Anemias: Classification and Approach — MCQs

10 questions

24 years old female patient presents with acute blood loss secondary to bilateral fracture femur. Reticulocytosis is evident on peripheral smear examination. Patient's anemia can be categorized into which of the following types?

A 69-year-old woman, with poor dietary habits and alcoholism, is found to have a macrocytic anemia with hyper segmented neutrophils. Which of the following is the most appropriate diagnostic test?

A patient has MCV <80, MCH <23. Which type of anaemia shall be classified?

A 65-year-old male presents with fatigue, pallor, and low hemoglobin. Which laboratory finding is most indicative of iron deficiency anemia?

All of the following decrease in iron deficiency anemia except:

PNH is associated with all of the following conditions, except:

Which of the following has Autosomal Recessive inheritance?

A 62-year-old man presents with back pain for 4 months. Laboratory tests show a white blood cell count of 3700/microliter, hemoglobin of 10.3 g/dL, hematocrit of 31.1%, mean corpuscular volume of 85 fL, and a platelet count of 110,000/microliter. His total serum protein is 8.5 g/dL, with an albumin level of 4.1 g/dL. A chest radiograph shows lucencies in the vertebral bodies. A sternal bone marrow aspirate yields a dark red jelly-like material. Which cell type is most likely to be numerous in this aspirate?

A 15-year-old girl presented with weakness for 2 months, accompanied by pallor and icterus on examination, with a palpable spleen. Laboratory examination findings include reticulocytosis, increased mean corpuscular hemoglobin concentration (MCHC), and a positive osmotic fragility test. The Coombs test is negative. What is the diagnosis?

Q10

Which of the following statements on lymphoma is not true?

Anemias: Classification and Approach Indian Medical PG Practice Questions and MCQs

Question 1: 24 years old female patient presents with acute blood loss secondary to bilateral fracture femur. Reticulocytosis is evident on peripheral smear examination. Patient's anemia can be categorized into which of the following types?

A. Normocytic normochromic (Correct Answer)
B. Microcytic hypochromic
C. Microcytic normochromic
D. Normocytic Hypochromic

Explanation: ***Normocytic normochromic*** - **Acute blood loss** results in a loss of whole blood, meaning that the remaining red blood cells are still of normal size and hemoglobin content, hence **normocytic normochromic** [1]. - The presence of **reticulocytosis** is a physiological response, indicating that the bone marrow is actively producing new red blood cells to compensate for the acute loss, which also tend to be of normal size initially [1]. *Microcytic hypochromic* - This type of anemia is typically seen in conditions involving **chronic blood loss** or **iron deficiency**, where there is insufficient iron to produce normal hemoglobin, leading to small, pale red blood cells [3]. - While blood loss is present, it is acute, and there hasn't been sufficient time for iron stores to be depleted to this extent [2]. *Microcytic normochromic* - This is not a common classification of anemia; red blood cells that are **microcytic** (small) are almost always **hypochromic** (pale) due to reduced hemoglobin content. - This option does not accurately represent the physiological response to acute blood loss. *Normocytic Hypochromic* - This is also not a common classification; **normocytic** (normal size) red blood cells usually have normal hemoglobin content and thus appear **normochromic** [2]. - Hypochromia typically accompanies microcytosis due to the same underlying issues of impaired hemoglobin synthesis.

Question 2: A 69-year-old woman, with poor dietary habits and alcoholism, is found to have a macrocytic anemia with hyper segmented neutrophils. Which of the following is the most appropriate diagnostic test?

A. serum folate levels
B. bone marrow
C. RBC folate levels (Correct Answer)
D. Schilling test

Explanation: RBC folate levels - **RBC folate levels** reflect **tissue folate stores** and are less susceptible to daily dietary fluctuations than serum folate. - This test is considered a more reliable indicator for diagnosing **chronic folate deficiency**, which is consistent with poor dietary habits and alcoholism. *serum folate levels* - **Serum folate levels** are easily influenced by recent dietary intake, making them less indicative of long-term folate stores [1]. - A normal serum folate level can be seen in patients with **tissue folate deficiency** if they have recently ingested folate-rich foods [1]. *bone marrow* - A **bone marrow biopsy** might show megaloblastic changes, but it is an invasive procedure and is usually reserved for cases where the diagnosis remains unclear after less invasive tests [2]. - While it can confirm **megaloblastic anemia**, it does not specifically differentiate between **folate** and **B12 deficiencies** as the primary diagnostic tool. *Schilling test* - The **Schilling test** is used to diagnose **vitamin B12 malabsorption** (pernicious anemia or other causes), not folate deficiency. - This patient's clinical picture points more towards a **folate deficiency** given the poor dietary habits and alcoholism, although B12 deficiency can also cause macrocytic anemia [3].

