Hematology — MCQs
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A 5-year-old boy presents with petechial bleeding and bruising on his torso and limbs. He has no other signs or symptoms and does not appear ill. His mother reports a gastrointestinal infection several weeks prior to the onset of petechiae and bruising. Complete blood count reveals thrombocytopenia (<20 x 10^9/L), with other parameters within the expected range for his age. Prothrombin time, partial thromboplastin time, and metabolic panels are all within the reference range. What is the expected outcome of this blood disorder?
A 9-year-old girl develops widespread pinpoint skin hemorrhages after recovering from a flu-like illness 1 week earlier. Laboratory findings reveal a platelet count of 20,000/mL with no other abnormalities. Her bone marrow shows an increased number of megakaryocytes. The platelet count is normal after 2 months. Which of the following is the appropriate diagnosis?
A patient presents with ecchymoses and petechiae all over the body and no hepatosplenomegaly. Which of the following statements is NOT true?
In a newborn, Harlequin skin change is due to what underlying condition?
A 3-year-old child presented with progressive anemia, jaundice, and failure to thrive. On examination, pallor and splenomegaly are seen. Peripheral smear showed normoblasts and small round intensely stained red cells. What is the likely diagnosis?
What is the hemoglobin level indicative of anemia in a child aged 2 to 5 years?
A 13-year-old girl presents with fatigue and weakness, found to have reduced hemoglobin. Her MCV is 70 fL, MCH is 22 pg, and RDW is 28%. What is her likely diagnosis?
Hemolytic disease of the newborn is commonly due to incompatibility of which antigen?
Goat milk anemia is caused by a deficiency of which of the following?
A 2-year-old child presents with discharge, seborrheic dermatitis, polyuria, and hepatosplenomegaly. Which of the following is the most likely diagnosis?
Hematology Indian Medical PG Practice Questions and MCQs
Question 1: A 5-year-old boy presents with petechial bleeding and bruising on his torso and limbs. He has no other signs or symptoms and does not appear ill. His mother reports a gastrointestinal infection several weeks prior to the onset of petechiae and bruising. Complete blood count reveals thrombocytopenia (<20 x 10^9/L), with other parameters within the expected range for his age. Prothrombin time, partial thromboplastin time, and metabolic panels are all within the reference range. What is the expected outcome of this blood disorder?
- A. Complete resolution is expected. (Correct Answer)
- B. Survival rate is up to 70% depending on risk stratification.
- C. Lifelong disease dependent on factor VIII substitution.
- D. Lifelong disease dependent on factor IX substitution.
Explanation: ### Explanation The clinical presentation describes a classic case of **Immune Thrombocytopenic Purpura (ITP)**, the most common cause of isolated thrombocytopenia in children. **1. Why Option A is Correct:** In children, ITP typically follows a viral infection (respiratory or gastrointestinal) after a 1–4 week latent period. It is characterized by the sudden onset of petechiae and bruising in an otherwise healthy-appearing child. The hallmark is **isolated thrombocytopenia** (Platelets <100 x 10⁹/L) with normal PT, PTT, and hemoglobin. The prognosis is excellent; approximately **70–80% of children achieve complete spontaneous resolution** within 6 months, regardless of therapy. **2. Why the Other Options are Incorrect:** * **Option B:** This refers to the survival rates of pediatric malignancies like Acute Lymphoblastic Leukemia (ALL). While ALL presents with bruising, it typically involves "sick" symptoms (fever, bone pain), hepatosplenomegaly, and abnormalities in other cell lines (anemia/leukocytosis). * **Options C & D:** These describe **Hemophilia A (Factor VIII)** and **Hemophilia B (Factor IX)**. Hemophilias are coagulation factor deficiencies that present with deep tissue bleeds (hemarthrosis/hematomas) and a **prolonged aPTT**, rather than petechiae and isolated thrombocytopenia. **3. NEET-PG High-Yield Pearls:** * **Pathophysiology:** Anti-platelet antibodies (IgG) directed against GP IIb/IIIa or GP Ib/IX. * **Bone Marrow:** Not routinely required but would show **increased megakaryocytes** (compensatory). * **Management:** Observation is preferred if bleeding is minimal (dry purpura). If treatment is needed (wet purpura/active bleeding), **IVIG** or **Corticosteroids** are first-line. * **Chronic ITP:** Defined as thrombocytopenia persisting >12 months (occurs in ~20% of cases).
