Thrombocytopenia — MCQs
Cause of ITP is
An 8-year-old boy presents with petechiae, azotemic oliguria and altered sensorium, in casualty. There is a history of diarrhoea for the past 5 days. The clinical diagnosis is –
Which of the following is not a characteristic of Fanconi's anemia?
A neonate presents with the condition shown in the image below. This condition has all of the following features EXCEPT:
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 21-year-old male presents with anemia and mild hepatosplenomegaly. His hemoglobin is 5 gm/dL, and he has a history of a single blood transfusion to date. What is the most probable diagnosis?
What is the recommended treatment for Kostmann's syndrome?
A child presents with a long history of severe anemia (hemoglobin 5 gm%). What is the next step in management?
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?
Thrombocytopenia Indian Medical PG Practice Questions and MCQs
Question 1: Cause of ITP is
- A. Vasculitis
- B. Antibody to platelets (Correct Answer)
- C. Antibody to vascular epithelium
- D. Antibody to clotting factors
Explanation: The cause of ITP is: ***Antibody to platelets*** - **Immune thrombocytopenic purpura (ITP)** is an autoimmune disorder [1] characterized by the destruction of platelets due to the presence of **autoantibodies**, primarily targeting platelet surface glycoproteins like **GPIIb/IIIa**. - These antibodies lead to premature destruction or increased consumption [1] of platelets by the reticuloendothelial system, particularly in the spleen, resulting in **thrombocytopenia**. *Vasculitis* - **Vasculitis** is inflammation of the blood vessels, which can cause symptoms like purpura but typically does not primarily cause isolated severe thrombocytopenia as seen in ITP. - While it can lead to bleeding manifestations, the underlying mechanism is vascular inflammation, not direct platelet destruction by antibodies. *Antibody to vascular epithelium* - Antibodies to **vascular endothelium** are seen in conditions such as some forms of vasculitis or autoimmune disorders like lupus, but they directly target vessel walls, not platelets. - This typically leads to endothelial damage and inflammation, rather than isolated thrombocytopenia from platelet destruction. *Antibody to clotting factors* - Antibodies to **clotting factors** (e.g., Factor VIII inhibitors) cause **hemophilia-like bleeding disorders** by interfering with the coagulation cascade. - This mechanism results in impaired clot formation, not primarily in low platelet counts as is characteristic of ITP.
Question 2: An 8-year-old boy presents with petechiae, azotemic oliguria and altered sensorium, in casualty. There is a history of diarrhoea for the past 5 days. The clinical diagnosis is –
- A. H.U.S. (Correct Answer)
- B. H.S. purpura
- C. Idiopathic thrombocytopenic purpura
- D. Acute porphyria
Explanation: **H.U.S.** * The constellation of **petechiae** (indicating **thrombocytopenia**), **azotemic oliguria** (suggesting **acute kidney injury**), and **altered sensorium** (neurological involvement) following recent **diarrhea** is highly characteristic of **Hemolytic Uremic Syndrome (HUS)**, specifically **Shiga toxin-producing E. coli (STEC)-HUS**. * HUS is defined by the triad of **microangiopathic hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury**, often precipitated by a gastrointestinal infection. *Acute prophyria* * **Acute porphyrias** are metabolic disorders affecting heme synthesis, presenting with acute neurovisceral attacks. * While they can cause neurological symptoms, they are not typically associated with **petechiae**, **thrombocytopenia**, or **renal failure** following diarrhea. *H.S. purpura* * **Henoch-Schönlein (IgA vasculitis) purpura** is characterized by palpable purpura, arthritis, abdominal pain, and renal involvement (hematuria/proteinuria). * While it can cause **purpuric rash** and **renal disease**, it typically presents with **palpable purpura** (due to vasculitis), not petechiae from thrombocytopenia, and is less commonly associated with severe oliguric acute kidney injury or profound altered mental status in this context. *Idiopathic thrombocytopenic purpura* * **Idiopathic Thrombocytopenic Purpura (ITP)** is characterized by **isolated thrombocytopenia** leading to bleeding manifestations like **petechiae** and purpura. * ITP does not typically cause **azotemic oliguria** or **altered sensorium**, as it primarily affects platelet count without involvement of other organ systems like the kidneys or central nervous system.
Question 3: Which of the following is not a characteristic of Fanconi's anemia?
