Hematology — MCQs

A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm³, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?

Q909

Which of these is not a risk factor for thromboembolism -

Q910

All of the following statements about Lupus Anticoagulant are true, EXCEPT:

Hematology Indian Medical PG Practice Questions and MCQs

Question 901: Complication of blood transfusion can be all except -

A. Metabolic alkalosis (Correct Answer)
B. Hyperkalemia
C. Citrate toxicity
D. Hypothermia

Explanation: ***Metabolic alkalosis*** - **Metabolic alkalosis** is generally not a direct complication of blood transfusion, as transfused blood typically has a buffering effect or contributes to acidosis due to stored products. - While citrate, a component of transfused blood, is metabolized to bicarbonate, leading to a theoretical alkalosis, clinically significant metabolic alkalosis is rare and overshadowed by other potential imbalances. *Hyperkalemia* - **Hyperkalemia** can occur, especially with massive transfusions or in patients with impaired renal function, due to the leakage of potassium from red blood cells during storage. - The breakdown of stored red blood cells releases intracellular potassium into the plasma of the stored blood product. *Citrate toxicity* - **Citrate toxicity** is a known complication, particularly with rapid or massive transfusions, as citrate in stored blood binds to calcium, leading to hypocalcemia. - This can result in symptoms such as paresthesias, tetany, and cardiac arrhythmias if not managed appropriately. *Hypothermia* - **Hypothermia** is a common complication, especially with rapid or massive transfusions of refrigerated blood products. - Administering large volumes of cold intravenous fluids can significantly lower the patient's core body temperature.

Question 902: Treatment of choice in intracranial ALL is:

A. Intrathecal methotrexate (Correct Answer)
B. Intrathecal vincristine
C. Vincristine and prednisolone
D. Prednisolone

Explanation: ***Intrathecal methotrexate*** - **Intrathecal methotrexate** is the cornerstone of central nervous system (CNS) prophylaxis and treatment for **intracranial acute lymphoblastic leukemia (ALL)** due to its ability to reach high concentrations in the cerebrospinal fluid (CSF). - It is highly effective in eradicating leukemic cells in the **CNS**, preventing leptomeningeal relapse, and is often combined with other intrathecal agents or cranial radiation. *Intrathecal vincristine* - **Vincristine** is primarily an intravenous chemotherapeutic agent and is **neurotoxic** when administered intrathecally, potentially causing severe and irreversible neurological damage, including paralysis and death. - Therefore, **intrathecal vincristine** is contraindicated due to its severe adverse effects on the CNS. *Vincristine and prednisolone* - **Vincristine** and **prednisolone** are systemic agents typically administered intravenously and orally, respectively, and are crucial components of **induction and consolidation therapy** for ALL. - However, their ability to penetrate the **blood-brain barrier** is limited, making them ineffective for directly treating or preventing intracranial ALL. *Prednisolone* - **Prednisolone** is a corticosteroid used systemically for its **anti-inflammatory** and **cytotoxic effects** on leukemic cells, particularly in inducing remission in ALL. - While it can partially penetrate the **blood-brain barrier**, its concentration in the CSF is usually insufficient to effectively treat or prevent established **intracranial ALL** on its own.

Question 903: The following condition is not associated with an Anti-phospholipid syndrome -

A. Neurological manifestations
B. Thrombocytosis (Correct Answer)
C. Venous thrombosis
D. Recurrent foetal loss

Explanation: ***Thrombocytosis*** - **Antiphospholipid syndrome (APS)** is characterized by a **prothrombotic state**, leading to **thrombocytopenia** (low platelet count), not thrombocytosis (elevated platelet count) [1]. - Elevated platelet counts are not part of the diagnostic criteria or typical clinical manifestations of APS. *Neurological manifestations* - **Neurological symptoms** are common in APS and can include **stroke**, **transient ischemic attacks (TIAs)**, **seizures**, and **cognitive dysfunction**. - These manifestations are due to the prothrombotic tendency affecting the cerebral vasculature. *Venous thrombosis* - **Venous thrombosis**, particularly **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**, is a hallmark feature of APS [2]. - The presence of antiphospholipid antibodies promotes clot formation in both venous and arterial systems. *Recurrent foetal loss* - **Recurrent foetal loss** (miscarriages or stillbirths) is a classic obstetric manifestation of APS [1]. - This occurs due to thrombosis in the placental circulation, impairing fetal development and viability [2].

