Hematology — MCQs

A patient presents with fever and altered consciousness. Investigations reveal anemia with fragmented red blood cells, a platelet count of 20,000/mm³, serum creatinine of 3.0 mg/dL, and normal prothrombin time (PT) and activated partial thromboplastin time (aPTT). Which of the following is the most appropriate treatment for this patient?

Q795Medium

Anemia of chronic disease is characterized by?

Q796Easy

What is the recommended hemoglobin level in male patients with polycythemia rubra vera to avoid thrombotic episodes?

Q797Easy

Microcytic hypochromic anaemia is seen in all of the following conditions except?

Q798Medium

A 39-year-old man is seeing red-colored urine in the morning. The CBC reveals anemia, low serum iron, and an elevated reticulocyte count. Laboratory studies show increased lysis of erythrocytes when incubated with either sucrose or acidified serum. Which of the following is the appropriate diagnosis?

Q799Easy

What is a hallmark of hemophilia?

Q800Easy

Neutropenia is seen in all of the following conditions except:

Hematology Indian Medical PG Practice Questions and MCQs

Question 791: All are true regarding Thrombotic Thrombocytopenia Purpura (TTP), except?

A. Normal complement levels (Correct Answer)
B. Microangiopathic hemolytic anemia
C. Thrombocytopenia
D. Thrombosis

Explanation: Thrombotic Thrombocytopenic Purpura (TTP) is a life-threatening hematologic emergency caused by a deficiency of the metalloproteinase ADAMTS13. This enzyme is responsible for cleaving large von Willebrand factor (vWF) multimers; its absence leads to ultra-large multimers that cause spontaneous platelet aggregation and microthrombi formation. **Why Option A is the correct answer:** In TTP, the primary pathology is a **non-immune** platelet consumption [2]. Unlike conditions like Systemic Lupus Erythematosus (SLE) or certain types of Glomerulonephritis, TTP does **not** involve the activation or consumption of the complement system. Therefore, **complement levels (C3, C4) remain normal**. This is a crucial diagnostic differentiator from other systemic microangiopathies. **Analysis of other options:** * **B. Microangiopathic Hemolytic Anemia (MAHA):** This is a hallmark of TTP [1]. As RBCs pass through small vessels partially occluded by platelet thrombi, they are mechanically shredded, leading to the presence of **schistocytes** on a peripheral smear [1]. * **C. Thrombocytopenia:** Extensive formation of microthrombi consumes platelets, leading to severe consumption-based thrombocytopenia [2]. * **D. Thrombosis:** The core pathophysiology involves widespread hyaline microthrombi in small vessels, which leads to end-organ ischemia (notably in the brain and kidneys) [1]. **High-Yield Clinical Pearls for NEET-PG:** * **The Classic Pentad (FAT RN):** **F**ever, **A**nemia (MAHA), **T**hrombocytopenia, **R**enal failure, and **N**eurological symptoms [1]. * **Coagulation Profile:** PT, aPTT, and Fibrinogen levels are typically **normal** in TTP (unlike DIC). * **Treatment of Choice:** Immediate **Plasmapheresis (Plasma Exchange)** to remove autoantibodies and replenish ADAMTS13.

Question 792: Pancytopenia with a cellular bone marrow is seen in all of the following conditions except:

