Hematology — MCQs

A 50-year-old man presents with a history of abdominal pain, weakness, lightheadedness, palpitations, and shortness of breath. On examination, glossitis, hyperpigmentation of the skin of the dorsum of hands and feet, and abnormal pigmentation of hair were observed. The patient's family reports frequent episodes of increased irritability over the past year. Laboratory findings include Hb: 9gm%, MCV: 110fL, MCH: 36Pg, MCHC: 34gm/dL, Reticulocyte count: 0.1 x 10^9/L, LDH: 600 U/L, Indirect bilirubin: 1 mg/dL, S. iron: Normal, S. Ferritin: Normal, WBC: 2 x 10^9/L, and Platelet count: 90 x 10^9/L. Peripheral blood smear and bone marrow aspiration were also performed. What is the infective form of the organism causing the above condition?

Hematology Indian Medical PG Practice Questions and MCQs

Question 741: A 17-year-old female with von Willebrand disease presents for dental extraction. What is the appropriate prior line of management?

A. Cryoprecipitate
B. Fresh Frozen Plasma (FFP)
C. Recombinant factor VIII
D. Desmopressin (DDAVP) (Correct Answer)

Explanation: **Explanation:** The correct answer is **Desmopressin (DDAVP)**. **1. Why Desmopressin (DDAVP) is the correct answer:** Desmopressin is a synthetic analogue of vasopressin (ADH) that acts on V2 receptors to stimulate the release of **endogenous von Willebrand Factor (vWF)** and **Factor VIII** from the Weibel-Palade bodies of endothelial cells. In patients with Type 1 vWD (the most common form), DDAVP can increase plasma levels of vWF 3 to 5-fold, making it the treatment of choice for minor surgical procedures like dental extractions. It avoids the risks associated with blood products. **2. Why other options are incorrect:** * **Cryoprecipitate:** While it contains vWF and Factor VIII, it is no longer the first-line treatment due to the risk of transfusion-transmitted infections. It is reserved only when specific concentrates are unavailable. * **Fresh Frozen Plasma (FFP):** FFP contains all coagulation factors but in low concentrations. To achieve therapeutic vWF levels, a large volume would be required, risking fluid overload. * **Recombinant Factor VIII:** Pure recombinant Factor VIII lacks vWF. While some vWF-containing concentrates are used in severe cases (Type 3), pure Factor VIII will not correct the primary platelet adhesion defect in vWD. **Clinical Pearls for NEET-PG:** * **Type 1 vWD:** Quantitative deficiency (Most common). Best response to DDAVP. * **Type 2B vWD:** DDAVP is **contraindicated** as it may cause transient thrombocytopenia due to increased platelet aggregation. * **Type 3 vWD:** Total deficiency; DDAVP is ineffective (requires vWF-containing concentrates). * **Side Effects of DDAVP:** Hyponatremia (due to water retention) and facial flushing. Patients should be advised on fluid restriction. * **Diagnostic screening:** Prolonged Bleeding Time (BT) and often a prolonged aPTT. Platelet count is usually normal.

Question 742: Acute hemolytic anemia in G6PD deficiency is triggered by all, EXCEPT:

A. Fava beans
B. Infections
C. Drugs
D. Anemia (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Anemia**. In G6PD deficiency, anemia is the **result** (clinical manifestation) of a hemolytic crisis, not the trigger that initiates it [2]. **Underlying Medical Concept:** Glucose-6-Phosphate Dehydrogenase (G6PD) is a rate-limiting enzyme in the pentose phosphate pathway, responsible for maintaining levels of **reduced glutathione** [3]. This molecule protects red blood cells (RBCs) from oxidative stress [3][4]. In G6PD-deficient individuals, exposure to oxidative triggers leads to the oxidation of hemoglobin into **Heinz bodies**, which are then removed by splenic macrophages (forming **Bite cells**), resulting in acute intravascular and extravascular hemolysis [1]. **Analysis of Incorrect Options:** * **A. Fava beans:** These contain vicine and covicine, which produce highly reactive oxygen species (ROS). This is known as **Favism**, a classic trigger for severe hemolysis [1]. * **B. Infections:** The most common trigger [1]. During infection, inflammatory cells (neutrophils) produce free radicals to kill pathogens, which inadvertently causes oxidative damage to G6PD-deficient RBCs. * **C. Drugs:** Several drugs act as oxidizing agents [1]. High-yield examples include **Primaquine**, Sulfonamides, Nitrofurantoin, and Dapsone [1][2]. **NEET-PG High-Yield Pearls:** * **Inheritance:** X-linked recessive (primarily affects males) [3]. * **Peripheral Smear:** Look for **Heinz bodies** (supravital stain like Crystal Violet) and **Bite cells** (Degmacytes) [3]. * **Timing:** Hemolysis typically occurs 2–3 days after exposure to the trigger [2]. * **Diagnosis:** Quantitative enzyme assay is the gold standard, but it should **not** be performed during an acute episode as reticulocytes (which have higher enzyme levels) can cause a false-normal result.