Question 2: A 9-year-old girl develops widespread pinpoint skin hemorrhages after recovering from a flu-like illness 1 week earlier. Laboratory findings reveal a platelet count of 20,000/mL with no other abnormalities. Her bone marrow shows an increased number of megakaryocytes. The platelet count is normal after 2 months. Which of the following is the appropriate diagnosis?
- A. Antiphospholipid antibody syndrome
- B. Disseminated intravascular coagulation
- C. Hemolytic-uremic syndrome
- D. Idiopathic thrombocytopenic purpura (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Idiopathic thrombocytopenic purpura (ITP)** **Concept:** The clinical presentation is classic for **Acute Immune Thrombocytopenic Purpura (ITP)**. In children, ITP typically follows a viral prodrome (like the flu) by 1–3 weeks. It is caused by **Type II hypersensitivity**, where IgG autoantibodies are directed against platelet surface glycoproteins (GPIIb/IIIa). These antibody-coated platelets are then sequestered and destroyed by splenic macrophages. **Key Diagnostic Features in this Case:** 1. **Isolated Thrombocytopenia:** Platelet count is low (20,000/mL), but other cell lines (RBCs, WBCs) are normal. 2. **Bone Marrow:** Shows **increased megakaryocytes**, indicating the marrow is healthy and attempting to compensate for peripheral destruction. 3. **Prognosis:** Most childhood cases are self-limiting and resolve spontaneously within 6 months (as seen here, resolving in 2 months). --- ### Why Other Options are Incorrect: * **A. Antiphospholipid antibody syndrome:** Characterized by arterial/venous thrombosis and pregnancy loss; while thrombocytopenia can occur, it doesn't typically follow a viral illness in a child with spontaneous resolution. * **B. Disseminated intravascular coagulation (DIC):** This is a consumptive coagulopathy. You would expect abnormal PT/aPTT, low fibrinogen, and elevated D-dimer. The patient would appear clinically ill (sepsis/trauma). * **C. Hemolytic-uremic syndrome (HUS):** Characterized by a triad of microangiopathic hemolytic anemia (schistocytes on smear), thrombocytopenia, and acute renal failure, usually following bloody diarrhea (*E. coli* O157:H7). --- ### NEET-PG High-Yield Pearls: * **First-line treatment (if bleeding/severe):** Corticosteroids or IVIG. * **Chronic ITP:** Defined as thrombocytopenia persisting >12 months (more common in adults). * **Splenectomy:** The most effective definitive treatment for refractory ITP, as the spleen is both the site of antibody production and platelet destruction. * **Wet Purpura:** Presence of mucosal bleeds (e.g., mouth, gums) is a warning sign of life-threatening hemorrhage (intracranial hemorrhage).
Question 3: A patient presents with ecchymoses and petechiae all over the body and no hepatosplenomegaly. Which of the following statements is NOT true?
