemochromatosis due to increased iron absorption exceeding the binding capacity of transferrin [1]. - This precedes significant iron overload and subsequent organ damage, making it a key diagnostic marker in early stages [3]. *Post-prandial increase in serum iron concentration* - While iron absorption is increased in hemochromatosis, a **post-prandial increase in serum iron** is a less specific and less consistently used marker for early diagnosis compared to transferrin saturation. - Serum iron levels can fluctuate significantly, making a single post-prandial measurement less reliable for detecting the initial stages of iron overload [2]. *Elevated serum ferritin level* - **Elevated serum ferritin** indicates total body iron stores and is a good marker for accumulated iron overload, but it usually rises later than transferrin saturation [3]. - Ferritin can also be an **acute phase reactant**, meaning it can be elevated in conditions other than hemochromatosis (e.g., inflammation, infection), making it less specific as an initial diagnostic marker [3]. *Slate grey pigmentation of skin* - **Slate grey pigmentation** is a late manifestation of hemochromatosis, indicating significant and prolonged iron deposition in the skin and other organs [1]. - This symptom suggests **advanced disease** and is not an early phenotypic expression.

Q: All of the following conditions are associated with Coombs-positive hemolytic anemia, except:

PAN. ***PAN*** - **Polyarteritis nodosa (PAN)** is a **necrotizing vasculitis** that typically affects medium-sized arteries. It is not generally associated with Coombs-positive hemolytic anemia. - While systemic inflammation can cause anemia of chronic disease, direct autoantibody-mediated red blood cell destruction is not a feature of PAN. *Thrombotic Thrombocytopenic Purpura* - **Thrombotic thrombocytopenic purpura (TTP)** is characterized by microangiopathic hemolytic anemia, but it is typically **Coombs-negative** [3]. - The hemolysis in TTP is due to mechanical fragmentation of red blood cells as they pass through fibrin networks in small vessels, not antibody-mediated destruction [3]. *Scleroderma* - **Systemic sclerosis (scleroderma)** can be associated with autoimmune phenomena including **autoimmune hemolytic anemia**, which can be Coombs-positive [2]. - While less common than in SLE, autoimmune hemolytic anemia is a recognized complication in some patients with scleroderma due to immune dysregulation [2], [3]. *SLE* - **Systemic lupus erythematosus (SLE)** is frequently associated with **Coombs-positive hemolytic anemia** [1]. - **Autoantibodies** against red blood cell surface antigens are common in SLE, leading to their destruction by the immune system [1], [2].

Q: Which of the following are the features of pernicious anemia?

All of the options. ***All of the above*** - Pernicious anemia features include various manifestations like **gastric mucosal atrophy**, **hyper-segmented neutrophils**, and **subacute combined degeneration of the spinal cord**. - It is an autoimmune condition leading to **vitamin B12 deficiency** [1], affecting multiple systems, confirming that all stated features are relevant. *Subacute combined degeneration of spinal cord* - While this condition is seen in **vitamin B12 deficiency**, it is not exclusive to pernicious anemia, as it can occur in **various causes** of B12 deficiency [1]. - The direct link to pernicious anemia is more about **gastric atrophy** and resultant malabsorption rather than spinal cord degeneration itself. *Gastric mucosal atrophy* - Gastric mucosal atrophy is a key feature of pernicious anemia but does not encompass the complete spectrum of its clinical implications. - This condition causes reduced **intrinsic factor production**, leading to vitamin B12 deficiency [1], thus confirming it is part but not all of the features. *Hyper-segmented neutrophils* - Hyper-segmented neutrophils are notably found in megaloblastic anemia due to B12 deficiency [1] but do not exclusively indicate pernicious anemia. - Their presence alone lacks specificity, as they can also arise in **folate deficiency** or other causes of megaloblastic anemia.

Question 1

In the evaluation of a newly diagnosed case of acute lymphoid leukemia (ALL), which of the following tests is not routinely included?

Accepted Answer

Plasma viscosity

Answer

Bone marrow biopsy

Answer

Complete metabolic panel

Answer

Cell surface phenotyping

Question 2

Which of the following does not cause deep venous thrombosis (DVT)?

Accepted Answer

Subungual hematoma

Answer

Lower limb trauma

Answer

Hip & pelvic surgeries

Answer

Cushing's syndrome

Question 3

Which is not seen in Polycythemia Vera?

Accepted Answer

Increased erythropoietin level

Answer

Increased RBC count

Answer

Ocular congestion

Answer

Increased Vitamin B12 binding capacity

Question 4

Multiple myeloma has been seen commonly after exposure to which of the following substances?

Accepted Answer

Radioactive isotopes

Answer

Gold

Answer

Asbestos

Answer

Organic dyes

Question 5

During the treatment of chronic myeloid leukemia, cytogenetic remission is least likely to occur with which one of the following treatment modalities?

Accepted Answer

Hydroxyurea

Answer

imatinib mesylate

Answer

Interferon-alpha

Answer

Bone marrow transplantation

Question 6

What is the best treatment option for a patient aged 65 years with severe aplastic anemia who has an HLA-compatible sibling available?

Accepted Answer

Antithymocyte globulin followed by cyclosporine

Answer

Non-myeloablative bone marrow transplantation from the HLA identical sibling

Answer

Cyclosporine monotherapy

Answer

Conventional myeloablative bone marrow transplantation from the HLA identical sibling

Question 7

In which of the following age groups is myelodysplastic syndrome (MDS) most commonly diagnosed?

Accepted Answer

>50 years

Answer

0-10 years

Answer

11-20 years

Answer

21-50 years

Question 8

Earliest phenotypic manifestation of idiopathic hereditary hemochromatosis is:

Accepted Answer

Increased transferrin saturation

Answer

Post-prandial increase in serum iron concentration

Answer

Elevated serum ferritin level

Answer

Slate grey pigmentation of skin

Question 9

All of the following conditions are associated with Coombs-positive hemolytic anemia, except:

Accepted Answer

PAN

Answer

SLE

Answer

Thrombotic Thrombocytopenic Purpura

Answer

Scleroderma

Question 10

Which of the following are the features of pernicious anemia?

Accepted Answer

All of the options

Answer

Gastric mucosal atrophy

Answer

Subacute combined degeneration of spinal cord

Answer

Hyper-segmented neutrophils

Hematology — MCQs

Hematology — MCQs

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