Question 743: In a patient of hemophilia scheduled for dental extraction, which of the following statements is true, EXCEPT?

A. All patients should be screened for HIV.
B. Extraction should be done under general anesthesia and skilled anesthetic care. (Correct Answer)
C. Factor VIII or cryoprecipitate may be needed.
D. The dose of lignocaine required for anesthesia is the same as for normal individuals.

Explanation: In Hemophilia management, the goal of dental procedures is to minimize trauma and ensure adequate hemostasis while avoiding unnecessary risks. **Explanation of the Correct Option (B):** The statement that extraction must be done under general anesthesia (GA) is **incorrect**, making it the right answer for this "EXCEPT" question. Most dental extractions in hemophiliacs can be safely performed under **local anesthesia** (LA). In fact, GA carries additional risks, such as trauma during intubation which can cause life-threatening airway bleeds (e.g., retropharyngeal hematoma). If LA is used, nerve blocks (like the Inferior Alveolar Nerve block) should be avoided unless factor levels are corrected to 30-50%, as they risk deep tissue hematomas; infiltration or intraligamentary injections are preferred. **Analysis of Other Options:** * **Option A:** Historically, many hemophiliacs were infected with HIV/Hepatitis C via plasma-derived factors before rigorous screening and heat treatment were implemented. Screening is a standard protocol for these patients. * **Option C:** Factor VIII replacement (for Hemophilia A) or Cryoprecipitate (if factor concentrates are unavailable) is essential to raise factor levels to roughly 50% before extraction to prevent prolonged post-operative bleeding [1]. * **Option D:** Hemophilia is a coagulation disorder, not a neurological or pharmacological one. The pharmacodynamics of lignocaine remain unchanged; the standard dose is effective. **High-Yield Clinical Pearls for NEET-PG:** * **Antifibrinolytics:** Tranexamic acid or Epsilon-aminocaproic acid (EACA) are excellent adjuncts in dental surgery to stabilize clots in the fibrinolytic oral environment. * **Desmopressin (DDAVP):** Can be used in mild Hemophilia A to raise Factor VIII levels by releasing it from endothelial stores. * **Target Levels:** For minor dental work, 30% factor activity is often sufficient; for extractions, 50% is targeted [1].

Question 744: A patient presents with macroglossia and loss of tongue papillae. His Hb is 11.5 g/dL and MCV is 100 fL. What should be the next step in investigating this patient?

A. Vitamin B12 estimation (Correct Answer)
B. Brush biopsy of the lesion
C. Fluconazole treatment
D. Incision biopsy

Explanation: ### Explanation The clinical presentation of **macroglossia** (enlarged tongue) combined with the **loss of tongue papillae** (atrophic glossitis/Hunter’s glossitis) and a **borderline high MCV** (100 fL) strongly suggests a nutritional deficiency, specifically **Vitamin B12 deficiency**. **1. Why Vitamin B12 estimation is the correct step:** Atrophic glossitis is a classic physical finding in megaloblastic anemia. Vitamin B12 is essential for DNA synthesis; its deficiency leads to ineffective erythropoiesis (causing macrocytosis/high MCV) and rapid turnover cell depletion, such as the lingual papillae [1]. While the Hb (11.5 g/dL) is only mildly low, the MCV and oral findings are early indicators that necessitate checking serum B12 levels before invasive procedures [3]. **2. Why other options are incorrect:** * **Brush/Incision Biopsy (B & D):** These are indicated for suspected malignancy (e.g., Squamous Cell Carcinoma). However, the diffuse loss of papillae and macroglossia in a patient with macrocytosis point toward a systemic metabolic cause rather than a localized neoplastic process. * **Fluconazole treatment (C):** This is used for Oral Candidiasis (thrush). While thrush can cause tongue discomfort, it typically presents with white curd-like plaques that can be scraped off, not a smooth, beefy red tongue with macrocytosis. **Clinical Pearls for NEET-PG:** * **Hunter’s Glossitis:** Specifically refers to the smooth, "beefy red" tongue seen in B12 deficiency. * **Macroglossia Differential:** Common causes include Amyloidosis (most common chronic cause), Hypothyroidism (Myxedema), Acromegaly, and Down Syndrome [2]. * **MCV Trends:** Always correlate a high-normal or elevated MCV with oral signs; B12 and Folate deficiencies are the most common culprits in the Indian subcontinent [3].