A. Megaloblastic anemia
B. Myelodysplasia
C. Paroxysmal Nocturnal hemoglobinuria
D. G6PD deficiency (Correct Answer)

Explanation: **Explanation:** The core concept tested here is the distinction between **ineffective hematopoiesis** (where the marrow is busy but cells die before reaching circulation) and **peripheral destruction/sequestration**. **Why G6PD Deficiency is the Correct Answer:** G6PD deficiency is a hereditary enzyme defect that leads to **isolated episodic hemolytic anemia**, typically triggered by oxidative stress (e.g., fava beans, infections, or drugs like Primaquine) [1], [2]. It does **not** cause pancytopenia. The bone marrow in G6PD deficiency is typically **hypercellular** (erythroid hyperplasia) as it compensates for the peripheral destruction of red blood cells, but the white cell and platelet counts remain normal. **Why the other options are incorrect (Conditions with Pancytopenia + Cellular Marrow):** * **Megaloblastic Anemia:** Vitamin B12 or Folate deficiency leads to defective DNA synthesis. This causes **ineffective hematopoiesis**, where the marrow is hypercellular with megaloblasts, but the cells are destroyed within the marrow, leading to pancytopenia. * **Myelodysplastic Syndrome (MDS):** Characterized by clonal stem cell disorders leading to "sick" marrow. The marrow is often hypercellular with dysplastic changes, but it fails to produce mature, functional peripheral cells, resulting in pancytopenia. * **Paroxysmal Nocturnal Hemoglobinuria (PNH):** PNH is a unique stem cell disorder. While it can present with an aplastic (hypocellular) marrow, it frequently presents with a **cellular marrow** during its hemolytic phase or when evolving from/into other myelodysplastic states. **High-Yield Clinical Pearls for NEET-PG:** 1. **Pancytopenia with Hypocellular Marrow:** Aplastic anemia, Hypoplastic MDS, and some post-chemotherapy states. 2. **Pancytopenia with Hypercellular Marrow:** Megaloblastic anemia, MDS, Aleukemic leukemia, PNH, and Hypersplenism (peripheral destruction). 3. **G6PD Hallmark:** Look for "Bite cells" and "Heinz bodies" (denatured hemoglobin) on a peripheral smear [2]. 4. **Megaloblastic Anemia Hallmark:** Hypersegmented neutrophils (≥ 5 lobes) are the earliest sign.

Question 793: A 40-year-old woman with chronic lymphocytic leukemia (CLL) presents with rapidly increasing swellings in her neck and axilla over the past few months, accompanied by fever and weight loss. Which of the following is the most likely complication?

A. Richter transformation (Correct Answer)
B. Progression of CLL
C. Development of secondary infections
D. Immunodeficiency-associated hemolytic anemia

Explanation: ### Explanation **Correct Option: A. Richter Transformation** Richter transformation (RT) refers to the sudden clinicopathological transformation of Chronic Lymphocytic Leukemia (CLL) or Small Lymphocytic Lymphoma (SLL) into a more aggressive form of high-grade non-Hodgkin lymphoma, most commonly **Diffuse Large B-Cell Lymphoma (DLBCL)** (approx. 90%) [1] or rarely Hodgkin Lymphoma. The clinical hallmark of RT is the **"B-symptoms" triad**: rapid enlargement of lymph nodes (lymphadenopathy), drenching night sweats, fever, and significant weight loss [2]. Laboratory findings often show a sudden rise in Serum LDH levels [1]. This transformation occurs in about 2–10% of CLL patients and carries a poor prognosis. **Why Incorrect Options are Wrong:** * **B. Progression of CLL:** While CLL is a progressive disease, it typically follows an indolent course [1]. Rapid, localized lymph node enlargement with systemic B-symptoms is more characteristic of a high-grade transformation than the natural slow progression of CLL. * **C. Development of secondary infections:** CLL patients are prone to infections due to hypogammaglobulinemia [1]; however, infections usually present with acute inflammatory signs (cough, dysuria, etc.) rather than rapidly growing, painless lymphadenopathy. * **D. Immunodeficiency-associated hemolytic anemia:** While Autoimmune Hemolytic Anemia (AIHA) is a known complication of CLL, it presents with jaundice, pallor, and fatigue, not rapidly enlarging lymph nodes [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Most common transformation:** DLBCL (90%). * **Best Initial Test:** LDH (elevated) and PET-CT (to identify the most metabolically active node). * **Gold Standard Diagnosis:** Excisional Lymph Node Biopsy [2]. * **Prognosis:** Generally poor, with a median survival of less than 1 year. * **Key Trigger:** Often associated with mutations in *TP53* or *NOTCH1*.