- A. Increased megakaryocytes in bone marrow
- B. Bleeding into the joints (Correct Answer)
- C. Decreased platelets in blood
- D. Disease resolves itself in 80% of patients in 2-6 weeks
Explanation: **Explanation:** The clinical presentation of petechiae and ecchymoses (superficial skin bleeds) without hepatosplenomegaly in a pediatric patient is a classic description of **Immune Thrombocytopenic Purpura (ITP)**. **Why Option B is the Correct Answer (The "NOT True" statement):** Bleeding into the joints (**Hemarthrosis**) is a hallmark of **coagulation factor deficiencies** (secondary hemostasis defects), such as Hemophilia. In contrast, platelet disorders like ITP present with **mucocutaneous bleeding** (petechiae, purpura, epistaxis, and gum bleeding). Hemarthrosis is extremely rare in ITP. **Analysis of Incorrect Options:** * **Option A (Increased megakaryocytes):** In ITP, platelets are destroyed peripherally by anti-platelet antibodies. The bone marrow responds by increasing production, leading to an increased number of megakaryocytes. * **Option C (Decreased platelets):** Thrombocytopenia (isolated low platelet count) is the defining laboratory feature of ITP. * **Option D (Self-resolution):** Acute ITP in children is typically a self-limiting condition. Approximately 80% of cases resolve spontaneously within 2–6 months (often following a viral infection) without requiring aggressive intervention. **Clinical Pearls for NEET-PG:** * **ITP Diagnosis:** It is a diagnosis of exclusion. The absence of hepatosplenomegaly and lymphadenopathy is crucial to rule out leukemia. * **First-line Treatment:** If treatment is indicated (usually when platelets <20,000/µL or significant bleeding occurs), **Corticosteroids** or **IVIG** are the preferred agents. * **Chronic ITP:** Defined as thrombocytopenia persisting for >12 months. * **Platelet vs. Coagulation Bleeding:** * *Platelet defects:* Immediate bleeding, petechiae, mucosal involvement. * *Coagulation defects:* Delayed bleeding, deep hematomas, hemarthrosis.
Question 4: In a newborn, Harlequin skin change is due to what underlying condition?
- A. Polycythemia
- B. Septicemia
- C. Autonomic dysfunction (Correct Answer)
- D. Ichthyosis
Explanation: **Explanation:** **Harlequin Color Change** is a transient, benign phenomenon seen in approximately 10% of healthy newborns, typically between the 2nd and 5th day of life. 1. **Why Autonomic Dysfunction is Correct:** The condition is attributed to the **immaturity of the hypothalamic centers** that control peripheral vascular tone. This leads to temporary **autonomic instability**, causing a sharp midline demarcation where one half of the body appears deep red (dependent side) and the other half appears pale (upper side) when the infant is placed on their side. Gravity causes blood to pool in the lower half due to dysregulated capillary tone. 2. **Why Other Options are Incorrect:** * **Polycythemia:** Presents as generalized "plethora" (ruddy, dusky red skin) throughout the body, not a midline-demarcated color change. * **Septicemia:** While sepsis can cause mottled skin (cutis marmorata) or peripheral cyanosis, it is accompanied by systemic signs like lethargy, poor feeding, and temperature instability. Harlequin change occurs in otherwise healthy infants. * **Ichthyosis:** Specifically "Harlequin Ichthyosis" is a severe genetic skin disorder characterized by thick, plate-like scales and ectropion. It is a structural skin defect, not a transient vascular phenomenon. **High-Yield Clinical Pearls for NEET-PG:** * **Duration:** The episodes typically last from 30 seconds to 20 minutes. * **Management:** It is a **benign, self-limiting** condition. No treatment is required other than reassurance and changing the baby's position. * **Differential:** Do not confuse this with *Harlequin Ichthyosis* (genetic) or *Port-wine stain* (permanent capillary malformation). * **Trigger:** Most commonly seen when the infant is placed in a lateral recumbent position.
Question 5: A 3-year-old child presented with progressive anemia, jaundice, and failure to thrive. On examination, pallor and splenomegaly are seen. Peripheral smear showed normoblasts and small round intensely stained red cells. What is the likely diagnosis?
