Hematopathology — MCQs

Hematopathology US Medical PG Practice Questions and MCQs

Question 11: The following electron microscopy picture is a cytoplasmic feature seen in:

A. Plasmacytoma
B. Neuroblastoma
C. Chloroma
D. Histiocytosis X (Correct Answer)
E. Gaucher disease

Explanation: ***Histiocytosis X*** - The electron microscopy picture likely shows **Birbeck granules**, which are characteristic cytoplasmic features of **Langerhans cells** [1]. - **Langerhans cell histiocytosis (Histiocytosis X)** is a disorder characterized by the proliferation of these abnormal Langerhans cells [1]. *Neuroblastoma* - Neuroblastoma is a tumor of neural crest origin, and its cells typically show **neurosecretory granules** on electron microscopy. - It does not exhibit Birbeck granules, which are specific to Langerhans cells. *Chloroma* - Chloroma (also known as granulocytic sarcoma) is an extramedullary manifestation of **acute myeloid leukemia (AML)**. - Electron microscopy of chloroma cells would show features of immature myeloid cells, such as **azurophilic granules**, not Birbeck granules. *Plasmacytoma* - Plasmacytoma is a localized proliferation of **plasma cells**. - Electron microscopy of plasma cells would reveal abundant **rough endoplasmic reticulum** and a prominent Golgi apparatus, reflecting their role in antibody production, not Birbeck granules. **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, p. 630.

Question 12: The image shows:

A. Langerhans cells
B. Plasma cells (Correct Answer)
C. Reed Sternberg cells
D. CMV infected cells
E. Mast cells

Explanation: ***Plasma cells*** - The image likely depicts cells with an **eccentric nucleus**, **perinuclear halo (hof)**, and abundant basophilic cytoplasm, which are characteristic features of **plasma cells**. - These cells are terminally differentiated **B lymphocytes** responsible for antibody production. *Langerhans cells* - Langerhans cells are **dendritic cells** found in the epidermis, characterized by a **multilobulated nucleus** and **Birbeck granules** on electron microscopy. - They are antigen-presenting cells and do not typically exhibit the morphology shown. *Reed Sternberg cells* - Reed-Sternberg cells are large, **multinucleated cells** with prominent eosinophilic nucleoli, often described as having an "**owl's eye**" appearance, pathognomonic for **Hodgkin lymphoma** [1]. - Their morphology is distinct from the cells typically seen in the image. *CMV infected cells* - Cytomegalovirus (CMV) infected cells are typically **enlarged (cytomegalic)** and contain characteristic **intranuclear and intracytoplasmic inclusions**, often described as an "**owl's eye**" appearance due to the large central inclusion. - While they can have an eccentric nucleus, the overall morphology and presence of inclusions would differentiate them from plasma cells. **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. 614-618.

Question 13: Name the anticoagulant used in the following method.

A. EDTA
B. Heparin
C. Trisodium citrate (Correct Answer)
D. Dalteparin
E. Sodium fluoride

Explanation: ***Trisodium citrate*** - The image displays a method for measuring **Erythrocyte Sedimentation Rate (ESR)**, typically performed using the **Westergren method**. - In the Westergren method, **trisodium citrate** is the standard anticoagulant used to prevent blood coagulation, allowing red blood cells to settle over time. *EDTA* - **EDTA (ethylenediaminetetraacetic acid)** is a common anticoagulant, primarily used for **hematology tests** such as complete blood counts (CBC), as it preserves cell morphology. - While it prevents clotting, it is not the standard anticoagulant for the Westergren ESR method, as it can cause red blood cell shrinkage affecting sedimentation. *Heparin* - **Heparin** acts as an anticoagulant by enhancing the activity of **antithrombin III**, and is commonly used for chemistry and general coagulation studies. - It interferes with the sedimentation rate in ESR measurements, making it unsuitable for this specific test. *Dalteparin* - **Dalteparin** is a type of **low molecular weight heparin (LMWH)** used therapeutically as an anticoagulant to prevent and treat blood clots. - It is not used as an in-vitro anticoagulant for blood collection tubes or lab diagnostic tests like ESR. *Sodium fluoride* - **Sodium fluoride** is an anticoagulant and enzymatic inhibitor primarily used for **glucose measurement**, as it inhibits glycolysis and preserves glucose levels. - It is not appropriate for ESR testing, as it does not provide the optimal conditions for red blood cell sedimentation measurement.

Question 14: Name the inclusions shown in the blast.