Question 794: A patient presents with fever and altered consciousness. Investigations reveal anemia with fragmented red blood cells, a platelet count of 20,000/mm³, serum creatinine of 3.0 mg/dL, and normal prothrombin time (PT) and activated partial thromboplastin time (aPTT). Which of the following is the most appropriate treatment for this patient?

A. Plasma exchange therapy (Correct Answer)
B. Corticosteroids and intravenous immunoglobulin
C. Immunoglobulins
D. Anticoagulation with heparin

Explanation: ### Explanation The clinical presentation describes the classic **pentad of Thrombotic Thrombocytopenic Purpura (TTP)**: 1. **Microangiopathic Hemolytic Anemia (MAHA):** Fragmented RBCs (schistocytes) [2]. 2. **Thrombocytopenia:** Low platelet count (20,000/mm³) [3]. 3. **Neurological symptoms:** Altered consciousness. 4. **Renal dysfunction:** Elevated creatinine (3.0 mg/dL) [2]. 5. **Fever.** The hallmark of TTP is a deficiency of the **ADAMTS13** enzyme, leading to ultra-large von Willebrand factor (vWF) multimers that cause spontaneous platelet aggregation and microthrombi. **Why Plasma Exchange (PEX) is correct:** PEX is the **treatment of choice** and a medical emergency. It works by removing the autoantibodies against ADAMTS13 and replacing the deficient enzyme. It should be initiated immediately upon suspicion to prevent irreversible organ damage and death. **Why other options are incorrect:** * **B & C (Corticosteroids/IVIG):** While steroids are often used as an adjunct to PEX, they are not the primary treatment. IVIG is the treatment for Immune Thrombocytopenic Purpura (ITP), which lacks MAHA and renal failure [3]. * **D (Heparin):** Anticoagulation is ineffective and contraindicated as it increases the risk of bleeding in the setting of severe thrombocytopenia. **High-Yield Clinical Pearls for NEET-PG:** * **Coagulation Profile:** In TTP/HUS, PT and aPTT are **normal** (unlike DIC, where they are prolonged) [1]. * **HUS vs. TTP:** Hemolytic Uremic Syndrome (HUS) presents similarly but is more common in children, usually follows bloody diarrhea (EHEC O157:H7), and features **predominant renal failure** with fewer neurological symptoms [2]. * **Contraindication:** **Platelet transfusion** is generally contraindicated in TTP as it may "fuel the fire" by promoting further microthrombi formation.

Question 795: Anemia of chronic disease is characterized by?

A. Increased sideroblasts
B. Increased TIBC
C. Increased bone marrow iron (Correct Answer)
D. Increased protoporphyrin

Explanation: **Explanation:** **Anemia of Chronic Disease (ACD)**, also known as Anemia of Inflammation, is primarily driven by the cytokine **Hepcidin** [1]. In chronic inflammatory states (infections, malignancy, autoimmune diseases), IL-6 stimulates the liver to produce Hepcidin. Hepcidin degrades ferroportin, the channel responsible for releasing iron from macrophages and enterocytes [2]. This leads to **iron sequestration** within the Reticuloendothelial System (RES) [1]. **Why Option C is Correct:** Because iron is trapped within the macrophages of the bone marrow and cannot be utilized for erythropoiesis, a Prussian blue stain of the bone marrow will show **increased storage iron**. This is the hallmark that distinguishes ACD from Iron Deficiency Anemia (IDA) [1]. **Why Other Options are Incorrect:** * **A. Increased sideroblasts:** In ACD, there is a *decrease* in sideroblasts (erythroid precursors with iron granules) because iron is trapped in macrophages and unavailable to the developing RBCs. * **B. Increased TIBC:** Total Iron Binding Capacity (TIBC) is a measure of Transferrin. In ACD, TIBC is **decreased** (or low-normal) as the body attempts to limit iron availability to potential pathogens. (TIBC is *increased* in IDA). * **D. Increased protoporphyrin:** While Free Erythrocyte Protoporphyrin (FEP) can be elevated in ACD due to lack of iron to complete the heme ring, it is not the defining characteristic compared to the definitive finding of increased marrow iron stores. **NEET-PG High-Yield Pearls:** * **Ferritin:** Increased (it is an acute-phase reactant) [1]. * **Serum Iron:** Decreased. * **Transferrin Saturation:** Decreased. * **MCV:** Usually Normocytic, but can become Microcytic in chronic cases [2]. * **Treatment:** Treat the underlying cause; Erythropoietin (EPO) may be used in specific cases like CKD [2].