Question 3: A patient has MCV <80, MCH <23. Which type of anaemia shall be classified?

A. Microcytic hypochromic (Correct Answer)
B. Normocytic normochromic
C. Normocytic hypochromic
D. Hyperchromic macrocytic

Explanation: ***Microcytic hypochromic*** - A **Mean Corpuscular Volume (MCV)** less than **80 fL** indicates **microcytosis** (small red blood cells) [1]. - A **Mean Corpuscular Hemoglobin (MCH)** less than **23 pg** indicates **hypochromia** (pale red blood cells due to reduced hemoglobin content) [1]. *Normocytic normochromic* - This classification refers to red blood cells with **normal MCV (80-100 fL)** and **normal MCH (27-32 pg)**. - Examples include anemia of chronic disease or acute blood loss, which do not fit the given lab values. *Normocytic hypochromic* - While **hypochromia (MCH <23)** is present, the **MCV is less than 80 fL**, which makes it microcytic, not normocytic. - This combination is not a standard classification; hypochromia typically accompanies microcytosis [1]. *Hyperchromic macrocytic* - **Macrocytic anemia** is characterized by an **MCV >100 fL**, which is the opposite of the given MCV of <80. - The term "hyperchromic" is generally not used for anemia classification because red blood cells have a maximal hemoglobin concentration and cannot be truly hyperchromic. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 590-591.

Question 4: A 65-year-old male presents with fatigue, pallor, and low hemoglobin. Which laboratory finding is most indicative of iron deficiency anemia?

A. Low ferritin level (Correct Answer)
B. High reticulocyte count
C. High TIBC
D. Normal MCV

Explanation: ***Low ferritin level*** - **Ferritin** is the primary storage protein for iron in the body, and its level is the most accurate indicator of the body's iron stores. - A **low ferritin level** directly reflects depleted iron stores, which is characteristic of iron deficiency anemia [2]. *High reticulocyte count* - A **high reticulocyte count** typically indicates that the bone marrow is actively producing red blood cells, which is usually a response to anemia, but not specifically diagnostic of iron deficiency. - In iron deficiency anemia, the bone marrow's ability to produce new red blood cells is impaired due to lack of iron, so the reticulocyte count might be normal or even low, not high. *High TIBC* - **Total iron-binding capacity (TIBC)** measures the blood's capacity to bind to iron and is usually high in iron deficiency anemia due to an increase in transferrin, which tries to capture any available iron [1]. - While a high TIBC is consistent with iron deficiency, a **low ferritin** is a more direct and reliable indicator of iron stores. *Normal MCV* - **Mean corpuscular volume (MCV)** measures the average size of red blood cells. In established iron deficiency anemia, MCV is typically low, indicating **microcytic anemia** [1]. - A normal MCV (normocytic anemia) can occur in the very early stages of iron deficiency or in other types of anemia, making it less specific for iron deficiency than ferritin levels.

Question 5: All of the following decrease in iron deficiency anemia except:

A. Ferritin
B. Transferrin saturation
C. TIBC (Correct Answer)
D. Serum iron

Explanation: ***TIBC*** - **Total iron-binding capacity (TIBC)** actually **increases** in iron deficiency anemia as the body attempts to maximize iron absorption and transport due to low iron stores. - This increase reflects the body's compensatory mechanism to bind any available iron when iron levels are low. *Ferritin* - **Ferritin** is a storage protein for iron, and its levels **decrease** in iron deficiency anemia as iron stores are depleted [1]. - It is often considered the most sensitive marker for diagnosing iron deficiency. *Transferrin saturation* - **Transferrin saturation** is a measure of how much iron is bound to transferrin, the main iron-transport protein [2]; it **decreases** in iron deficiency anemia. - This decrease reflects the reduced amount of iron available to bind to transferrin. *Serum iron* - **Serum iron** refers to the amount of iron circulating in the blood, and it **decreases** directly in iron deficiency anemia due to insufficient iron intake or increased iron loss. - Low serum iron is a direct indicator of reduced iron availability for erythropoiesis [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, p. 658. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 657-658.