Question 904: False about Marble bone disease

A. Pancytopenia
B. Associated with Type II Renal Tubular Acidosis (Correct Answer)
C. Treated with bone marrow transplantation
D. Mandible osteomyelitis

Explanation: ***Associated with Type II Renal Tubular Acidosis*** - **Marble bone disease**, or **osteopetrosis**, is characterized by increased bone density due to defective osteoclast function [1]. - It is **not typically associated** with Type II Renal Tubular Acidosis; instead, some forms of osteopetrosis, particularly carbonic anhydrase II deficiency, can lead to **Type I (distal) Renal Tubular Acidosis** [1]. *Pancytopenia* - **Osteopetrosis** leads to bone marrow encroachment, reducing the space available for hematopoiesis. - This often results in **pancytopenia** (anemia, leukopenia, and thrombocytopenia) due to bone marrow failure. *Treated with bone marrow transplantation* - **Bone marrow transplantation (BMT)** is a crucial treatment for severe forms of osteopetrosis, especially the infantile malignant autosomal recessive type. - BMT can introduce functional **osteoclast precursors** from the donor, which can then differentiate and restore bone resorption. *Mandible osteomyelitis* - Patients with **osteopetrosis** have bones that are dense but paradoxically brittle, making them prone to fractures and infections. - The **mandible** is particularly susceptible to **osteomyelitis** due to its dense structure and vascular compromise in osteopetrosis, often complicated by dental issues.

Question 905: Splenectomy is least useful in

A. Hereditary nonspherocytic haemolytic anaemia (Correct Answer)
B. Congenital elliptocytosis
C. Thalassemia major
D. Congenital spherocytic anaemia

Explanation: ***Hereditary nonspherocytic hemolytic anemia*** - This group of anemias primarily involves **defects in red blood cell enzymes**, such as G6PD deficiency or pyruvate kinase deficiency, leading to premature destruction of red blood cells (hemolysis) mainly in the **bone marrow** and peripheral circulation, not predominantly in the spleen. - Since the spleen is not the primary site of red blood cell destruction in these conditions, **splenectomy generally offers little to no benefit** and may even be contraindicated due to increased risks without significant clinical improvement. *Congenital elliptocytosis* - This condition involves **abnormalities in red blood cell membrane proteins**, leading to elliptical-shaped red blood cells that are more fragile and prone to splenic sequestration and destruction [1]. - **Splenectomy is a treatment option** for severe cases of congenital elliptocytosis, as it reduces splenic trapping and destruction of abnormal red blood cells, thereby alleviating anemia and hemolysis [1]. *Thalassemia major* - **Thalassemia major** is characterized by severe impairment of hemoglobin synthesis, leading to ineffective erythropoiesis, chronic hemolysis, and significant splenomegaly due to increased splenic sequestration and destruction of abnormal red blood cells. - **Splenectomy is often considered in thalassemia major** to reduce transfusion requirements and alleviate symptoms related to splenomegaly like abdominal discomfort and early satiety. *Congenital spherocytic anemia* - Also known as **hereditary spherocytosis**, this condition is caused by defects in red blood cell membrane proteins, leading to fragile, spherical red blood cells that are preferentially targeted and destroyed by the spleen [1]. - **Splenectomy is a highly effective treatment** for hereditary spherocytosis, as it removes the primary organ responsible for destroying the abnormal red blood cells, leading to a significant reduction in hemolysis and improvement in anemia [1].

Question 906: Which of the following is false regarding transfusion-associated anaphylactic reactions?

