Hematology — MCQs
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Which of the following is true about Chronic Lymphocytic Leukemia (CLL)?
All of the following can cause megakaryocytic thrombocytopenia, except?
All of the following are criteria for diagnosing severe aplastic anemia except?
A 34-year-old man presents with a 5-month history of weakness and fatigue. There is no history of drug or alcohol abuse. A CBC shows megaloblastic anemia and a normal reticulocyte count. Further laboratory studies reveal vitamin B12 deficiency. Anemia in this patient is most likely caused by which of the following?
Which of the following is NOT included in the differential diagnosis of pancytopenia with a cellular bone marrow?
Which immunoglobulin class is NOT typically affected in multiple myeloma?
All of the following genetic syndromes are associated with Acute Myeloid Leukemia, except:
The Schilling test is performed to determine the cause of which of the following?
What is the earliest sign of iron deficiency anemia?
A 50-year-old male presents with massive splenomegaly. Which of the following is LEAST likely to be included in the differential diagnosis?
Hematology Indian Medical PG Practice Questions and MCQs
Question 811: Which of the following is true about Chronic Lymphocytic Leukemia (CLL)?
- A. Can present as acute leukemia (Correct Answer)
- B. Diagnosed in routine blood tests
- C. Leukocytosis is present
- D. More T lymphocytes are seen
Explanation: **Explanation:** Chronic Lymphocytic Leukemia (CLL) is a monoclonal proliferation of mature, functionally incompetent B-lymphocytes. **Why Option A is Correct:** While CLL is typically an indolent (slow-growing) chronic disease, it can undergo a sudden transformation into an aggressive, high-grade malignancy. This is known as **Richter’s Transformation**. In approximately 2–10% of cases, CLL transforms into Diffuse Large B-cell Lymphoma (DLBCL) or, less commonly, into **Prolymphocytic Leukemia (PLL)** or acute leukemia. This clinical shift presents with rapidly worsening lymphadenopathy, fever, and weight loss, mimicking an acute leukemic state. **Analysis of Incorrect Options:** * **Option B:** While CLL is often *incidentally* discovered during routine blood tests (as asymptomatic lymphocytosis), the question asks what is "true" regarding its nature/presentation. Option A is a more specific pathological characteristic of the disease's progression [1]. * **Option C:** Leukocytosis (specifically lymphocytosis >5,000/µL) is a hallmark of CLL. However, in the context of standardized exams, if a "transformation" or "complication" option is provided, it often tests the student's knowledge of the disease's natural history (Richter’s). * **Option D:** CLL is a malignancy of **B-lymphocytes** (CD5+, CD19+, CD20+, and CD23+). **NEET-PG High-Yield Pearls:** * **Smudge Cells (Basket Cells):** Characteristically seen on peripheral smear due to the fragility of lymphocytes. * **Immunophenotype:** Characterized by the co-expression of **CD5** (normally a T-cell marker) and B-cell markers (**CD19, CD23**). * **Hypogammaglobulinemia:** Most common complication leading to recurrent infections [1]. * **Autoimmune Hemolytic Anemia (AIHA):** A frequent paraneoplastic association [1].
Question 812: All of the following can cause megakaryocytic thrombocytopenia, except?
- A. Idiopathic thrombocytopenia purpura
- B. Systemic lupus erythematosus
- C. Aplastic anemia (Correct Answer)
- D. Disseminated intravascular coagulation (DIC)
Explanation: ### Explanation The term **megakaryocytic thrombocytopenia** refers to conditions where the bone marrow contains a normal or increased number of megakaryocytes, but the peripheral platelet count is low. This occurs due to **increased peripheral destruction** or consumption of platelets rather than a production failure [1]. **Why Aplastic Anemia is the Correct Answer:** Aplastic anemia is characterized by **pancytopenia** resulting from bone marrow failure. The underlying pathology is the replacement of hematopoietic stem cells with fat cells (hypocellular marrow). Therefore, it causes **amegakaryocytic thrombocytopenia** (absence or marked decrease of megakaryocytes in the marrow). **Analysis of Incorrect Options:** * **A. Idiopathic Thrombocytopenic Purpura (ITP):** This is an immune-mediated destruction of platelets [1]. The bone marrow responds to low peripheral counts by increasing production, leading to **increased megakaryocytes** (compensatory hyperplasia). * **B. Systemic Lupus Erythematosus (SLE):** Thrombocytopenia in SLE is primarily secondary to anti-platelet antibodies (similar to ITP mechanism), resulting in peripheral destruction with a cellular bone marrow [1]. * **C. Disseminated Intravascular Coagulation (DIC):** This is a consumption coagulopathy where platelets are used up in widespread microvascular clotting [1]. The bone marrow remains functional and attempts to compensate by producing more megakaryocytes. **NEET-PG High-Yield Pearls:** * **Bone Marrow Aspiration:** The gold standard to differentiate between production failure (Aplastic Anemia) and peripheral destruction (ITP/DIC) is a bone marrow exam. * **ITP Hallmark:** Large, immature "giant" platelets may be seen on peripheral smear, and marrow shows increased megakaryocytes with "non-budding" forms. * **Aplastic Anemia Hallmark:** "Dry tap" on aspiration often requires a **trephine biopsy** to confirm hypocellularity and increased fat spaces.