Question 6: PNH is associated with all of the following conditions, except:

A. Aplastic anemia
B. Venous thrombosis
C. Iron deficiency anemia
D. Increased LAP scores (Correct Answer)

Explanation: ***Increased LAP scores*** - **Paroxysmal nocturnal hemoglobinuria (PNH)** is characterized by **acquired intrinsic stem cell defect**, leading to a deficiency of **glycosylphosphatidylinositol (GPI)-anchored proteins** on the surface of hematopoietic cells [1]. - PNH typically shows **decreased or low leukocyte alkaline phosphatase (LAP) scores**, similar to chronic myeloid leukemia (CML). **Increased LAP scores are NOT a feature of PNH**, making this the correct answer to the "except" question. - Elevated LAP scores are instead seen in conditions like leukemoid reactions, polycythemia vera, and infections. *Aplastic anemia* - **Aplastic anemia** frequently precedes or coexists with **PNH** due to shared underlying **bone marrow suppression** or immune-mediated injury [2]. - Both conditions involve defects in hematopoietic stem cells, making the development of one a risk factor for the other [3]. *Venous thrombosis* - **PNH** patients have an increased risk of **thrombosis**, particularly in unusual sites such as **hepatic (Budd-Chiari syndrome)** or **mesenteric veins**, due to increased platelet activation and endothelial damage [1]. - This prothrombotic state is a major cause of morbidity and mortality in PNH [1]. *Iron deficiency anemia* - **Chronic intravascular hemolysis** in PNH leads to significant **urinary iron loss** as **hemosiderin**, which can cause **iron deficiency anemia** [1]. - This is a direct consequence of the continuous destruction of **red blood cells** and subsequent **iron excretion** [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 650-651. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 595-596. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, p. 662.

Question 7: Which of the following has Autosomal Recessive inheritance?

A. Osteogenesis imperfecta
B. Hereditary spherocytosis
C. von Willebrand Disease Type 1
D. Sickle cell anaemia (Correct Answer)

Explanation: **Sickle cell anaemia** - This condition is inherited in an **autosomal recessive** pattern [2], meaning an individual must inherit two copies of the defective gene (one from each parent) to manifest the disease [3]. - It is caused by a mutation in the **beta-globin gene** [1], leading to abnormal hemoglobin production and characteristic sickle-shaped red blood cells [1]. *Osteogenesis imperfecta* - This disorder is predominantly inherited in an **autosomal dominant** pattern, meaning only one copy of the mutated gene is sufficient to cause the condition. - It is characterized by **brittle bones** due to defects in type I collagen synthesis. *Hereditary spherocytosis* - The most common and severe forms of hereditary spherocytosis are inherited as an **autosomal dominant** trait, though rarer autosomal recessive forms exist. - It involves defects in red blood cell membrane proteins, leading to **spherocytes** and hemolytic anemia. *von Willebrand Disease Type 1* - This is the most common type of von Willebrand disease and is inherited in an **autosomal dominant** pattern. - It is characterized by a **partial quantitative deficiency** of von Willebrand factor. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 598-599. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 53-54. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Genetic Disorders, pp. 150-151.

Question 8: A 62-year-old man presents with back pain for 4 months. Laboratory tests show a white blood cell count of 3700/microliter, hemoglobin of 10.3 g/dL, hematocrit of 31.1%, mean corpuscular volume of 85 fL, and a platelet count of 110,000/microliter. His total serum protein is 8.5 g/dL, with an albumin level of 4.1 g/dL. A chest radiograph shows lucencies in the vertebral bodies. A sternal bone marrow aspirate yields a dark red jelly-like material. Which cell type is most likely to be numerous in this aspirate?