A. Different from allergy
B. Epinephrine is the drug of choice
C. Washed blood products prevent it
D. Seen in IgG deficient individuals (Correct Answer)

Explanation: ***Seen in IgG deficient individuals*** - Transfusion-associated **anaphylactic reactions** are most commonly seen in **IgA-deficient individuals** who develop **anti-IgA antibodies** and receive blood products containing IgA. - Anaphylaxis occurs when these pre-formed IgA antibodies react with donor IgA, leading to mast cell degranulation and severe allergic symptoms. *Different from allergy* - Transfusion-associated **anaphylactic reactions** are a severe form of allergic reaction, often distinguished by their **rapid onset** and life-threatening nature [1]. - While all allergies involve an immune response to an allergen, anaphylaxis represents the most extreme systemic manifestation. *Epinephrine is the drug of choice* - **Epinephrine** is indeed the **first-line treatment** for acute anaphylaxis, regardless of its cause, including transfusion-associated reactions [2]. - It acts rapidly to counteract the systemic effects of histamine and other mediators by acting on α and β adrenergic receptors [3]. *Washed blood products prevent it* - **Washing blood products** (e.g., packed red blood cells or platelets) is an effective strategy to **remove plasma proteins**, including IgA. - This is particularly crucial for patients with a known **IgA deficiency and anti-IgA antibodies** to prevent severe anaphylactic reactions.

Question 907: A patient presents with MCV = 60, Hb = 5 gm%, MCHC = 20 & PCV = 32%. What is the MOST COMMON cause of this type of anemia in developing countries?

A. A) Phenytoin
B. B) Blind loop syndrome
C. C) Hookworm infection (Correct Answer)
D. D) Chronic kidney disease with normal iron studies
E.

Explanation: ***Hookworm infection*** - The presented lab values (MCV = 60, Hb = 5 gm%, MCHC = 20) indicate severe **microcytic hypochromic anemia**, which is a classic presentation of **iron deficiency anemia** [1], [2]. - In developing countries, **chronic blood loss** due to **hookworm infection** is the most common cause of sustained iron deficiency, leading to this type of anemia [2], [3]. *Phenytoin* - **Phenytoin** is an anticonvulsant that can cause **megaloblastic anemia** due to **folate deficiency**, not microcytic hypochromic anemia. - Its effects on red blood cells typically result in an **increased MCV**, not a decreased one. *Blind loop syndrome* - **Blind loop syndrome** leads to bacterial overgrowth in the small intestine, which can cause **vitamin B12 deficiency** due to bacterial consumption of B12. - This deficiency results in **megaloblastic anemia** (high MCV), not microcytic hypochromic anemia. *Chronic kidney disease with normal iron studies* - **Chronic kidney disease** primarily causes **normocytic normochromic anemia** due to decreased erythropoietin production [4]. - While it causes anemia, the red blood cell indices (MCV, MCHC) would typically be within the normal range, unlike the **microcytic hypochromic** values observed here.

Question 908: A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm³, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?

A. Factor VIII
B. Desmopressin (DDAVP) (Correct Answer)
C. Platelets
D. Vitamin K

Explanation: ***Desmopressin (DDAVP)*** - **Desmopressin** is the first-line treatment for **von Willebrand disease (vWD)** [1], especially for type 1, which this patient's profile suggests (prolonged aPTT, normal PT, normal platelet count, and abnormal bleeding time). - It works by stimulating the release of endogenous **von Willebrand factor (vWF)** and **factor VIII** from endothelial cells [1]. *Factor VIII* - While Factor VIII deficiency can cause prolonged aPTT, this patient's presentation with a family history of **vWD**, normal PT, and abnormal bleeding time points specifically to a **vWF** defect rather than isolated **Factor VIII** deficiency [1]. - Administration of direct **Factor VIII** is not the primary treatment for **vWD**, although vWF concentrate (which contains Factor VIII) may be used for severe cases [1]. *Platelets* - The patient's **platelet count is normal** (350,000/mm³), indicating that a platelet transfusion is not necessary. - **vWD** is a disorder of platelet adhesion, not a problem with platelet quantity. *Vitamin K* - **Vitamin K** is essential for the synthesis of coagulation factors II, VII, IX, and X, as well as proteins C and S. - A deficiency in **Vitamin K** typically results in a prolonged **PT** [2], which is normal in this patient.