- A. Skeletal anomalies
- B. Pancytopenia
- C. Chromosome fragility
- D. Bone marrow failure in infancy (Correct Answer)
Explanation: ***Bone marrow failure in infancy*** - Fanconi anemia patients are typically **asymptomatic at birth** with normal blood counts. - **Progressive bone marrow failure** develops gradually, with median age of onset around **7 years** (range 5-10 years). - While subtle hematologic changes (macrocytosis, elevated HbF) may appear earlier, clinically significant **pancytopenia does not occur in infancy**. - This delayed hematologic presentation distinguishes Fanconi anemia from other congenital bone marrow failure syndromes. *Pancytopenia* - **Pancytopenia** is the hallmark hematologic feature of Fanconi anemia, but develops in **mid-childhood**, not infancy. - Results from progressive bone marrow failure affecting all three cell lines: **red blood cells, white blood cells, and platelets**. - Thrombocytopenia is often the first manifestation, followed by anemia and neutropenia. *Skeletal anomalies* - **Skeletal anomalies** are common congenital malformations present in approximately **60-75%** of patients. - Include **radial ray defects** (absent or hypoplastic thumbs, absent radius), **short stature**, and other limb abnormalities. - These are present from birth and often lead to early clinical suspicion. *Chromosome fragility* - **Chromosome fragility** is the **diagnostic hallmark** of Fanconi anemia due to defective DNA repair mechanisms. - Diagnostic test uses **diepoxybutane (DEB)** or **mitomycin C (MMC)** to induce DNA crosslinks, revealing increased chromosomal breaks and rearrangements. - This test is positive regardless of age or hematologic status.
Question 4: A neonate presents with the condition shown in the image below. This condition has all of the following features EXCEPT:
- A. Ectropion
- B. Eclabium
- C. Hard elastic scales over the neck area
- D. Satellite lesions (Correct Answer)
Explanation: ***Satellite lesions*** - **Satellite lesions** (smaller lesions located near a main rash) are characteristic of certain fungal infections like candidiasis or some viral rashes, but not of **collodion baby/harlequin ichthyosis**, which is suggested by the image. - The image shows features consistent with a severe congenital ichthyosis, where **skin scaling** and **facial deformities** are prominent, not scattered papules or pustules. *Ectropion* - **Ectropion** (eversion of the eyelids) is clearly visible in the image, where the eyelids are pulled outwards, exposing the conjunctiva. - This is a common feature in conditions like **collodion baby** and **harlequin ichthyosis** due to the restrictive outer skin layer. *Eclabium* - **Eclabium** (eversion of the lips) is also distinctly present in the image, with the lips appearing stretched and everted. - This is another characteristic manifestation of severe congenital ichthyosis, resulting from the **tight, hardened skin** around the mouth. *Hard elastic scales over the neck area* - The image shows **thickened, furrowed, and scaly skin** texture, particularly noticeable around the neck area (indicated by the arrow), which aligns with the description of **hard, elastic scales**. - This is a hallmark feature of **ichthyosis**, where there is impaired skin barrier function and excessive scale production.
Question 5: 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 6: A 21-year-old male presents with anemia and mild hepatosplenomegaly. His hemoglobin is 5 gm/dL, and he has a history of a single blood transfusion to date. What is the most probable diagnosis?
- A. Thalassemia major
- B. Thalassemia minor
- C. Thalassemia intermedia
- D. Autoimmune hemolytic anemia (Correct Answer)
Explanation: ### Explanation **Correct Option: D. Autoimmune Hemolytic Anemia (AIHA)** The key to this question lies in the **age of presentation** and the **transfusion history**. 1. **Age:** A 21-year-old presenting with severe anemia (Hb 5 gm/dL) for the first time suggests an acquired or late-onset condition rather than a severe congenital hemoglobinopathy. 2. **Transfusion History:** The patient has received only **one transfusion** in 21 years despite a very low hemoglobin. This "transfusion-sparing" clinical course rules out Thalassemia Major. 3. **Clinical Features:** Hepatosplenomegaly is common in AIHA due to extramedullary hematopoiesis and splenic sequestration of antibody-coated RBCs. --- ### Why the other options are incorrect: * **A. Thalassemia Major:** This typically presents in **infancy (6–9 months)** as fetal hemoglobin (HbF) levels drop. Without regular monthly transfusions, these patients do not survive to age 21 with a hemoglobin of 5 gm/dL. * **B. Thalassemia Minor:** This is usually an asymptomatic carrier state. While mild anemia may be present, the hemoglobin rarely drops to 5 gm/dL, and hepatosplenomegaly is typically absent. * **C. Thalassemia Intermedia:** While these patients present later than Thalassemia Major and are "transfusion-independent," they usually maintain a hemoglobin between 7–10 gm/dL. A drop to 5 gm/dL at age 21 without a prior history of regular transfusions is more characteristic of an acute hemolytic process like AIHA. --- ### NEET-PG High-Yield Pearls: * **Thalassemia Major:** "Transfusion-dependent"; presents with "Chipmunk facies" and "Hair-on-end" appearance on X-ray. * **AIHA Diagnosis:** The gold standard investigation is the **Direct Coombs Test (Direct Antiglobulin Test)**. * **Clinical Clue:** If a young adult presents with sudden severe anemia and splenomegaly, always consider AIHA or a late-presenting Hereditary Spherocytosis.