A. Auer rods (Correct Answer)
B. Azurophilic granules
C. Dohle bodies
D. Heinz bodies
E. Howell-Jolly bodies

Explanation: ***Auer rods*** - The image clearly displays **rod-shaped cytoplasmic inclusions** within the blast cell, characteristic of **Auer rods**. - Auer rods are usually composed of fused **azurophilic granules** and are pathognomonic for **acute myeloid leukemia (AML)**. *Azurophilic granules* - While Auer rods are derived from azurophilic granules, the image shows distinct **rod-like structures**, not individual, small, round azurophilic granules. - Azurophilic granules are primary granules found in early myeloid cells, but they appear as **fine, dust-like particles** or small spheres, not large rods. *Dohle bodies* - **Dohle bodies** are pale blue-gray cytoplasmic inclusions usually found in **neutrophils** during infection or inflammation, representing aggregates of rough endoplasmic reticulum. - They appear as **oval or round structures** in the peripheral cytoplasm and do not resemble the rod-shaped inclusions seen in the blast. *Heinz bodies* - **Heinz bodies** are inclusions composed of **denatured hemoglobin** found within red blood cells, not white blood cells or blasts. - They are typically associated with **oxidative stress** or certain enzyme deficiencies in red blood cells. *Howell-Jolly bodies* - **Howell-Jolly bodies** are small, round nuclear remnants (DNA fragments) found in **red blood cells**, not in blast cells. - They appear as single or multiple dark purple-blue inclusions in RBCs and are seen in conditions like **asplenia** or **severe hemolytic anemia**.

Question 15: This test is used as a screening tool for:

A. Thalassemia (Correct Answer)
B. Hereditary spherocytosis
C. G6PD
D. Megaloblastic anemia
E. Sickle cell disease

Explanation: ***Thalassemia*** - The image shows the **NESTROFT (Naked Eye Single Tube Red Cell Osmotic Fragility Test)**, used as a simple, cheap **community screening tool** for **beta-thalassemia trait**. - In NESTROFT, RBCs are placed in hypotonic saline; thalassemia trait cells (due to reduced MCV) show **increased osmotic resistance**, resulting in a **clear/non-turbid** tube (positive test). - **Hemoglobin electrophoresis** is the definitive confirmatory test, but NESTROFT serves as the primary screening step. *Hereditary spherocytosis* - Diagnosed by **osmotic fragility test** or **flow cytometry** for eosin-5-maleimide (EMA) binding. - Spherocytes show **increased osmotic fragility** (lyse in less hypotonic saline), unlike thalassemia trait cells. - Not typically screened at a community level with a single-tube test. *G6PD* - Diagnosed by **G6PD enzyme assay** measuring enzyme activity. - **Heinz bodies** may be seen on peripheral smear during hemolytic episodes. - Screening is done by fluorescent spot test or enzyme quantification, not the tube-based osmotic fragility approach. *Megaloblastic anemia* - Diagnosed by **macrocytic anemia** on CBC, along with **hypersegmented neutrophils** on peripheral smear. - Confirmed by **serum B12** and **folate levels**; no tube-based osmotic test is used for screening. *Sickle cell disease* - Screened by the **sickling test** (sodium metabisulfite test) or **solubility test**, and confirmed by **Hb electrophoresis**. - Sickled cells show **normal osmotic fragility** (unlike spherocytes), so a tube osmotic fragility test would not screen for this condition. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 597-598. [2] Kumar V, Abbas AK, et al. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 641-642.

Question 16: Name the test given.

A. Osmotic fragility
B. NESTROFT
C. Sickling test
D. ESR measurement (Correct Answer)
E. Packed cell volume (PCV)

Explanation: ***ESR measurement*** - The image displays a **Westergren tube** with a column of blood, showing distinct layers of plasma on top and red blood cells settled below against a calibrated scale. - This setup is characteristic of an **Erythrocyte Sedimentation Rate (ESR)** test, which measures the rate at which red blood cells fall in a standardized tube over a specific time, indicating inflammation. *Osmotic fragility* - This test involves exposing red blood cells to varying concentrations of **hypotonic saline solutions** to assess their resistance to lysis. - The results are typically reported as a curve showing the percentage of hemolysis at different saline concentrations, not a simple sedimentation in a tube. *NESTROFT* - The **Naked Eye Single Tube Red Cell Osmotic Fragility Test (NESTROFT)** is a quick screening test for **beta-thalassemia trait**. - It involves mixing blood with a hypotonic saline solution and observing for complete hemolysis or partial hemolysis with a button of red cells, which is different from the image shown. *Sickling test* - A sickling test is used to detect the presence of **sickle hemoglobin**, which causes red blood cells to deform into a sickle shape under low oxygen conditions. - This test is usually performed by adding a reducing agent like **sodium metabisulfite** to a blood sample and observing cell morphology under a microscope or by turbidity, not by sedimentation in a calibrated tube. *Packed cell volume (PCV)* - PCV or **hematocrit** measures the proportion of blood volume occupied by red blood cells after centrifugation in a **microhematocrit tube**. - While it does involve blood in a tube, the tube is much smaller (capillary tube) and requires **centrifugation** to separate components, unlike ESR which relies on natural sedimentation under gravity in a larger calibrated Westergren tube.