Question 909: Which of these is not a risk factor for thromboembolism -

A. Regular exercise (Correct Answer)
B. Superficial thrombophlebitis
C. Myocardial infarction
D. Estrogen therapy

Explanation: ***Regular exercise*** - **Regular exercise** is a protective factor against thromboembolism, as it improves blood circulation and reduces venous stasis. - It also helps maintain a healthy weight and cardiovascular fitness, lowering overall risk. *Superficial thrombophlebitis* - While typically less serious than deep vein thrombosis (DVT), **superficial thrombophlebitis** can extend into deeper veins or serve as a risk marker for DVT. - Inflammation and clot formation in superficial veins can sometimes trigger or coexist with more significant thromboembolic events [1]. *Myocardial infarction* - A **myocardial infarction** increases the risk for thromboembolism due to cardiac wall motion abnormalities and subsequent eddy currents causing thrombus formation within the ventricle [2]. - The damaged heart muscle can also release pro-coagulant factors, further elevating the risk. *Estrogen therapy* - **Estrogen therapy**, particularly in higher doses or certain formulations, is known to increase the risk for venous and arterial thromboembolism. - This is due to stimulating the production of clotting factors and reducing the activity of natural anticoagulants.

Question 910: All of the following statements about Lupus Anticoagulant are true, EXCEPT:

A. May present with Recurrent Abortions
B. May occur with minimal clinical manifestations
C. Thrombotic spells can be followed by severe life threatening hemorrhage (Correct Answer)
D. May present with an isolated prolongation of APTT

Explanation: Self-Correction: None of the provided 5 references directly address Lupus Anticoagulant or its specific diagnostic criteria and clinical manifestations such as placental thrombosis or isolated APTT prolongation. Reference discusses Antithrombin and Protein C/S deficiencies. Reference discusses von Willebrand Factor. Reference discusses Monitoring Anticoagulant Therapy generally. Reference discusses Disseminated Intravascular Coagulation (DIC). Reference discusses Systemic Lupus Erythematosus (SLE) skin manifestations and mentions livedo reticularis as a feature of antiphospholipid syndrome (APS) [1], but provides no detail regarding the specific claims about Lupus Anticoagulant tests or clinical exclusions asked in the question. Consequently, none of the references meet the required relevance score of 7 or higher for citation. ***Thrombotic spells can be followed by severe life threatening hemorrhage*** - While lupus anticoagulant (LA) is associated with both **thrombosis** and, less commonly, **bleeding**, severe, life-threatening hemorrhage as a direct follow-up to a thrombotic spell is not a typical pattern. LA primarily predisposes to **thrombosis**. - In the rare instances where bleeding occurs, it is usually due to acquired **factor deficiencies** or **thrombocytopenia**, conditions that can sometimes co-exist with antiphospholipid antibody syndrome (APS) but are not direct consequences of the thrombotic event itself. *May present with Recurrent Abortions* - **Recurrent abortions** (miscarriages) are a classic and well-recognized clinical manifestation of **antiphospholipid syndrome (APS)**, of which lupus anticoagulant is a key diagnostic criterion. - The presence of lupus anticoagulant indicates an increased risk for **placental thrombosis**, which can lead to fetal loss. *May occur with minimal clinical manifestations* - Some individuals test positive for lupus anticoagulant antibodies without experiencing any significant **thrombotic events** or other clinical symptoms of antiphospholipid syndrome for extended periods. - This condition is often referred to as **asymptomatic antiphospholipid antibody positivity**, highlighting that the presence of the antibody does not always immediately translate into severe clinical disease. *May present with an isolated prolongation of APTT* - Lupus anticoagulant is an in-vitro phenomenon that interferes with **phospholipid-dependent coagulation tests**, such as the **activated partial thromboplastin time (APTT)**, causing it to be prolonged. - This prolongation occurs because the antibody binds to phospholipids used in the assay, mimicking an **anticoagulant effect** in the test tube, even though the patient is actually hypercoagulable in vivo.

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Leukemias

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Lymphomas

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Hematology — MCQs

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