Question 7: What is the recommended treatment for Kostmann's syndrome?
- A. Anti-thymocyte globulin plus cyclosporin
- B. Anti-thymocyte globulin plus cyclosporin plus GM-CSF
- C. G-CSF (Correct Answer)
- D. GM-CSF
Explanation: **Explanation:** **Kostmann’s Syndrome** (Severe Congenital Neutropenia) is an autosomal recessive disorder characterized by a maturation arrest of neutrophil precursors in the bone marrow at the **promyelocyte/myelocyte stage**. This leads to absolute neutrophil counts (ANC) frequently below 200/mm³, predisposing infants to life-threatening pyogenic infections. **Why G-CSF is the Correct Answer:** The primary goal of treatment is to increase the production and maturation of neutrophils. **Granulocyte Colony-Stimulating Factor (G-CSF)** is the gold-standard treatment. It effectively increases the ANC in over 90% of patients, significantly reducing the frequency of infections and improving survival. While Hematopoietic Stem Cell Transplant (HSCT) is the definitive cure, G-CSF is the first-line medical management. **Why Other Options are Incorrect:** * **Options A & B:** Anti-thymocyte globulin (ATG) and Cyclosporin are immunosuppressive therapies used for **Aplastic Anemia**, where the pathology is T-cell mediated destruction of stem cells. Kostmann’s is a genetic maturation defect, not an autoimmune process. * **Option D:** **GM-CSF** (Granulocyte-Macrophage CSF) is less effective than G-CSF and is associated with more systemic side effects (like fever and bone pain) without providing a superior neutrophil response in these patients. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Most common mutation in Severe Congenital Neutropenia is **ELANE** (autosomal dominant), but the classic **Kostmann’s** specifically refers to the **HAX1** mutation (autosomal recessive). * **Bone Marrow Finding:** Characterized by "maturation arrest" at the promyelocyte stage. * **Malignancy Risk:** Patients have a significantly increased risk of developing **Acute Myeloid Leukemia (AML)** or Myelodysplastic Syndrome (MDS), even with G-CSF treatment. * **Definitive Treatment:** For patients refractory to G-CSF or those developing MDS/AML, **Stem Cell Transplant** is the only curative option.
Question 8: A child presents with a long history of severe anemia (hemoglobin 5 gm%). What is the next step in management?
- A. Blood transfusion
- B. Complete blood count (CBC), reticulocyte count, and peripheral smear (Correct Answer)
- C. Start iron supplementation
- D. Hemoglobin electrophoresis
Explanation: **Explanation:** In clinical pediatrics, the management of severe anemia (Hb <7 g/dL) follows a systematic diagnostic approach. While the patient is symptomatic, the **first step is always to establish an etiological diagnosis** before initiating treatment, unless the patient is in life-threatening heart failure. **Why Option B is Correct:** A **Complete Blood Count (CBC)** provides the MCV (Mean Corpuscular Volume), which classifies anemia as microcytic, normocytic, or macrocytic. The **Peripheral Smear** is the "gold standard" for visualizing red cell morphology (e.g., target cells, sickling, or megaloblasts), and the **Reticulocyte Count** is crucial to differentiate between bone marrow suppression (low retic) and hemolysis/hemorrhage (high retic). Together, these three tests form the "initial anemia workup" required to narrow down the differential diagnosis. **Why Other Options are Incorrect:** * **Option A (Blood Transfusion):** While Hb 5 gm% is low, transfusion is generally reserved for patients with cardiovascular instability or specific thresholds (e.g., Hb <5 in chronic anemia or <7 in acute). Transfusing before drawing blood can mask the underlying diagnosis by altering morphology and indices. * **Option C (Iron Supplementation):** Starting iron empirically is incorrect. If the anemia is due to Thalassemia or Sideroblastic anemia, iron supplementation can lead to dangerous iron overload. * **Option D (Hb Electrophoresis):** This is a specialized test used to diagnose hemoglobinopathies (like Thalassemia or Sickle Cell). It is performed *after* the initial CBC and smear suggest such a pathology, not as the very first step. **NEET-PG High-Yield Pearls:** * **Mentzer Index (MCV/RBC count):** <13 suggests Thalassemia trait; >13 suggests Iron Deficiency Anemia. * **Corrected Reticulocyte Count (CRC):** Essential in severe anemia to assess true bone marrow response. * **Hypersegmented neutrophils** on peripheral smear are the earliest sign of Megaloblastic anemia.
Question 9: 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 10: 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.
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