Question 745: What is the first sign of improvement in oral iron therapy?

A. Reticulocytosis (Correct Answer)
B. Rise of hemoglobin
C. Rise in RBC count
D. Increase in ESR

Explanation: **Explanation:** In the treatment of Iron Deficiency Anemia (IDA), the body’s response to oral iron therapy follows a predictable chronological sequence [1]. **1. Why Reticulocytosis is Correct:** Reticulocytosis (an increase in young, immature red blood cells) is the **earliest objective laboratory sign** of a response to iron therapy. Once iron is available, the bone marrow rapidly increases erythropoiesis. This peak in reticulocyte count typically occurs between **5 to 10 days** after starting treatment. Subjectively, the patient may feel a sense of well-being (increased appetite and energy) within 24–48 hours, but reticulocytosis is the first measurable hematological sign. **2. Why Other Options are Incorrect:** * **Rise of Hemoglobin:** While essential, this is a slower process. Hemoglobin typically begins to rise after 1–2 weeks, usually at a rate of approximately 1 g/dL every 7–10 days. * **Rise in RBC Count:** Similar to hemoglobin, the total red cell mass increases gradually as the marrow produces mature cells over several weeks. * **Increase in ESR:** ESR (Erythrocyte Sedimentation Rate) is a non-specific marker of inflammation. In IDA, ESR may actually be slightly elevated and tends to normalize with treatment; it is never a sign of "improvement" in iron status [2]. **High-Yield Clinical Pearls for NEET-PG:** * **Sequence of Response:** Subjectively improvement (24-48h) → Reticulocytosis (5-10 days) → Rise in Hb (2 weeks) → Normalization of Hb (2 months) → **Replenishment of Iron Stores/Ferritin (3-6 months).** * **Failure to Respond:** If reticulocytosis does not occur within 2 weeks, consider: non-compliance (most common), malabsorption (e.g., Celiac disease), ongoing blood loss, or an incorrect diagnosis (e.g., Thalassemia) [2]. * **Best Absorption:** Oral iron is best absorbed on an empty stomach or with Vitamin C (ascorbic acid).

Question 746: Which of the following is FALSE regarding sickle cell anemia?

A. Dactylitis
B. Osteomyelitis
C. Granulocytosis
D. High reticulocyte count (Correct Answer)

Explanation: **Explanation:** In the context of this specific question, **High reticulocyte count** is the correct answer because it is a **characteristic feature** of sickle cell anemia (SCA), making the statement "False" in the context of identifying a *non-feature* or an *exception* (depending on the question's framing of clinical findings). However, in most standard NEET-PG patterns, if the question asks for a "False" statement and the answer is "High reticulocyte count," it implies that a **low** reticulocyte count occurs during specific crises (like Aplastic Crisis) [1], or it is a distractor highlighting that while hemolysis is present, the count may not always be elevated during marrow failure. **1. Why the Correct Answer is Right:** Sickle cell anemia is a chronic hemolytic anemia. Under steady-state conditions, the body compensates for the short lifespan of RBCs (10–20 days) by increasing erythropoiesis, leading to a **high reticulocyte count**. If a question marks this as "False," it typically refers to an **Aplastic Crisis** (often triggered by Parvovirus B19), where the reticulocyte count drops precipitously [1], or it is a poorly phrased question where the other options are more definitive clinical complications. **2. Analysis of Incorrect Options:** * **A. Dactylitis:** Also known as "Hand-foot syndrome," this is often the first clinical manifestation of SCA in infants (6 months to 2 years) due to microinfarction of bone marrow in small bones. * **B. Osteomyelitis:** SCA patients are predisposed to osteomyelitis. While *Staphylococcus aureus* is the most common cause overall, **Salmonella** is a high-yield, specific pathogen associated with SCA. * **C. Granulocytosis:** Chronic inflammation and stress in SCA lead to a baseline elevation of white blood cells (granulocytes), which is a known poor prognostic marker. **Clinical Pearls for NEET-PG:** * **Most common cause of death:** Acute Chest Syndrome (Adults); Sepsis/Infection (Children). * **Autosplenectomy:** Occurs by age 6–8 due to repeated splenic infarctions [1]; **Howell-Jolly bodies** are seen on peripheral smear. * **Treatment:** Hydroxyurea is used to increase **HbF** levels, reducing the frequency of painful crises [1].

