Hematopathology Practice Questions

Q: A 15-year-old boy presented with a one-day history of bleeding gums, subconjunctival bleed, and purpuric rash. Investigations revealed the following results: Hb - 6.4 gm/dL; TLC - 26,500/mm3; Platelets - 35,000/mm3; Prothrombin time - 20 sec (control 13 sec); Partial thromboplastin time - 50 sec; and Fibrinogen - 10 mg/dL. Peripheral smear was suggestive of acute myeloblastic leukemia. Which of the following is the most likely diagnosis?

Promyelocytic leukemia. **Explanation:** The clinical presentation of a young patient with sudden onset bleeding (gums, subconjunctival, purpura) and laboratory evidence of **Disseminated Intravascular Coagulation (DIC)** is the hallmark of **Acute Promyelocytic Leukemia (APL)**, classified as AML-M3. **Why Option C is correct:** The key to this diagnosis is the combination of leukocytosis and severe coagulopathy. In APL, the promyelocytes contain numerous **procoagulant-rich granules** (and multiple Auer rods). When these cells lyse, they release tissue factor-like substances and plasminogen activators, triggering a massive consumption of clotting factors. This is reflected in the patient's labs: prolonged PT/aPTT and **profoundly low Fibrinogen (10 mg/dL)**. **Why other options are incorrect:** * **Options A (M1) and B (M2):** While these are common forms of AML, they typically present with features of bone marrow failure (anemia, infections) but are rarely associated with primary DIC at presentation. * **Option D (M4):** Myelomonocytic leukemia often presents with gum hypertrophy and extramedullary involvement (skin/CNS), but DIC is not its defining initial feature. **High-Yield Clinical Pearls for NEET-PG:** * **Cytogenetics:** Associated with **t(15;17)**, involving the PML-RARA fusion gene. * **Morphology:** Presence of **"Faggot cells"** (cells with bundles of Auer rods). * **Treatment:** Medical emergency! Start **ATRA (All-Trans Retinoic Acid)** immediately to induce differentiation of promyelocytes and resolve coagulopathy. * **Complication:** Watch for **Differentiation Syndrome** (fever, respiratory distress, pulmonary infiltrates) during ATRA therapy.

Q: What is the most common plasma cell tumor?

Multiple myeloma. **Explanation:** **Multiple Myeloma (MM)** is the most common primary malignancy of the bone marrow and the most common plasma cell dyscrasia [1]. It is characterized by the neoplastic proliferation of a single clone of plasma cells (M-protein) that produce monoclonal immunoglobulins. It typically presents in older adults with the classic **CRAB** features: Hyper**C**alcemia, **R**enal insufficiency, **A**nemia, and **B**one lesions (lytic) [2]. **Analysis of Incorrect Options:** * **Plasmacytoma:** This refers to a localized collection of neoplastic plasma cells. It can be solitary (bone or extramedullary) but is significantly less common than the systemic involvement seen in Multiple Myeloma. * **Waldenstrom’s Macroglobulinemia:** This is a lymphoproliferative disorder characterized by **IgM** monoclonal gammopathy [1]. It involves lymphoplasmacytic cells rather than pure plasma cells and is clinically distinguished by hyperviscosity and lymphadenopathy rather than bone lesions. * **Primary Amyloidosis (AL):** While associated with plasma cell dyscrasias (deposition of light chain fragments), it is a systemic metabolic complication rather than the most common primary tumor itself. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Bone pain (usually involving the back/ribs). * **Diagnostic Hallmark:** Presence of >10% clonal plasma cells in bone marrow [2]. * **Peripheral Smear:** **Rouleaux formation** (due to decreased zeta potential from high globulins). * **Urine:** Bence-Jones proteins (detected by sulfosalicylic acid test, not by standard dipstick). * **Radiology:** "Punched-out" lytic lesions; **Skull X-ray** is a classic board favorite [2]. * **Note:** Bone scans are often negative in MM because they detect osteoblastic activity, whereas MM is primarily osteolytic. Use a Skeletal Survey or MRI instead.

Question 1

Sezary-Lutzner cells are characterized by all of the following except?

Accepted Answer

Malignant CD 4 T-cells

Answer

Hyperconvoluted cerebriform nucleus

Answer

Hallmark of mycosis fungoides

Answer

Mostly affects the older population over 40 years

Question 2

Direct Coombs test is positive in hemolytic anemia due to which of the following conditions?

Accepted Answer

Paroxysmal cold hemoglobinuria

Answer

Paroxysmal nocturnal hemoglobinuria

Answer

Idiopathic thrombocytopenic purpura

Answer

Hemolytic uremic syndrome

Question 3

A lymph node from a 10-year-old boy reveals large pleomorphic lymphocytes with CD30 positivity, frequent mitoses, and scattered cells bearing kidney-shaped nuclei. Which of the following statements is true?

Accepted Answer

Hallmark cells are a feature.

Answer

t(2;5) translocation imparts a worsened prognosis.

Answer

ALK protein immunostaining is seen in a minority of cases.

Answer

This tumor occurs exclusively in children.

Question 4

A 15-year-old boy presented with a one-day history of bleeding gums, subconjunctival bleed, and purpuric rash. Investigations revealed the following results: Hb - 6.4 gm/dL; TLC - 26,500/mm3; Platelets - 35,000/mm3; Prothrombin time - 20 sec (control 13 sec); Partial thromboplastin time - 50 sec; and Fibrinogen - 10 mg/dL. Peripheral smear was suggestive of acute myeloblastic leukemia. Which of the following is the most likely diagnosis?

Accepted Answer

Promyelocytic leukemia

Answer

Myeloblastic leukemia without maturation

Answer

Myeloblastic leukemia with maturation

Answer

Myelomonocytic leukemia

Question 5

Gingiva are enlarged in leukemia because of which of the following?

Accepted Answer

WBC infiltration

Answer

Capillary dilation

Answer

Erythrocyte engorgement

Answer

Edema

Question 6

An adult patient presents with generalized lymphadenopathy and blood film shows 70% immature looking lymphocytes. What is the next best investigation?

Accepted Answer

Immunophenotyping

Answer

Genotyping/karyotyping

Answer

Bone marrow examination

Answer

Peripheral smear study

Question 7

Osmotic fragility of RBCs is increased in which of the following conditions?

Accepted Answer

Hereditary Spherocytosis

Answer

Sickle cell anemia

Answer

Thalassemia

Answer

Paroxysmal Nocturnal Hemoglobinuria (PNH)

Question 8

What is the most common plasma cell tumor?

Accepted Answer

Multiple myeloma

Answer

Plasmacytoma

Answer

Waldenstrom's macroglobulinemia

Answer

Primary amyloidosis

Question 9

Which of the following is NOT a condition affecting the vessel wall that leads to bleeding?

Accepted Answer

Autoimmune thrombocytopenic purpura

Answer

Henoch-Schonlein purpura

Answer

Cushing's syndrome

Answer

Scurvy

Question 10

Idiopathic thrombocytopenic purpura is associated with all of the following except?

Accepted Answer

Splenomegaly

Answer

Mucosal bleeding

Answer

Thrombocytopenia

Answer

Increased megakaryocytes

Hematopathology — MCQs

Hematopathology — MCQs

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