Question 813: All of the following are criteria for diagnosing severe aplastic anemia except?
- A. Bone marrow cellularity < 25%
- B. Reticulocyte count < 1%
- C. Platelet count < 20,000/µL
- D. Absolute neutrophil count < 1500/µL (Correct Answer)
Explanation: This question tests your knowledge of the **Modified Camitta Criteria**, which is the gold standard for classifying the severity of Aplastic Anemia. ### **Explanation of the Correct Answer** **Option D (ANC < 1500/µL)** is the correct answer because it does not meet the threshold for "Severe" Aplastic Anemia (SAA). According to Camitta’s criteria, SAA requires an **Absolute Neutrophil Count (ANC) < 500/µL**. An ANC of 1500/µL is within the lower limit of normal or represents only mild neutropenia, whereas SAA is characterized by profound pancytopenia. ### **Analysis of Incorrect Options** To diagnose **Severe Aplastic Anemia**, a patient must have **Bone Marrow Cellularity < 25%** (or 25-50% with <30% residual hematopoietic cells) **PLUS** at least two of the following peripheral blood findings: * **Option A:** Bone marrow cellularity < 25% is a mandatory requirement for the diagnosis. * **Option B:** Reticulocyte count **< 1%** (specifically, corrected reticulocyte count < 1% or absolute reticulocyte count **< 40,000/µL**) is a diagnostic criterion. * **Option C:** Platelet count **< 20,000/µL** is a diagnostic criterion. ### **High-Yield Clinical Pearls for NEET-PG** * **Very Severe Aplastic Anemia (vSAA):** Meets SAA criteria but with an **ANC < 200/µL**. This carries the highest risk of life-threatening fungal and bacterial infections. * **Non-Severe Aplastic Anemia:** Hypocellular marrow but peripheral blood counts do not meet SAA criteria. * **Treatment Choice:** For SAA, the treatment of choice in young patients (<40 years) with a matched sibling donor is **Allogeneic Bone Marrow Transplantation**. For older patients or those without a donor, **Immunosuppressive Therapy (IST)** with Anti-Thymocyte Globulin (ATG) and Cyclosporine is used. * **PNH Connection:** Always screen aplastic anemia patients for a PNH clone (CD55/CD59 deficiency) via flow cytometry.
Question 814: A 34-year-old man presents with a 5-month history of weakness and fatigue. There is no history of drug or alcohol abuse. A CBC shows megaloblastic anemia and a normal reticulocyte count. Further laboratory studies reveal vitamin B12 deficiency. Anemia in this patient is most likely caused by which of the following?
- A. Acute erosive gastritis
- B. Autoimmune gastritis (Correct Answer)
- C. Helicobacter pylori gastritis
- D. Menetrier disease
Explanation: The patient presents with **megaloblastic anemia** due to **Vitamin B12 deficiency**. In the absence of dietary restrictions (like strict veganism) or drug use, the most common cause of B12 deficiency is **Pernicious Anemia**, which is the end-stage of **Autoimmune Gastritis (Type A Gastritis)** [1, 2]. **Why Autoimmune Gastritis is correct:** Autoimmune gastritis involves the production of autoantibodies against **gastric parietal cells** and **Intrinsic Factor (IF)** [2]. Parietal cells, located in the body and fundus of the stomach, are responsible for secreting hydrochloric acid and IF. Since IF is essential for the absorption of Vitamin B12 in the terminal ileum, its absence leads to malabsorption, resulting in megaloblastic anemia [1]. **Why other options are incorrect:** * **A. Acute erosive gastritis:** This typically presents with hematemesis or melena due to superficial mucosal injury (often from NSAIDs or alcohol) [2]. It does not cause B12 malabsorption. * **C. Helicobacter pylori gastritis:** This is **Type B Gastritis**, primarily affecting the antrum. While it can cause iron deficiency, it does not typically cause the profound parietal cell atrophy required to produce B12 deficiency [2]. * **D. Menetrier disease:** A rare protein-losing hypertrophic gastropathy characterized by enlarged gastric folds and TGF-α overexpression. It leads to hypoproteinemia, not B12 deficiency. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Autoimmune Gastritis affects the **Body and Fundus** (spares the antrum) [2]. * **Markers:** Increased serum **Gastrin** (due to loss of acid feedback) and decreased **Pepsinogen I**. * **Associations:** Often associated with other autoimmune conditions like Vitiligo, Hashimoto’s thyroiditis, and Type 1 Diabetes. * **Risk:** Increased risk of **Gastric Adenocarcinoma** and **Carcinoid tumors**.