- A. Hereditary spherocytosis (Correct Answer)
- B. Thalassemia
- C. Sickle cell anemia
- D. Vitamin B12 deficiency anemia
Explanation: ### Explanation **1. Why Hereditary Spherocytosis (HS) is Correct:** The clinical triad of **anemia, jaundice, and splenomegaly** in a young child strongly suggests a chronic hemolytic process. The definitive clue lies in the peripheral smear: **"small round intensely stained red cells"** are **Spherocytes**. These cells lack central pallor because they have lost their biconcave shape due to defects in RBC membrane proteins (most commonly **Ankyrin**, followed by Spectrin). The presence of **normoblasts** (nucleated RBCs) indicates a robust compensatory bone marrow response to hemolysis. **2. Why Other Options are Incorrect:** * **Thalassemia:** While it presents with anemia and splenomegaly, the peripheral smear typically shows **microcytic hypochromic** cells, target cells, and basophilic stippling, not spherocytes. * **Sickle Cell Anemia:** Characterized by **sickle-shaped cells** and Howell-Jolly bodies. Splenomegaly is usually seen only in early childhood; later, "autosplenectomy" occurs due to repeated infarcts. * **Vitamin B12 Deficiency:** This is a **megaloblastic anemia** (macrocytic). The smear would show macro-ovalocytes and hypersegmented neutrophils, not spherocytes or jaundice from hemolysis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Most commonly Autosomal Dominant. * **Gold Standard Test:** Eosin-5-maleimide (EMA) binding test (Flow cytometry). * **Screening Test:** Osmotic Fragility Test (increased fragility). * **MCHC:** Characteristically **elevated** (>36 g/dL) due to relative dehydration of the cell. * **Complications:** Pigmented gallstones (calcium bilirubinate) and Aplastic crisis (associated with **Parvovirus B19**). * **Treatment of Choice:** Splenectomy (usually deferred until after age 5–6 to reduce sepsis risk).
Question 6: What is the hemoglobin level indicative of anemia in a child aged 2 to 5 years?
- A. Less than 14 g/dL
- B. Less than 11 g/dL (Correct Answer)
- C. Less than 12 g/dL
- D. Less than 13 g/dL
Explanation: **Explanation:** The definition of anemia in children is based on hemoglobin (Hb) thresholds that vary by age, reflecting the physiological changes in red blood cell mass and plasma volume during growth. According to **WHO criteria**, the cutoff for anemia in children aged **6 months to 5 years (60 months)** is a hemoglobin level of **<11 g/dL**. **Why Option B is Correct:** In the 2 to 5-year age group, the hematopoietic system has stabilized after the "physiological anemia of infancy," but the iron requirements remain high due to rapid growth. A value below 11 g/dL indicates that the oxygen-carrying capacity is insufficient for the metabolic needs of this age group. **Analysis of Incorrect Options:** * **Option A (<14 g/dL):** This is a normal range for newborns (who have high Hb due to fetal hemoglobin) or adult males. It is too high a threshold for toddlers. * **Option C (<12 g/dL):** This is the diagnostic cutoff for **children aged 12–14 years** and **non-pregnant adult females**. * **Option D (<13 g/dL):** This is the diagnostic cutoff for **adult males** (aged 15 years and above). **High-Yield Clinical Pearls for NEET-PG:** * **Newborn (at birth):** Anemia is defined as Hb **<13.5 g/dL**. * **6 months to 5 years:** Hb **<11 g/dL**. * **5 years to 11 years:** Hb **<11.5 g/dL**. * **12 years to 14 years:** Hb **<12 g/dL**. * **Most Common Cause:** Nutritional **Iron Deficiency Anemia (IDA)** is the most common cause of anemia in this age group worldwide. * **Mentzer Index:** (MCV/RBC count) <13 suggests Thalassemia trait, while >13 suggests Iron Deficiency Anemia—a frequent "distractor" in pediatric hematology questions.
Question 7: A 13-year-old girl presents with fatigue and weakness, found to have reduced hemoglobin. Her MCV is 70 fL, MCH is 22 pg, and RDW is 28%. What is her likely diagnosis?