Question 796: What is the recommended hemoglobin level in male patients with polycythemia rubra vera to avoid thrombotic episodes?

A. 14 g/dL (Correct Answer)
B. 12 g/dL
C. 10 g/dL
D. 8 g/dL

Explanation: In Polycythemia Vera (PV), the primary goal of management is to reduce the risk of arterial and venous thrombosis, which are the leading causes of morbidity and mortality [1]. The cornerstone of therapy is therapeutic phlebotomy. **1. Why 14 g/dL is correct:** The risk of thrombotic episodes in PV is directly correlated with blood viscosity, which rises exponentially once the hematocrit (Hct) exceeds 45%. Clinical guidelines (based on the landmark CYTO-PV trial) recommend maintaining a **hematocrit <45%** in men. Since the hemoglobin (Hb) level is roughly one-third of the hematocrit value, a Hct of 45% corresponds to an **Hb of 15 g/dL**. To ensure a safety margin and keep the Hct strictly below 45%, the target Hb is maintained at **14 g/dL**. (Note: In females, the target Hct is <42%, corresponding to an Hb of ~12-13 g/dL). **2. Why incorrect options are wrong:** * **12 g/dL (Option B):** While this is a safe level, it is the target for females rather than males. Aiming for 12 g/dL in males may lead to unnecessary phlebotomies and symptomatic iron deficiency. * **10 g/dL and 8 g/dL (Options C & D):** These levels are unnecessarily low. Maintaining such levels would induce severe iron deficiency anemia and related symptoms (pica, glossitis, fatigue) without providing additional protection against thrombosis compared to the 14 g/dL target. **High-Yield Clinical Pearls for NEET-PG:** * **Mutation:** >95% of PV patients have the **JAK2 V617F** mutation [1]. * **Diagnostic Hallmark:** Low serum Erythropoietin (EPO) levels (unlike secondary polycythemia). * **Symptom:** **Aquagenic pruritus** (itching after a warm bath) is a classic board-exam clue [1]. * **Treatment:** Low-dose Aspirin is indicated for all patients unless contraindicated. Hydroxyurea is the first-line myelosuppressive agent for high-risk patients (age >60 or prior thrombosis).

Question 797: Microcytic hypochromic anaemia is seen in all of the following conditions except?