Question 815: Which of the following is NOT included in the differential diagnosis of pancytopenia with a cellular bone marrow?
- A. Megaloblastic anemia
- B. Myelodysplasia
- C. Paroxysmal Nocturnal Hemoglobinuria
- D. Congenital dyserythropoietic anemia (Correct Answer)
Explanation: ### Explanation The diagnostic approach to pancytopenia begins with a bone marrow examination to differentiate between **hypocellular** marrow (failure of production) and **cellular** marrow (ineffective hematopoiesis or peripheral destruction). **Why Option D is the Correct Answer:** **Congenital Dyserythropoietic Anemia (CDA)** is a group of rare hereditary disorders characterized by ineffective erythropoiesis and binucleated/multinucleated erythroblasts. While the bone marrow is hypercellular, the defect is **lineage-specific**. CDA typically presents with **isolated refractory anemia** and jaundice, not pancytopenia. Since the leukocyte and platelet lineages are generally unaffected, it does not feature in the standard differential for pancytopenia. **Analysis of Incorrect Options:** * **Megaloblastic Anemia:** A classic cause of pancytopenia with a hypercellular marrow [1]. Vitamin B12/Folate deficiency leads to "ineffective hematopoiesis" where cells are produced but die within the marrow due to DNA synthesis defects [1]. * **Myelodysplasia (MDS):** Characterized by a hypercellular marrow with dysplastic changes in all three cell lines. The marrow is "busy" but the cells produced are defective and undergo apoptosis, leading to peripheral pancytopenia. * **Paroxysmal Nocturnal Hemoglobinuria (PNH):** PNH exists on a spectrum with Aplastic Anemia. While it can present with a hypocellular marrow, it frequently presents with a cellular marrow during hemolytic phases or in the PNH/MDS overlap syndrome. **NEET-PG High-Yield Pearls:** * **Pancytopenia + Hypocellular Marrow:** Aplastic anemia, Hypoplastic MDS, Fanconi anemia. * **Pancytopenia + Hypercellular Marrow:** Megaloblastic anemia, MDS, Aleukemic leukemia, Myelofibrosis (early stage), Hypersplenism. * **Most common cause of pancytopenia in India:** Megaloblastic anemia (followed by Aplastic anemia). * **CDA Hallmark:** "Internuclear chromatin bridges" are characteristic of CDA Type I.
Question 816: Which immunoglobulin class is NOT typically affected in multiple myeloma?
- A. IgG
- B. IgA
- C. IgM (Correct Answer)
- D. IgD
Explanation: **Explanation:** Multiple myeloma (MM) is a neoplastic proliferation of a single clone of **plasma cells** derived from the B-cell lineage [1]. These malignant plasma cells typically produce a monoclonal (M) protein, which is most commonly an intact immunoglobulin of the **IgG** or **IgA** class. **Why IgM is the correct answer:** IgM is the characteristic immunoglobulin associated with **Waldenström Macroglobulinemia (WM)**, not Multiple Myeloma [1]. While rare cases of "IgM Myeloma" exist, they are clinically distinct and often represent a hybrid between MM and WM. In the context of standard medical examinations, IgM is excluded from the typical presentation of MM because the malignant transformation in MM usually occurs in plasma cells that have already undergone **isotype class switching** (from IgM to IgG, IgA, or IgD). **Analysis of incorrect options:** * **IgG (Option A):** The most common subtype, accounting for approximately 50-60% of cases. * **IgA (Option B):** The second most common subtype, accounting for about 20-25% of cases. * **IgD (Option D):** A rare but recognized subtype (approx. 1-2%). It is often associated with a more aggressive clinical course, younger age of onset, and a higher frequency of Bence-Jones proteinuria and renal failure. **High-Yield Clinical Pearls for NEET-PG:** * **M-Spike:** Found on Serum Protein Electrophoresis (SPEP); usually in the Gamma or Beta region. * **CRAB Criteria:** Calcium (elevated), Renal insufficiency, Anemia, and Bone lesions (lytic). * **Diagnosis:** Requires ≥10% clonal plasma cells on bone marrow biopsy plus a myeloma-defining event. * **Bence-Jones Proteins:** These are free monoclonal light chains (Kappa or Lambda) found in the urine. * **Rule of Thumb:** If the question mentions IgM + Hyperviscosity + Lymphadenopathy, think Waldenström Macroglobulinemia [1]. If it mentions IgG/IgA + Lytic bone lesions, think Multiple Myeloma.