A. Osteoblasts
B. Plasma cells (Correct Answer)
C. Giant cells
D. Fibroblasts

Explanation: ***Plasma cells*** - The presence of **dark red jelly-like material** in the bone marrow aspirate indicates a possible **myeloma**, which is characterized by an abundance of plasma cells [1]. - The lucencies in the vertebral bodies combined with low white blood cell count and **anemia** further support a diagnosis related to plasma cell dyscrasias like multiple myeloma [1][2][3]. *Osteoblasts* - Osteoblasts are responsible for **bone formation** and would not be expected to be numerous in this scenario where there is evidence of **bone loss** (lucencies). - Their presence would typically indicate **active bone remodeling**, not consistent with the findings of anemia and low cellularity in the context presented. *Fibroblasts* - Fibroblasts are involved in **connective tissue formation** and repair, and their numbers are not typically indicative of any hematologic disorders. - They do not directly relate to the findings of **anemia** and **bone lesions**, making them unlikely to be predominant in this aspirate. *Giant cells* - Giant cells, often associated with **inflammatory responses** or granulomatous conditions, do not correlate with the clinical picture of myeloma or the findings outlined in the case. - Their presence would suggest a different pathological process, unrelated to the presence of **plasma cells** in bone marrow aspirate [2]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 616-617. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 617-618. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 606-609.

Question 9: A 15-year-old girl presented with weakness for 2 months, accompanied by pallor and icterus on examination, with a palpable spleen. Laboratory examination findings include reticulocytosis, increased mean corpuscular hemoglobin concentration (MCHC), and a positive osmotic fragility test. The Coombs test is negative. What is the diagnosis?

A. Hereditary spherocytosis (Correct Answer)
B. Iron deficiency anemia
C. Autoimmune hemolytic anemia (AIHA)
D. G6PD deficiency anemia

Explanation: ***Hereditary spherocytosis*** - The combination of **reticulocytosis**, **macrocytic anemia (increased MCV)**, and **positive osmotic fragility test** indicates spherocytes, which are typical in hereditary spherocytosis [1]. - The **negative Coombs test** further supports this diagnosis by ruling out autoimmune hemolytic anemia (AIHA) [2]. *AIHA* - AIHA is characterized by a **positive Coombs test** due to the presence of autoantibodies, which is not the case here [2]. - It typically presents with **normocytic anemia** rather than macrocytic changes like in hereditary spherocytosis. *G-6-PD deficiency anemia* - G-6-PD deficiency usually presents with **episodic hemolysis** and often shows **bite cells**, but the osmotic fragility would not be positive in this scenario. - Symptoms often occur after certain triggers (e.g., infections, drugs), differing from the chronic symptoms noted in this patient [3]. *Iron deficiency anemia* - Iron deficiency anemia typically shows **microcytic hypochromic cells**, with a **low MCV** and **MCHC**, which is inconsistent with the findings of increased MCV and reticulocytosis here. - It doesn't cause a positive osmotic fragility test. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 597-598. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 602-603. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 641-642. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 640-641.

Question 10: Which of the following statements on lymphoma is not true?

A. In general, follicular (nodular) NHL has worse prognosis compared to diffuse NHL. (Correct Answer)
B. HD more often tends to remain localized to a single group of lymph nodes and spreads by contiguity.
C. Several types of non-Hodgkin's lymphoma (NHL) may have a leukemic phase.
D. A single classification system for Hodgkin's disease (HD) is almost universally accepted.

Explanation: ***In general follicular NHL has worse prognosis compared to diffuse NHL*** - Follicular Non-Hodgkin's lymphoma (NHL) typically has a **more indolent** course than diffuse lymphoma, leading to **better long-term survival** [1]. - Diffuse Large B-cell Lymphoma (DLBCL) is usually more aggressive and tends to have a **poorer prognosis** despite being treatable. *HD tends to remain localized to a single group of lymph nodes and spreads by contiguity* - Hodgkin's Disease (HD) is known for progressing in a **contiguous manner** [2], but it can **spread beyond localized regions** as well. - While it often starts in a single area, advanced stages may show **systemic spread**, contradicting the strict localization concept. *Several types of Non-Hodgkin's lymphoma may have a leukemic phase* - Certain Non-Hodgkin's lymphomas, such as **chronic lymphocytic leukemia (CLL)**, indeed can present with a significant **leukemic phase** [3]. - This characteristic differentiates them from other lymphomas that typically do not exhibit this phase. *A single classification system of Hodgkin's disease is almost universally accepted* - There are **multiple classification systems** for Hodgkin's Disease [4], including the Ann Arbor system and others, indicating no **universal acceptance**. - Ongoing research may lead to updates and varied classification approaches, showing the **evolution of diagnostic criteria**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 561-562. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 557-558. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 560-561. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 559-560.

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