Question 747: Stage of Hodgkin's lymphoma with right-sided neck nodes and a left inguinal node, without fever?

A. Stage Ia
B. Stage IIa
C. Stage IIIa (Correct Answer)
D. Stage IVa

Explanation: ### Explanation The staging of Hodgkin’s Lymphoma follows the **Ann Arbor Staging System** (modified by the Cotswolds criteria). The stage is determined by the location of lymph node involvement relative to the **diaphragm** [1]. **Why Stage IIIa is correct:** * **Stage III** is defined as involvement of lymph node regions on **both sides of the diaphragm**. In this case, the right-sided neck nodes (cervical) are above the diaphragm, and the left inguinal node is below the diaphragm [1]. * The suffix **'a'** denotes the **absence** of constitutional "B" symptoms (fever, night sweats, or weight loss >10% in 6 months) [1]. Since the patient does not have fever, it is classified as Stage IIIa. **Why other options are incorrect:** * **Stage Ia:** Involvement of a single lymph node region or a single extralymphatic site [1]. This patient has multiple regions involved on both sides of the diaphragm. * **Stage IIa:** Involvement of two or more lymph node regions on the **same side** of the diaphragm [1]. * **Stage IVa:** Diffuse or disseminated involvement of one or more **extralymphatic organs** (e.g., liver, bone marrow, or lungs), with or without associated lymph node involvement [1]. **High-Yield Clinical Pearls for NEET-PG:** 1. **B Symptoms:** Fever (>38°C), drenching night sweats, and unexplained weight loss (>10% in 6 months). Their presence adds the suffix 'b' (e.g., IIIb) [1]. 2. **Bulky Disease:** Defined as a nodal mass >10 cm or >1/3rd of the transthoracic diameter [1]. 3. **Pel-Ebstein Fever:** A classic but rare cyclic fever pattern associated with Hodgkin’s Lymphoma. 4. **Alcohol-induced pain:** Pain in the lymph nodes after drinking alcohol is a highly specific (though uncommon) symptom of Hodgkin’s. 5. **Most Common Subtype:** Nodular Sclerosis is the most common histological subtype overall.

Question 748: Which of the following is NOT a feature of hereditary spherocytosis?

A. Increased osmotic fragility
B. Increased MCHC
C. Increased MCV (Correct Answer)
D. Decreased surface area to volume ratio

Explanation: Hereditary Spherocytosis (HS) is an autosomal dominant disorder caused by defects in red cell membrane proteins (most commonly **Ankyrin**, followed by Spectrin) [2]. This leads to a loss of membrane surface area, forcing the RBC to adopt a spherical shape rather than a biconcave disc [1], [2]. **Why "Increased MCV" is the correct answer:** In HS, the **MCV (Mean Corpuscular Volume) is typically normal or slightly decreased**. Because the cell loses membrane fragments (vesiculation) while maintaining its internal contents, the cell becomes smaller and more compact. An increased MCV is characteristic of megaloblastic anemias or reticulocytosis, not the primary pathology of HS. **Analysis of incorrect options:** * **Increased MCHC:** This is a **hallmark finding** of HS [1]. As the cell loses surface area but retains hemoglobin, the concentration of hemoglobin per cell increases (often >36 g/dL) [1]. * **Increased Osmotic Fragility:** Spherocytes have a **decreased surface area-to-volume ratio**, making them unable to expand when placed in hypotonic solutions. They lyse much earlier than normal cells. * **Decreased surface area to volume ratio:** This is the fundamental morphological change in HS [1]. The spherical shape is the most geometrically efficient way to hold a volume, resulting in the lowest possible surface area for that volume. **NEET-PG High-Yield Pearls:** * **Gold Standard Test:** Eosin-5-maleimide (EMA) binding test (Flow cytometry). * **Screening Test:** Osmotic Fragility Test (using incubated blood). * **Peripheral Smear:** Spherocytes (small, dark cells lacking central pallor). * **Clinical Triad:** Anemia, Jaundice (unconjugated), and Splenomegaly [2]. * **Complication:** Pigmented gallstones (calcium bilirubinate) and Aplastic crisis (associated with Parvovirus B19).

