Hematopathology Practice Questions

Q: Where are Dutcher bodies typically seen?

Bone marrow. ***Bone marrow*** - **Dutcher bodies** are **intranuclear inclusions** of immunoglobulin, characteristically seen in **plasma cells** within the bone marrow. - Their presence is a classic morphological feature of **Waldenström macroglobulinemia** and other lymphoproliferative disorders. *Brain* - The brain is not the typical site for finding Dutcher bodies; structures like **Lewy bodies** (Parkinson's disease) or **neurofibrillary tangles** (Alzheimer's disease) are seen here. - Dutcher bodies are specifically associated with plasma cell abnormalities and **B-cell lymphomas**. *Spleen* - While the spleen can be involved in various hematological malignancies, Dutcher bodies are not primarily identified within splenic tissue but rather in the **plasma cells** of the **bone marrow**. - Splenic pathology typically involves changes in spleen size and cellular architecture, not intranuclear inclusions like Dutcher bodies. *Liver* - The liver is not the primary site for the detection of Dutcher bodies. Liver pathology might show infiltration by malignant cells in some systemic diseases, but not these specific inclusions within hepatocytes or other liver cells. - **Councilman bodies** (apoptotic hepatocytes in viral hepatitis) are an example of liver-specific microscopic findings.

Q: Flow cytometry is primarily used for analysis of which of the following cell types?

Lymphocytes. ***Lymphocytes*** - Flow cytometry is excellently suited for **lymphocyte analysis** due to their distinct surface markers (CD antigens) that can be labeled with fluorescent antibodies. - It allows for the **identification and quantification of various lymphocyte subsets** (e.g., T cells, B cells, NK cells), crucial in diagnosing immunodeficiencies, autoimmune diseases, and hematologic malignancies. *Erythrocytes* - While flow cytometry can detect erythrocytes, their primary role is oxygen transport, and they **lack cell surface markers** commonly analyzed by flow cytometry for classification. - **Complete blood count (CBC)** is the standard method for erythrocyte quantification and morphological analysis. *Platelets* - Flow cytometry can be used to study platelet activation and surface markers, but it's not their **primary or routine analytical tool** for mere count or general assessment. - **Automated hematology analyzers** are routinely used for platelet counts and basic morphology. *Basophil* - Basophils are a type of granulocyte and can be identified by flow cytometry, but they are a **very small percentage of circulating leukocytes**, making them less commonly the *primary* target of a typical flow cytometry panel focused on overall leukocyte populations. - While they can be analyzed, lymphocytes offer a much **broader range of clinical utility** due to their diverse subpopulations and roles in immunity and disease.

Q: Richter's syndrome refers to which of the following malignant transformations?

CLL evolving into aggressive lymphoma. ***CLL evolving into aggressive lymphoma*** - **Richter's transformation** specifically describes the malignant transformation of Chronic Lymphocytic Leukemia (CLL) into a more aggressive form of B-cell non-Hodgkin lymphoma, most commonly **diffuse large B-cell lymphoma (DLBCL)**. - This transformation is characterized by a rapid clinical decline, palpable lymphadenopathy, and splenomegaly, with a distinct change in morphology and immunophenotype of the malignant cells. *Hairy cell leukemia evolving to AML* - Hairy cell leukemia (HCL) is a chronic lymphoproliferative disorder that rarely transforms into secondary malignancies; however, transformation into **acute myeloid leukemia (AML)** is not a hallmark of HCL and is not referred to as Richter's syndrome. - HCL is characterized by pancytopenia and distinctive hairy-looking lymphocytes, distinct from the progression pattern seen in Richter's. *Blast crisis in CML* - **Blast crisis** is the terminal phase of chronic myeloid leukemia (CML), where the number of myeloid blasts in the blood or bone marrow increases to >20%. - This is a progression of CML, a myeloproliferative neoplasm, and is distinct from the lymphoid transformation described by Richter's syndrome. *Splenic infiltration in NHL* - While non-Hodgkin lymphoma (NHL) can involve the spleen, **splenic infiltration** itself does not describe a malignant transformation syndrome like Richter's. - Richter's syndrome describes a transformation *from* CLL *to* a more aggressive lymphoma, not just a site of involvement for NHL.

Q: Left shift in Arneth's count is seen in?

Septicemia. ***Septicemia*** - A **left shift** indicates a higher proportion of **immature neutrophils (bands or metamyelocytes)** in the blood, which is a hallmark of the body rapidly producing white blood cells to fight severe bacterial infections like **septicemia**. - This response is due to overwhelming bacterial load and systemic inflammation, prompting the bone marrow to release less mature neutrophils into circulation. *Megaloblastic anemia* - Characterized by **hypersegmented neutrophils** (a right shift), not a left shift, due to impaired DNA synthesis and delayed nuclear maturation. - The primary defect is in red blood cell production, although white blood cell morphology can also be affected. *Liver disease* - Liver disease does not typically cause a left shift in the Arneth count; instead, it can lead to various hematological abnormalities, including **anemia**, **thrombocytopenia**, or altered coagulation factors. - Neutrophil counts might fluctuate, but a sustained left shift is not a characteristic feature. *TB* - Tuberculosis usually causes a mild to moderate **neutrophilic leukocytosis** and sometimes a **monocytosis**, but a significant **left shift** is not a characteristic feature unless there is a severe acute exacerbation or secondary bacterial infection. - Chronic infections like TB are more often associated with changes like monocytosis or lymphocytosis.