A. Beta thalassemia
B. Iron deficiency
C. Malaria (Correct Answer)
D. Lead poisoning

Explanation: Microcytic hypochromic anemia is characterized by a Mean Corpuscular Volume (MCV) < 80 fL and a Mean Corpuscular Hemoglobin Concentration (MCHC) < 32 g/dL [3]. This occurs due to defects in hemoglobin synthesis (either heme or globin). **Why Malaria is the correct answer:** Malaria typically causes a **Normocytic Normochromic anemia** [4]. The primary mechanism is the destruction of mature red blood cells (hemolysis) and splenic sequestration, rather than a defect in hemoglobin production [3, 5]. While chronic or severe malaria can occasionally lead to dyserythropoiesis, it is not a classic cause of microcytosis [4]. **Analysis of incorrect options:** * **Iron Deficiency Anemia (IDA):** The most common cause of microcytic hypochromic anemia worldwide [1, 4]. Lack of iron leads to decreased heme synthesis. * **Beta Thalassemia:** A quantitative defect in globin chain synthesis. It presents with significant microcytosis (often very low MCV) and a characteristic "target cell" appearance on peripheral smear. * **Lead Poisoning:** Lead inhibits enzymes in the heme synthesis pathway (ferrochelatase and ALA dehydratase), resulting in microcytic anemia with characteristic **basophilic stippling**. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Microcytic Anemia (TAILS):** **T**halassemia, **A**nemia of chronic disease (some cases), **I**ron deficiency, **L**ead poisoning, **S**ideroblastic anemia [1]. * **Mentzer Index:** (MCV/RBC count). If **<13**, it suggests Thalassemia; if **>13**, it suggests Iron Deficiency Anemia. * **RDW (Red Cell Distribution Width):** Usually increased in IDA (anisocytosis) but normal in uncomplicated Thalassemia trait.

Question 798: A 39-year-old man is seeing red-colored urine in the morning. The CBC reveals anemia, low serum iron, and an elevated reticulocyte count. Laboratory studies show increased lysis of erythrocytes when incubated with either sucrose or acidified serum. Which of the following is the appropriate diagnosis?

A. Anemia of chronic renal failure
B. Hereditary spherocytosis
C. Microangiopathic hemolytic anemia
D. Paroxysmal nocturnal hemoglobinuria (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Paroxysmal Nocturnal Hemoglobinuria (PNH)** **1. Why it is correct:** The clinical triad of **dark-colored urine in the morning** (hemoglobinuria), **intravascular hemolysis** (elevated reticulocytes, anemia), and **iron deficiency** (due to chronic urinary iron loss) is classic for PNH. Paroxysmal nocturnal haemoglobinuria is a recognized cause of lysis occurring within the blood stream due to membrane damage by complement [1]. The definitive diagnostic clue in this question is the positive **Sucrose Hemolysis Test** and **Ham’s Test (Acidified Serum Test)**. * **Pathophysiology:** PNH is an acquired stem cell disorder caused by a mutation in the **PIGA gene**, leading to a deficiency of GPI-anchored proteins like **CD55 (DAF)** and **CD59 (MIRL)**. These proteins normally protect RBCs from complement-mediated lysis. In an acidic environment (like sleep-induced mild respiratory acidosis), complement activation increases, leading to the lysis of these defective cells. **2. Why the other options are incorrect:** * **A. Anemia of Chronic Renal Failure:** Typically presents as a normocytic, normochromic anemia with a **low reticulocyte count** due to erythropoietin deficiency. It does not cause hemolysis or positive Ham's tests. * **B. Hereditary Spherocytosis:** While it causes hemolysis, it is characterized by an abnormal **Osmotic Fragility Test** and red cell membrane defects where cells lose elasticity due to protein deficiencies [1]. It typically presents with splenomegaly and spherocytes on a peripheral smear. * **C. Microangiopathic Hemolytic Anemia (MAHA):** Characterized by mechanical destruction of RBCs (schistocytes) on a peripheral smear. It is associated with conditions like TTP, HUS, or DIC, and is not triggered by acidified serum. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Flow cytometry to detect the absence of **CD55 and CD59** on RBCs and WBCs. * **Classic Triad:** Hemolytic anemia, Pancytopenia, and Venous Thrombosis (most common cause of death, often in unusual sites like the Budd-Chiari syndrome). * **Treatment:** The monoclonal antibody **Eculizumab** (targets C5 complement) is the drug of choice. * **Association:** PNH can evolve into or arise from **Aplastic Anemia** or **Acute Myeloid Leukemia (AML)**.

Question 799: What is a hallmark of hemophilia?

