Hematopathology Practice Questions

Q: In a patient with acute leukemia, the immunophenotype pattern shows CD 19+ve, CD 10+ve, CD33+ve, and CD13+ve. What is the most likely diagnosis?

Biphenotypic leukemia. **Explanation:** The correct answer is **Biphenotypic Leukemia**, now classified under **Mixed Phenotype Acute Leukemia (MPAL)** according to the WHO classification [1]. **1. Why it is correct:** Biphenotypic leukemia is characterized by the expression of markers from two different lineages on a single population of blasts. In this case: * **CD19 and CD10** are definitive markers for **B-lymphoid** lineage. * **CD33 and CD13** are definitive markers for **Myeloid** lineage. The simultaneous presence of both B-cell and myeloid markers satisfies the criteria for MPAL, as the blasts do not belong to a single restricted lineage. **2. Why the other options are incorrect:** * **B. Acute Lymphoblastic Leukemia (ALL):** While CD19 and CD10 are classic for B-ALL, the strong expression of myeloid markers (CD13, CD33) excludes a diagnosis of pure ALL [1]. * **C & D. AML (M2 and M0):** Although CD13 and CD33 are hallmarks of AML, the presence of B-cell specific markers like CD19 and CD10 is not typical for pure myeloid leukemia [1]. While "lineage infidelity" (weak expression of lymphoid markers) can occur in AML, the combination provided here strongly points toward a mixed phenotype. **High-Yield Clinical Pearls for NEET-PG:** * **MPAL Criteria:** Diagnosis relies on the **EGIL scoring system** or the **WHO criteria**, which require specific "strong" markers (e.g., MPO for myeloid; CD19/CD22/CD79a for B-lymphoid; cytoplasmic CD3 for T-lymphoid). * **Cytogenetics:** MPAL is frequently associated with **t(9;22)** (Philadelphia chromosome) or **MLL gene rearrangements** (11q23) [1]. * **Prognosis:** Generally carries a **poorer prognosis** compared to standard AML or ALL and often requires intensive "hybrid" chemotherapy protocols. **References:** [1] 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. 596-600.

Q: Appearance of characteristic “burr cells”, “helmet cells” and “triangle cells” in peripheral blood smears is indicative of:

Schistocytosis. The presence of fragmented red blood cells, such as **burr cells (echinocytes)**, **helmet cells**, and **triangle cells**, is the hallmark of **Schistocytosis**. 1. **Why Schistocytosis is correct:** Schistocytes are fragmented parts of red blood cells formed when the RBC membrane is mechanically severed. This typically occurs in **Microangiopathic Hemolytic Anemia (MAHA)**, such as TTP, HUS, or DIC, where fibrin strands in small vessels "slice" the RBCs as they pass through. They are also seen in mechanical heart valve-induced hemolysis. 2. **Why other options are incorrect:** * **Polychromasia:** Refers to the presence of young, bluish-grey RBCs (reticulocytes) on a peripheral smear, indicating active erythropoiesis in the bone marrow. * **Anisocytosis:** Refers to a variation in the **size** of RBCs (measured by RDW). It is a non-specific finding seen in most anemias (e.g., Iron Deficiency Anemia). * **Poikilocytosis:** This is a general umbrella term for any variation in the **shape** of RBCs. While schistocytes are a type of poikilocyte, "Schistocytosis" is the specific and most accurate clinical term for the fragments described in the question. **NEET-PG High-Yield Pearls:** * **Burr cells (Echinocytes):** Characterized by small, uniform blunt projections. Commonly seen in **Uremia** and chronic kidney disease. * **Acanthocytes (Spur cells):** Irregular, sharp projections. Seen in **Abetalipoproteinemia** and Liver disease. * **Bite cells (Degmacytes):** Result from splenic macrophages pitting out Heinz bodies. Diagnostic of **G6PD Deficiency** [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. 642-643.

Q: Dohle bodies are seen in which of the following cells?