Q: Which condition is most commonly associated with basophilic leukocytosis?

Chronic Myeloid Leukemia (CML). ***Chronic Myeloid Leukemia (CML)*** - **Basophilic leukocytosis** is a characteristic feature of **CML**, resulting from the clonal expansion of myeloid stem cells. - The presence of **immature granulocytes**, including basophils, is key to diagnosing CML, particularly in the chronic phase. *Acute Myeloid Leukemia (AML)* - AML is characterized by an excessive proliferation of **myeloblasts** (immature myeloid cells) in the bone marrow and peripheral blood, not mature basophils. - While other myeloid lineages can be affected, basophilic leukocytosis is not a defining or common feature. *Acute Lymphoblastic Leukemia (ALL)* - ALL involves the uncontrolled proliferation of **lymphoblasts** (immature lymphoid cells). - This condition is specifically associated with the lymphoid lineage and does not typically cause an increase in myeloid cells like basophils. *Chronic Lymphocytic Leukemia (CLL)* - CLL is characterized by the accumulation of **mature, but dysfunctional, B lymphocytes**. - It involves the lymphoid lineage and does not lead to basophilic leukocytosis, which is a feature of myeloid disorders.

Q: Commonest malignancy that can cause splenic metastasis is which of the following?

Ca. Melanoma. ***Correct: Ca. Melanoma*** - **Melanoma** is the **most common primary malignancy** to metastasize to the spleen in autopsy series [1] - Despite splenic metastases being rare overall (2-9% of cancer patients), melanoma has the **highest propensity** for splenic involvement due to its aggressive hematogenous spread pattern [1] - Melanoma can metastasize to virtually any organ, and the spleen is a recognized site with melanoma being the leading primary source - Other common primaries include breast, lung, ovarian, and colorectal cancers *Incorrect: Ca. Pancreas* - While pancreatic cancer can involve the spleen, this typically occurs through **direct extension** due to anatomical proximity rather than true hematogenous metastasis - Pancreatic cancer more commonly spreads to liver, peritoneum, and regional lymph nodes - It is not the most common source of splenic metastases overall *Incorrect: Ca. Stomach* - Gastric cancer can rarely metastasize to the spleen, but this is uncommon - More typical sites of gastric cancer metastasis include liver, peritoneum, lungs, and lymph nodes - Splenic involvement is much less frequent than with melanoma *Incorrect: Ca. Cervix* - Cervical cancer typically spreads by **local extension** and via lymphatics to pelvic and para-aortic nodes - It may involve bladder, rectum, and vagina through direct spread - **Splenic metastases** from cervical cancer are extremely rare and not a characteristic pattern of spread **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 650-651.

Q: Heinz bodies are removed by?

Macrophages. ***Macrophages*** - Macrophages, particularly those in the **spleen**, are responsible for pitting out Heinz bodies from red blood cells. - This process is part of the **extravascular hemolysis** that occurs when red blood cells containing Heinz bodies are prematurely destroyed. *Lymphocytes* - Lymphocytes are primary cells of the **adaptive immune system**, involved in recognizing and targeting specific pathogens or abnormal cells. - They do not play a role in the removal of intracellular inclusions like Heinz bodies from red blood cells. *Neutrophils* - Neutrophils are a type of **phagocyte** and a crucial component of the **innate immune system**, primarily involved in fighting bacterial and fungal infections. - Their function is mainly in acute inflammation and phagocytosing microbes, not in the removal of inclusions from red blood cells. *Fibroblasts* - Fibroblasts are responsible for producing the **extracellular matrix** and **collagen**, playing a critical role in wound healing and tissue repair. - They are not immune cells and are not involved in the removal of cellular debris or inclusions like Heinz bodies.

Q: TEL-AML1 fusion is associated with?

ALL. ***ALL*** - The **TEL-AML1 fusion gene** (also known as ETV6-RUNX1) is a common chromosomal abnormality found in approximately 25% of cases of **B-cell precursor acute lymphoblastic leukemia (ALL)**, particularly in children. - This fusion creates an abnormal protein that interferes with normal blood cell development, leading to the uncontrolled proliferation of immature lymphocytes characteristic of ALL. *CLL* - **Chronic lymphocytic leukemia (CLL)** is a cancer of mature lymphocytes, specifically B cells, and is not associated with the TEL-AML1 fusion. - Typical genetic abnormalities in CLL include deletions or mutations in chromosomes 13q, 17p, 11q, and trisomy 12. *CML* - **Chronic myeloid leukemia (CML)** is characterized by the presence of the **Philadelphia chromosome (BCR-ABL1 fusion gene)**, which results from a translocation between chromosomes 9 and 22. - CML is a myeloproliferative neoplasm affecting myeloid stem cells, distinct from the lymphoid origin of ALL. *AML* - **Acute myeloid leukemia (AML)** involves the myeloid lineage and is associated with various chromosomal translocations and mutations, but **TEL-AML1 fusion is not characteristic of AML**. - Common genetic alterations in AML include t(8;21), inv(16), t(15;17) (PML-RARA), and mutations in FLT3, NPM1, or CEBPA.