- A. Iron deficiency anemia (Correct Answer)
- B. Thalassemia major
- C. Sideroblastic anemia
- D. Thalassemia minor
Explanation: **Explanation:** The patient presents with **microcytic hypochromic anemia** (MCV <80 fL, MCH <27 pg). The key diagnostic clue in this question is the **Red Cell Distribution Width (RDW) of 28%**. 1. **Why Iron Deficiency Anemia (IDA) is correct:** IDA is characterized by a high RDW (typically >15%). This reflects **anisocytosis** (variation in red cell size), as the bone marrow struggles to produce uniform cells due to fluctuating iron availability. In a 13-year-old girl, IDA is the most common cause of microcytic anemia, often exacerbated by the onset of menstruation and nutritional gaps. 2. **Why other options are incorrect:** * **Thalassemia Minor:** This is the most important differential. However, Thalassemia minor typically presents with a **normal or only slightly elevated RDW** because the genetic defect results in a uniform population of small cells. The Mentzer Index (MCV/RBC count) is usually <13 in Thalassemia and >13 in IDA. * **Thalassemia Major:** Patients usually present in infancy (6–9 months) with severe anemia, hepatosplenomegaly, and skeletal changes. A 13-year-old presenting only now with mild fatigue is unlikely to have Major. * **Sideroblastic Anemia:** While it can be microcytic, it is much rarer and often associated with a dimorphic blood picture or specific triggers (drugs/toxins). **High-Yield Clinical Pearls for NEET-PG:** * **RDW** is the earliest laboratory indicator of Iron Deficiency Anemia, rising even before hemoglobin drops. * **Mentzer Index:** MCV ÷ RBC count. If **<13**, suspect Thalassemia; if **>13**, suspect IDA. * **Gold Standard Investigation for IDA:** Bone marrow iron stores (Prussian blue staining), though Serum Ferritin is the most sensitive non-invasive test. * **Treatment Response:** The first sign of response to oral iron therapy is a rise in **reticulocyte count**, peaking at 7–10 days.
Question 8: Hemolytic disease of the newborn is commonly due to incompatibility of which antigen?
- A. C antigen in the Rh group
- B. D antigen in the Rh group (Correct Answer)
- C. E antigen in the Rh group
- D. Lewis antigen
Explanation: **Explanation:** **Hemolytic Disease of the Newborn (HDN)**, also known as erythroblastosis fetalis, occurs when maternal antibodies cross the placenta and destroy fetal red blood cells. This happens when the mother is sensitized to a fetal blood group antigen that she lacks. **Why Option B is Correct:** The **D antigen** of the Rh blood group system is the most potent immunogen among all human blood group antigens. Rh incompatibility typically occurs when an **Rh-negative mother (d/d)** carries an **Rh-positive fetus (D/d)**. If fetal D-positive cells enter the maternal circulation (usually during delivery), the mother produces anti-D IgG antibodies. In subsequent pregnancies, these IgG antibodies cross the placenta, leading to hemolysis. Despite the use of Rh immunoglobulin (Anti-D prophylaxis), it remains the most common cause of severe HDN. **Why Other Options are Incorrect:** * **Options A & C (C and E antigens):** While other Rh antigens like C, c, E, and e can cause HDN, they are significantly less immunogenic than the D antigen and are rare causes of clinical disease. * **Option D (Lewis antigen):** Lewis antigens (Le^a, Le^b) are not implicated in HDN because they are primarily IgM (which does not cross the placenta) and are not well-developed on fetal red cells at birth. **NEET-PG High-Yield Pearls:** * **Most Common Cause of HDN overall:** ABO incompatibility (usually Mother 'O' and Baby 'A' or 'B'). It is often milder and can occur in the first pregnancy. * **Most Common Cause of SEVERE HDN:** Rh (D) incompatibility. * **Standard Prophylaxis:** 300 mcg of Anti-D is given to Rh-negative mothers at 28 weeks gestation and within 72 hours of delivery of an Rh-positive infant. * **Kleihauer-Betke Test:** Used to quantify the amount of fetal-maternal hemorrhage to determine the required dose of Anti-D.
Question 9: Goat milk anemia is caused by a deficiency of which of the following?