Neutrophils. **Explanation:** **Dohle bodies** are small, light blue-gray, oval inclusions found in the periphery of the cytoplasm of **neutrophils**. They represent remnants of **rough endoplasmic reticulum (RER)** arranged in parallel stacks. 1. **Why Neutrophils are Correct:** Dohle bodies are classic markers of "toxic changes" in neutrophils. They appear when there is accelerated granulopoiesis (rapid production of white blood cells), typically during severe bacterial infections, burns, trauma, or systemic inflammatory states [1], [2]. They are often seen alongside other toxic features like toxic granulation and cytoplasmic vacuolation. 2. **Why Other Options are Incorrect:** * **Macrophages & Histiocytes:** While these cells are part of the mononuclear phagocyte system and may contain phagocytosed debris or pigments (like hemosiderin), they do not form Dohle bodies. * **Plasma Cells:** These cells are characterized by Russell bodies (intracellular immunoglobulin aggregates) or Mott cells, but not Dohle bodies. **High-Yield Clinical Pearls for NEET-PG:** * **Composition:** Dohle bodies consist of aggregated **ribosomes and RER**. * **May-Hegglin Anomaly:** This is a key differential. It is an autosomal dominant triad of: 1. Large, **Dohle-like bodies** in neutrophils (composed of non-muscle myosin heavy chain IIA). 2. Giant platelets. 3. Thrombocytopenia. * **Differential Diagnosis:** Apart from infections, they can be seen in pregnancy and after the administration of G-CSF (Granulocyte colony-stimulating factor). **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 580-581. [2] 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, p. 592.

Q: A 22-year-old woman has experienced increasing dyspnea for the past 2 months. On physical examination, she is afebrile and normotensive. Inspiratory wheezes are noted on auscultation of the chest. A chest CT scan shows an 8x10 cm posterior mediastinal mass that impinges on the trachea and esophagus. A mediastinoscopy is performed, and a biopsy of the mass microscopically shows scattered large multinucleated cells, with prominent nucleoli that mark with CD15, and lymphocytes and macrophages separated by dense collagenous bands. Which of the following cells is most likely to be seen microscopically in this biopsy specimen?

Lacunar cells. ### Explanation The clinical presentation and histopathology point toward **Hodgkin Lymphoma (HL)**, specifically the **Nodular Sclerosis** subtype. **1. Why the correct answer is right:** The biopsy describes "scattered large multinucleated cells with prominent nucleoli" (Reed-Sternberg cells) that are **CD15+ and CD30+**. The presence of **dense collagenous bands** (fibrosis) is the hallmark of the Nodular Sclerosis subtype, which is the most common form of HL, particularly in young women, and frequently presents as a large mediastinal mass. **Lacunar cells** are a specific variant of Reed-Sternberg cells characteristic of this subtype. They appear to sit in empty spaces (lacunae) created by formalin fixation, which causes their abundant pale cytoplasm to retract. **2. Why the incorrect options are wrong:** * **Atypical lymphocytes:** While seen in various lymphomas or viral infections (like Mononucleosis), they do not match the specific CD15+ multinucleated morphology or the fibrotic background described. * **Hairy cells:** These are associated with Hairy Cell Leukemia, characterized by "fried-egg" appearance and TRAP positivity, typically presenting with splenomegaly, not a mediastinal mass. * **Langerhans cells:** These are found in Langerhans Cell Histiocytosis (LCH). They have characteristic "coffee-bean" nuclei and are CD1a/S100 positive, often associated with Birbeck granules on EM. **3. Clinical Pearls for NEET-PG:** * **Nodular Sclerosis HL:** Most common subtype; affects young adults; female predominance; involves mediastinal lymph nodes. * **RS Cell Markers:** Classically **CD15+ and CD30+**; CD20 is usually negative (except in Lymphocyte Predominant type, which is CD20+ and CD15-/30-). * **Mediastinal Masses (The 4 Ts):** Thymoma, Teratoma, "Terrible" Lymphoma, and Thyroid masses. * **Radiology:** A "bulky" mediastinal mass in HL is defined as a mass width >1/3 of the internal transthoracic diameter.