Q: Which of the following is NOT a feature of G-6PD deficiency?

Hereditary spherocytosis. ***Membrane defect*** - **G-6PD deficiency** is primarily characterized by a deficiency in the enzyme glucose-6-phosphate dehydrogenase, rather than a membrane defect [1]. - It leads to **oxidative stress** rather than issues with red blood cell membranes [1]. *Bite cells* - Bite cells are actually a result of **oxidative damage** due to G-6PD deficiency and occur during hemolytic episodes [2]. - They are formed when **macrophages** remove denatured hemoglobin from erythrocytes. *Intravascular hemolysis* - This condition often occurs in G-6PD deficiency due to oxidative stress leading to the destruction of red blood cells, particularly during crises [2]. - The hemolysis is often **acute** and triggered by infections, certain drugs, or food (like fava beans) [3]. *Oxidative stress* - Oxidative stress is a key pathological mechanism in G-6PD deficiency, causing vulnerability of red blood cells to hemolysis [1]. - It leads to **increased susceptibility** to infections and hemolytic episodes upon exposure to oxidant drugs or agent [2].

Q: With regards to hereditary spherocytosis, which of the following is false?

Aplastic crises are common. ***Aplastic crises are common*** - Aplastic crises occur in cases of **hereditary spherocytosis** due to parvovirus B19 infections, leading to **acute cessation of erythropoiesis** [1][3]. - They are characterized by a **sudden drop in hemoglobin levels**, which is not a common feature of hereditary spherocytosis itself, hence the misconception [1]. *Usually has autosomal dominant inheritance* - Hereditary spherocytosis is primarily inherited in an **autosomal dominant pattern**, where one copy of the mutated gene is sufficient to cause the disease. - However, it can also present in an **autosomal recessive** form, making this statement misleading. *Red blood cells are destroyed in the spleen* - This statement is actually **true**; hereditary spherocytosis leads to the **destruction of abnormally shaped red blood cells** in the spleen due to their rigid membrane structure [2][3]. - The condition is characterized by **hemolytic anemia** resulting from splenic sequestration [3]. *Caused by mutations in genes for proteins such as spectrin, ankrin or band 3* - This is a **correct statement**, as hereditary spherocytosis results from mutations in **membrane proteins** that result in loss of elasticity and stability of the red blood cell membrane [2]. - The mutations commonly involve **spectrin, ankyrin, and band 3 proteins**, leading to the pathophysiology seen in this condition [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 641-642. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 640-641. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 597-598.

Question 1

Where are Dutcher bodies typically seen?

Accepted Answer

Bone marrow

Answer

Brain

Answer

Spleen

Answer

Liver

Question 2

Flow cytometry is primarily used for analysis of which of the following cell types?

Accepted Answer

Lymphocytes

Answer

Platelets

Answer

Erythrocytes

Answer

Basophils

Question 3

Richter's syndrome refers to which of the following malignant transformations?

Accepted Answer

CLL evolving into aggressive lymphoma

Answer

Hairy cell leukemia evolving to AML

Answer

Blast crisis in CML

Answer

Splenic infiltration in NHL

Question 4

Left shift in Arneth's count is seen in?

Accepted Answer

Septicemia

Answer

Megaloblastic anemia

Answer

Liver disease

Answer

TB

Question 5

Which condition is most commonly associated with basophilic leukocytosis?

Accepted Answer

Chronic Myeloid Leukemia (CML)

Answer

Acute Myeloid Leukemia (AML)

Answer

Acute Lymphoblastic Leukemia (ALL)

Answer

Chronic Lymphocytic Leukemia (CLL)

Question 6

Commonest malignancy that can cause splenic metastasis is which of the following?

Accepted Answer

Ca. Melanoma

Answer

Ca. Stomach

Answer

Ca. Cervix

Answer

Ca. Pancreas

Question 7

Heinz bodies are removed by?

Accepted Answer

Macrophages

Answer

Lymphocytes

Answer

Neutrophils

Answer

Fibroblasts

Question 8

TEL-AML1 fusion is associated with?

Accepted Answer

ALL

Answer

CLL

Answer

CML

Answer

AML

Question 9

Which of the following is NOT a feature of G-6PD deficiency?

Accepted Answer

Hereditary spherocytosis

Answer

Oxidative stress

Answer

Bite cells

Answer

Intravascular hemolysis

Question 10

With regards to hereditary spherocytosis, which of the following is false?

Accepted Answer

Aplastic crises are common

Answer

Caused by mutations in genes for proteins such as spectrin, ankyrin or band 3

Answer

Usually has autosomal dominant inheritance

Answer

Red blood cells are destroyed in the spleen

Hematopathology — MCQs

Hematopathology — MCQs

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