- A. Iron deficiency
- B. Folate deficiency (Correct Answer)
- C. Vitamin B12 deficiency
- D. None of the above
Explanation: **Explanation:** **Goat milk anemia** is a classic pediatric hematology topic frequently tested in NEET-PG. The correct answer is **Folate deficiency** because goat milk is notoriously deficient in folic acid (containing only about 6 mcg/L compared to 50 mcg/L in cow's milk). 1. **Why Folate Deficiency is Correct:** Infants exclusively fed on unfortified goat milk are at high risk of developing **Megaloblastic Anemia**. Folate is essential for DNA synthesis; its deficiency leads to ineffective erythropoiesis and the characteristic large, nucleated red blood cell precursors (megaloblasts) in the bone marrow. 2. **Why Other Options are Incorrect:** * **Iron Deficiency:** While goat milk is low in iron (similar to cow's milk), the term "Goat milk anemia" specifically refers to the unique megaloblastic anemia caused by its profound lack of folate. * **Vitamin B12 Deficiency:** Goat milk contains adequate amounts of Vitamin B12. B12 deficiency is more commonly seen in infants of strictly vegetarian mothers or those with malabsorption syndromes. **High-Yield Clinical Pearls for NEET-PG:** * **Heat Sensitivity:** Folate is heat-labile. Boiling goat milk (a common practice) further destroys the minimal folate present, exacerbating the deficiency. * **Peripheral Smear:** Look for **hypersegmented neutrophils** (earliest sign) and macro-ovalocytes. * **Cow’s Milk vs. Goat Milk:** While both are poor sources of iron, cow’s milk has significantly more folate than goat milk. * **Management:** Treatment involves folic acid supplementation and transitioning the infant to a folate-rich diet or fortified formula.
Question 10: A 2-year-old child presents with discharge, seborrheic dermatitis, polyuria, and hepatosplenomegaly. Which of the following is the most likely diagnosis?
- A. Leukemia
- B. Lymphoma
- C. Langerhan's cell histiocytosis (Correct Answer)
- D. Germ cell tumor
Explanation: ### Explanation The clinical presentation described is a classic manifestation of **Langerhans Cell Histiocytosis (LCH)**, specifically the multisystem variant (formerly known as Letterer-Siwe disease or Hand-Schüller-Christian syndrome). **Why Option C is Correct:** LCH is a proliferative disorder of myeloid dendritic cells. The diagnosis is based on a characteristic "clinical triad" and associated findings: 1. **Skin Involvement:** Seborrheic dermatitis-like rash (often involving the scalp, diaper area, and trunk) is a hallmark. 2. **Ear Involvement:** Chronic ear discharge (otitis media/externa) that is refractory to antibiotics. 3. **Diabetes Insipidus (DI):** Infiltration of the posterior pituitary leads to polyuria and polydipsia. 4. **Organomegaly:** Hepatosplenomegaly and lymphadenopathy indicate multisystem involvement, which carries a poorer prognosis. **Why Other Options are Incorrect:** * **Leukemia (A):** While it causes hepatosplenomegaly and bone pain, it does not typically present with seborrheic dermatitis or diabetes insipidus. * **Lymphoma (B):** Primarily presents with painless lymphadenopathy and B-symptoms (fever, weight loss). It rarely causes the specific combination of skin rash and polyuria. * **Germ Cell Tumor (D):** While these can occur in the pineal/suprasellar region causing DI, they do not present with seborrheic dermatitis or hepatosplenomegaly. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Marker:** **Birbeck granules** (tennis-racket shaped) seen on Electron Microscopy. * **Immunohistochemistry (IHC):** Positive for **CD1a, S100, and CD207 (Langerin)**. * **Radiology:** "Punched-out" lytic lesions in the skull. * **Hand-Schüller-Christian Triad:** Lytic bone lesions, Exophthalmos, and Diabetes Insipidus.
Practice by Chapter
Anemias in Children
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Hemoglobinopathies
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Hemolytic Anemias
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Nutritional Anemias
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Thrombocytopenia
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Bleeding Disorders
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Thrombotic Disorders
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White Blood Cell Disorders
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Bone Marrow Failure Syndromes
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Blood Component Therapy
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Hemophilia and Von Willebrand Disease
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Evaluation of Bleeding Tendencies
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