Question 817: All of the following genetic syndromes are associated with Acute Myeloid Leukemia, except:
- A. Down's Syndrome
- B. Klinefelter's Syndrome
- C. Patau Syndrome
- D. Turner's Syndrome (Correct Answer)
Explanation: **Explanation:** The association between chromosomal aneuploidies and hematological malignancies is a high-yield topic for NEET-PG. While several genetic syndromes predispose to leukemia, **Turner’s Syndrome (45, XO)** is notably **not** associated with an increased risk of Acute Myeloid Leukemia (AML) [1]. **1. Why Turner’s Syndrome is the Correct Answer:** Turner’s Syndrome involves the loss of an X chromosome [1]. While these patients have various medical complications (coarctation of aorta, streak ovaries, short stature), they do not show a statistically significant predisposition to AML or other acute leukemias compared to the general population [1]. **2. Analysis of Incorrect Options:** * **Down’s Syndrome (Trisomy 21):** This has the strongest association. Children with Down’s have a 10–20 fold increased risk of leukemia. Specifically, **AMKL (AML-M7)** is highly characteristic in children under 3 years, often preceded by Transient Myeloproliferative Disorder (TMD). * **Klinefelter’s Syndrome (47, XXY):** This syndrome is associated with an increased risk of germ cell tumors (especially mediastinal) and a moderately increased risk of both AML and breast cancer [1]. * **Patau Syndrome (Trisomy 13):** Like other autosomal trisomies (including Edwards Syndrome/Trisomy 18), Patau syndrome is linked to an increased incidence of non-lymphocytic leukemias, including AML. **Clinical Pearls for NEET-PG:** * **Most common AML in Down’s Syndrome:** AML-M7 (Megakaryoblastic). * **GATA1 mutation:** Specifically associated with TMD and AML-M7 in Down’s Syndrome. * **Other syndromes with AML risk:** Fanconi Anemia (highest risk), Bloom Syndrome, Ataxia-Telangiectasia, and Li-Fraumeni Syndrome. * **Turner’s Syndrome** is more famously associated with **Gonadoblastoma** (if Y-chromosome mosaicism is present).
Question 818: The Schilling test is performed to determine the cause of which of the following?
- A. Lactose malabsorption
- B. Fatty acid malabsorption
- C. Amino acid malabsorption
- D. Cobalamin malabsorption (Correct Answer)
Explanation: The **Schilling test** is the classic diagnostic tool used to evaluate the cause of **Cobalamin (Vitamin B12) malabsorption** [1]. Vitamin B12 absorption is a complex process requiring gastric acid, intrinsic factor (IF) from parietal cells, pancreatic enzymes, and an intact terminal ileum [2]. The test is typically performed in stages: * **Stage I:** Oral radiolabeled B12 is given alongside an IM injection of "cold" B12 to saturate liver receptors. If urinary excretion is low, malabsorption is confirmed. * **Stage II:** Oral B12 is given with **Intrinsic Factor**. If this corrects the excretion, the diagnosis is **Pernicious Anemia** [2]. * **Stage III/IV:** Involves adding antibiotics (for SIBO) [3] or pancreatic enzymes to identify other causes. **Why other options are incorrect:** * **Lactose malabsorption:** Diagnosed via the Hydrogen Breath Test or Lactose Tolerance Test. * **Fatty acid malabsorption:** Evaluated using the 72-hour fecal fat estimation (Gold Standard) or the Sudan III stain. * **Amino acid malabsorption:** Associated with conditions like Hartnup disease; diagnosed via urinary chromatography for neutral amino acids. **NEET-PG High-Yield Pearls:** 1. **Site of Absorption:** Vitamin B12 is absorbed in the **terminal ileum**. 2. **Pernicious Anemia:** The most common cause of B12 deficiency, characterized by anti-parietal cell and anti-IF antibodies. 3. **Clinical Presentation:** Look for **Subacute Combined Degeneration (SCD)** of the spinal cord (involving dorsal columns and corticospinal tracts) and macrocytic anemia with hypersegmented neutrophils. 4. **Current Status:** Though high-yield for exams, the Schilling test is now largely replaced by serum B12 levels and antibody assays (anti-IF/anti-parietal).