Question 1

In a patient with acute leukemia, the immunophenotype pattern shows CD 19+ve, CD 10+ve, CD33+ve, and CD13+ve. What is the most likely diagnosis?

Accepted Answer

Biphenotypic leukemia

Answer

Acute Lymphoblastic Leukemia (ALL)

Answer

Acute Myeloid Leukemia - M2 (AML-M2)

Answer

Acute Myeloid Leukemia - M0 (AML-M0)

Question 2

Appearance of characteristic “burr cells”, “helmet cells” and “triangle cells” in peripheral blood smears is indicative of:

Accepted Answer

Schistocytosis

Answer

Polychromasia

Answer

Anisocytosis

Answer

Poikilocytosis

Question 3

Dohle bodies are seen in which of the following cells?

Accepted Answer

Neutrophils

Answer

Macrophages

Answer

Plasma cells

Answer

Histiocytes

Question 4

What bone marrow finding is characteristic of myelofibrosis?

Accepted Answer

All of the above

Answer

Leucoerythroblastosis

Answer

Tear drop cells

Answer

Leucocytopenia

Question 5

A 22-year-old woman has experienced increasing dyspnea for the past 2 months. On physical examination, she is afebrile and normotensive. Inspiratory wheezes are noted on auscultation of the chest. A chest CT scan shows an 8x10 cm posterior mediastinal mass that impinges on the trachea and esophagus. A mediastinoscopy is performed, and a biopsy of the mass microscopically shows scattered large multinucleated cells, with prominent nucleoli that mark with CD15, and lymphocytes and macrophages separated by dense collagenous bands. Which of the following cells is most likely to be seen microscopically in this biopsy specimen?

Accepted Answer

Lacunar cells

Answer

Atypical lymphocytes

Answer

Hairy cells

Answer

Langerhans cells

Question 6

Direct Coombs test positive is seen in all of the following conditions EXCEPT?

Accepted Answer

Aplastic anemia

Answer

ABO incompatibility

Answer

Hemolytic disease of the newborn

Answer

Autoimmune hemolysis

Question 7

A 7-month-old child presents with failure to thrive and a hemoglobin level of 4.4 g/dL. Peripheral smear examination reveals very small red blood cells with marked pallor. Laboratory tests show very low levels of hemoglobin A, with elevated fractions of hemoglobin A2 and hemoglobin F. Which of the following underlying mechanisms is most likely responsible for these findings?

Accepted Answer

Insufficient production of beta-globin

Answer

Amino acid substitution on the beta-globin chain

Answer

Antibody against fetal red blood cells

Answer

Defect in cytoskeletal proteins

Question 8

Synthesis of which of the following clotting factors is not affected in liver disease?

Accepted Answer

Factor VIII

Answer

Factor II

Answer

Factor V

Answer

Factor IX

Question 9

A 5-year-old boy is being evaluated for recurrent epistaxis and other abnormal bleeding episodes, including excessive bleeding from the umbilical cord. Laboratory studies reveal the following: decreased hemoglobin (with microcytic hypochromic red cell indices), normal platelet count, markedly prolonged prothrombin time (PT) and partial thromboplastin time (PTT), and unmeasurable thrombin time (TT). Platelet aggregation studies reveal a normal platelet response to ristocetin, but with other substances (including collagen, ADP, and epinephrine), this patient's platelets exhibit a primary wave defect. Based on these findings, what is the most likely diagnosis?

Accepted Answer

Afibrinogenemia

Answer

Bernard-Soulier syndrome

Answer

Glanzmann's thrombasthenia

Answer

Wiskott-Aldrich syndrome

Question 10

Massive splenomegaly is not seen in which of the following conditions?

Accepted Answer

Sickle cell anemia

Answer

Malaria

Answer

Chronic myelogenous leukemia

Answer

Syphilis

Hematopathology — MCQs

Hematopathology — MCQs

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