A. Epistaxis
B. Hemarthrosis (Correct Answer)
C. Abdominal pain
D. Anemia

Explanation: **Explanation:** **Hemophilia** (A or B) is a classic example of a **secondary hemostasis defect** (clotting factor deficiency) [1]. Unlike primary hemostasis defects (platelet disorders), which present with superficial bleeding like petechiae and epistaxis, secondary hemostasis defects typically manifest as deep-seated bleeding [3]. **Why Hemarthrosis is the Correct Answer:** **Hemarthrosis** (bleeding into joint spaces) is the clinical hallmark of hemophilia [1]. It most commonly affects large weight-bearing joints like the knees, elbows, and ankles [1]. Recurrent hemarthrosis leads to synovial hypertrophy and chronic joint destruction, known as **hemophilic arthropathy** [1]. **Analysis of Incorrect Options:** * **A. Epistaxis:** This is more characteristic of **primary hemostasis defects** (e.g., Von Willebrand Disease or thrombocytopenia) [3]. While it can occur in hemophilia, it is not the "hallmark" feature. * **C. Abdominal pain:** While internal bleeding (like iliopsoas hematoma) can cause pain, it is a complication rather than a diagnostic hallmark [1]. * **D. Anemia:** Anemia is a non-specific consequence of chronic or acute blood loss and is not diagnostic of any specific bleeding disorder. **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Both Hemophilia A (Factor VIII deficiency) and B (Factor IX deficiency) are **X-linked recessive** [2]. * **Lab Profile:** Characterized by **Prolonged aPTT** with a **Normal PT and Normal Bleeding Time**. * **Mixing Study:** A prolonged aPTT that **corrects** upon mixing with normal plasma indicates a factor deficiency (like Hemophilia), whereas failure to correct suggests an inhibitor. * **Treatment:** Factor replacement is the mainstay. For mild Hemophilia A, **Desmopressin (DDAVP)** can be used to release stored Factor VIII and vWF.

Question 800: Neutropenia is seen in all of the following conditions except:

A. Scurvy (Correct Answer)
B. Aplastic anemia
C. Typhoid fever
D. Chloramphenicol

Explanation: ### Explanation **Correct Option: A. Scurvy** **1. Why Scurvy is the correct answer:** Scurvy is caused by a deficiency of **Vitamin C (Ascorbic acid)** [1]. Its primary clinical manifestations are related to defective collagen synthesis, leading to capillary fragility, gingival bleeding, perifollicular hemorrhages, and impaired wound healing [1]. While Vitamin C deficiency can lead to **anemia** (due to impaired iron absorption or bleeding), it does **not** typically cause neutropenia. In fact, severe scurvy is more likely to be associated with a normal or even elevated white blood cell count if secondary infections occur. **2. Analysis of Incorrect Options:** * **B. Aplastic Anemia:** This is a stem cell disorder characterized by **pancytopenia** (anemia, neutropenia, and thrombocytopenia) due to bone marrow failure. Neutropenia is a hallmark feature. * **C. Typhoid Fever:** Unlike most bacterial infections which cause leukocytosis, *Salmonella typhi* is a classic cause of **leukopenia and neutropenia** (relative or absolute) during the first two weeks of illness. * **D. Chloramphenicol:** This antibiotic is notorious for causing bone marrow suppression. It can cause dose-related reversible suppression or, more severely, idiosyncratic **irreversible aplastic anemia**, both of which result in neutropenia. **3. NEET-PG High-Yield Pearls:** * **Common causes of Neutropenia:** Viral infections (HIV, Hepatitis, EBV), drugs (NSAIDs, Antithyroid drugs, Clozapine), Megaloblastic anemia (B12/Folate deficiency), and Hypersplenism. * **Typhoid Fever:** Look for the triad of "Bradycardia, Rose spots, and Leukopenia/Neutropenia" in clinical vignettes. * **Scurvy:** Remember the "4 H's": Hemorrhage, Hyperkeratosis, Hypochondriasis, and Hematologic abnormalities (Anemia). Neutropenia is notably absent.

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Hematology — MCQs

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