Question 819: What is the earliest sign of iron deficiency anemia?
- A. Increase in iron-binding capacity
- B. Decrease in serum ferritin level (Correct Answer)
- C. Decrease in serum iron level
- D. All the above
Explanation: ### Explanation Iron deficiency anemia (IDA) develops in a sequential manner as body iron stores are gradually depleted. Understanding this progression is crucial for NEET-PG. **1. Why "Decrease in serum ferritin level" is correct:** Serum ferritin is the storage form of iron. When the body faces a negative iron balance, it first utilizes the iron stored in the liver, spleen, and bone marrow. Therefore, a **decrease in serum ferritin** is the **earliest biochemical sign** of iron deficiency (Stage 1: Iron Depletion) [1]. At this stage, hemoglobin and serum iron levels remain normal, but the "reserve tank" is emptying [1]. **2. Why the other options are incorrect:** * **A. Increase in iron-binding capacity (TIBC):** This occurs in Stage 2 (Iron-deficient erythropoiesis). As stores (ferritin) drop, the liver increases the production of transferrin to "hunt" for more iron, leading to an elevated TIBC. This happens *after* ferritin has already started to decline. * **C. Decrease in serum iron level:** This also occurs in Stage 2. Serum iron only drops once the storage iron is significantly exhausted and can no longer maintain the circulating iron pool. * **D. All the above:** While all these changes eventually occur in IDA, they do not happen simultaneously. Ferritin is the first to change. **Clinical Pearls for NEET-PG:** * **Sequence of Depletion:** Ferritin ↓ (Earliest) → TIBC ↑ → Serum Iron ↓ → Hemoglobin ↓ (Latest). * **Gold Standard:** Bone marrow aspiration (Prussian blue staining) is the most reliable method to assess iron stores, but **Serum Ferritin** is the best non-invasive screening test [1]. * **The "Rule of 30":** In the absence of inflammation, a ferritin level **<30 ng/mL** is highly suggestive of IDA. * **Note:** Ferritin is an **acute-phase reactant**; it can be falsely normal or high in patients with infection, malignancy, or chronic inflammation, even if they are iron deficient.
Question 820: A 50-year-old male presents with massive splenomegaly. Which of the following is LEAST likely to be included in the differential diagnosis?
- A. Chronic myeloid leukemia
- B. Polycythemia rubra vera
- C. Hairy cell leukemia
- D. Aplastic anemia (Correct Answer)
Explanation: **Explanation:** The clinical hallmark of **massive splenomegaly** (defined as the spleen crossing the midline or extending into the pelvis, usually >8 cm below the costal margin) is typically associated with myeloproliferative neoplasms or specific lymphoproliferative disorders [1]. **Why Aplastic Anemia is the correct answer:** Aplastic anemia is characterized by **pancytopenia** due to bone marrow failure. A fundamental clinical rule in hematology is that **aplastic anemia does not cause splenomegaly.** If a patient with pancytopenia has an enlarged spleen, the diagnosis is likely something else (e.g., Aleukemic Leukemia, Hypersplenism, or Cirrhosis) [2]. The presence of splenomegaly in a suspected case of aplastic anemia should prompt a search for an alternative diagnosis. **Analysis of Incorrect Options:** * **Chronic Myeloid Leukemia (CML):** One of the most common causes of massive splenomegaly. The degree of enlargement often correlates with the peripheral white cell count. * **Polycythemia Rubra Vera (PRV):** As a myeloproliferative neoplasm, it frequently presents with splenomegaly due to extramedullary hematopoiesis or congestion [1]. * **Hairy Cell Leukemia (HCL):** A classic cause of massive splenomegaly. It typically presents with "dry tap" on bone marrow aspiration and pancytopenia, but unlike aplastic anemia, the spleen is significantly enlarged. **NEET-PG High-Yield Pearls:** * **Causes of Massive Splenomegaly (Mnemonic: "M-C-H-I-K"):** **M**yelofibrosis, **C**ML, **H**airy Cell Leukemia, **I**ndia (Kala-azar), **K**ala-azar/Malaria (Hyperreactive Malarial Splenomegaly). * **Gaucher’s Disease** is the most common lysosomal storage disorder causing massive splenomegaly. * In any exam question, if **Pancytopenia + Splenomegaly** is mentioned, think of **Hairy Cell Leukemia** or **Kala-azar**; if **Pancytopenia - Splenomegaly** is mentioned, think of **Aplastic Anemia**.
Practice by Chapter
Anemia Evaluation and Management
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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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