Question 749: Cold agglutinin disease can be associated with all of the following, except:

A. Mycoplasma pneumoniae infection
B. Waldenstrom macroglobulinemia
C. Systemic Lupus Erythematosus (Correct Answer)
D. Epstein-Barr virus infection

Explanation: **Explanation:** The core concept in this question is differentiating between **Warm** and **Cold Autoimmune Hemolytic Anemia (AIHA)**. **Why Systemic Lupus Erythematosus (SLE) is the correct answer:** SLE is classically associated with **Warm AIHA**, which is mediated by **IgG** antibodies that react at body temperature ($37^\circ\text{C}$) [1]. In contrast, Cold Agglutinin Disease (CAD) is mediated by **IgM** antibodies that react at low temperatures ($0\text{--}4^\circ\text{C}$) [3]. While SLE involves multiple autoantibodies, it is not a typical cause of cold agglutinins [2]. **Analysis of Incorrect Options:** * **Mycoplasma pneumoniae:** This is a classic trigger for **transient/acute CAD** [3]. The bacteria share antigenic similarities with the **I antigen** on human RBCs, leading to cross-reactive IgM production. * **Waldenstrom Macroglobulinemia:** This is a lymphoproliferative disorder characterized by monoclonal IgM production. It is a leading cause of **chronic/primary CAD** [3]. * **Epstein-Barr Virus (EBV):** Similar to Mycoplasma, EBV (Infectious Mononucleosis) can trigger cold agglutinins, specifically targeting the **i antigen** (lowercase 'i') on fetal/neonatal RBCs. **High-Yield Clinical Pearls for NEET-PG:** 1. **Antibody Type:** Warm AIHA = **IgG** (Extravascular hemolysis in Spleen); Cold AIHA = **IgM** (Intravascular or Liver-based hemolysis) [1], [3]. 2. **Antigen Targets:** Mycoplasma = **I antigen**; EBV = **i antigen** [3]. 3. **Blood Smear:** Look for **RBC agglutination** (clumping) in CAD, which disappears upon warming the slide [3]. 4. **Coombs Test:** In CAD, the Direct Antiglobulin Test (DAT) is positive for **C3d** (complement) but negative for IgG [1].

Question 750: A 50-year-old man presents with a history of abdominal pain, weakness, lightheadedness, palpitations, and shortness of breath. On examination, glossitis, hyperpigmentation of the skin of the dorsum of hands and feet, and abnormal pigmentation of hair were observed. The patient's family reports frequent episodes of increased irritability over the past year. Laboratory findings include Hb: 9gm%, MCV: 110fL, MCH: 36Pg, MCHC: 34gm/dL, Reticulocyte count: 0.1 x 10^9/L, LDH: 600 U/L, Indirect bilirubin: 1 mg/dL, S. iron: Normal, S. Ferritin: Normal, WBC: 2 x 10^9/L, and Platelet count: 90 x 10^9/L. Peripheral blood smear and bone marrow aspiration were also performed. What is the infective form of the organism causing the above condition?

A. Miracidium
B. Coracidium
C. Plerocercoid (Correct Answer)
D. Procercoid

Explanation: ### Explanation The clinical presentation and laboratory findings point towards **Megaloblastic Anemia** caused by **Vitamin B12 deficiency** [1]. **Clinical Reasoning:** * **Hematology:** The patient has macrocytic anemia (MCV 110 fL), pancytopenia (low WBC and Platelets), and a low reticulocyte count. Elevated LDH and indirect bilirubin indicate **ineffective erythropoiesis** (intramedullary hemolysis). * **Physical Findings:** Glossitis and hyperpigmentation (dorsum of hands/feet) are classic cutaneous markers of B12 deficiency. * **Neuropsychiatric:** Irritability and cognitive changes are common in B12 deficiency. The question asks for the infective form of the organism causing this condition. In the context of parasitic causes of B12 deficiency, the culprit is **_Diphyllobothrium latum_** (Fish Tapeworm). It competes with the host for Vitamin B12 in the proximal jejunum. Humans acquire the infection by consuming undercooked fish containing the **Plerocercoid larva**. **Analysis of Options:** * **C. Plerocercoid (Correct):** This is the third-stage larva found in the muscles of freshwater fish and is the **infective stage** for humans. * **A. Miracidium:** The first larval stage of **Trematodes** (flukes), which infects the intermediate host (snail). * **B. Coracidium:** The ciliated first-stage larva of _D. latum_ that hatches from the egg and is ingested by the first intermediate host (Cyclops). * **D. Procercoid:** The second-stage larva of _D. latum_ that develops inside the Cyclops. **High-Yield Clinical Pearls for NEET-PG:** * **_D. latum_** is the largest tapeworm infecting humans (up to 10 meters). * **Mechanism:** It absorbs ~80-100% of dietary B12, leading to megaloblastic anemia. * **Diagnosis:** Identification of operculated eggs in stool. * **Treatment:** Praziquantel is the drug of choice.

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Hematology — MCQs

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