Question 17: Identify the cell.

A. Eosinophil
B. Basophil
C. Monocyte (Correct Answer)
D. Lymphocyte
E. Neutrophil

Explanation: ***Monocyte*** - Monocytes are characterized by their **large size** (12-20 µm), **kidney-shaped or horseshoe-shaped nucleus**, and **abundant, often grayish-blue cytoplasm** with fine azurophilic granules [1]. - They are precursors to **macrophages** and play a crucial role in phagocytosis and antigen presentation [1]. *Eosinophil* - Eosinophils have a **bilobed nucleus** and prominent **red-orange granules** in their cytoplasm, which stain with eosin [1]. - They are primarily involved in allergic reactions and defense against **parasitic infections** [1]. *Basophil* - Basophils are characterized by a **lobed nucleus** often obscured by large, coarse, **dark purple-blue granules** that contain histamine and heparin [1]. - They are the least common granulocyte and are involved in **allergic and inflammatory responses** [1]. *Lymphocyte* - Lymphocytes are typically **smaller** than monocytes, with a **large, round, or slightly indented nucleus** that occupies most of the cell [1]. - Their cytoplasm is usually **scanty and pale blue**, often appearing as a thin rim around the nucleus [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 578-580.

Question 18: A 15-year-old patient presents with eczematous lesions for last 5 years. On physical examination, the lesions have progressed to present as plaques. Enlarged liver and spleen are noted with increased TLC. The peripheral smear was made. Clinical diagnosis is:

A. Peripheral T cell lymphoma (Correct Answer)
B. Immunoblastic lymphoma
C. DLBCL
D. Lymphoplasmacytic lymphoma
E. Hodgkin lymphoma

Explanation: ***Peripheral T cell lymphoma*** - The progression of **eczematous lesions** to **plaques** over 5 years, along with **hepatosplenomegaly** and **increased TLC**, is highly suggestive of a cutaneous T-cell lymphoma, which falls under the umbrella of peripheral T-cell lymphomas. - Mycosis fungoides, a common type of cutaneous T-cell lymphoma, often presents with these skin findings and can progress to systemic involvement with **lymphadenopathy**, **hepatosplenomegaly**, and **leukemia** (Sézary syndrome) [1,2]. The clinical progression from eczematous patches to plaques is characteristic of mycosis fungoides, which typically progresses through patch, plaque, and tumor stages [1]. *Immunoblastic lymphoma* - Immunoblastic lymphoma is a **high-grade B-cell lymphoma** characterized by large immunoblasts, not typically presenting with a long history of eczematous lesions. - While it can cause systemic symptoms like hepatosplenomegaly, the primary skin presentation as progressive eczematous lesions is not characteristic. *DLBCL* - **Diffuse Large B-cell Lymphoma (DLBCL)** is an aggressive B-cell lymphoma that can present with rapidly growing masses, but a 5-year history of progressive eczematous lesions is not its typical presentation. - While DLBCL can involve the skin, it usually manifests as nodules or tumors, not chronic eczematous patches and plaques. *Lymphoplasmacytic lymphoma* - **Lymphoplasmacytic lymphoma** is a low-grade B-cell lymphoma often associated with **Waldenström macroglobulinemia** and characterized by IgM paraprotein. - It typically presents with symptoms related to hyperviscosity, lymphadenopathy, and hepatosplenomegaly, but not primarily with chronic eczematous skin lesions. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 564-565. [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, pp. 613-614.

Question 19: The following bone marrow specimen is suggestive of diagnosis of:

A. Pure red cell aplasia
B. Myelodysplasia
C. Normal marrow
D. Aplastic anemia (Correct Answer)
E. Hairy cell leukemia

Explanation: ***Aplastic anemia*** - Aplastic anemia is characterized by a **hypocellular bone marrow** with a significant reduction in hematopoietic cells and replacement by **fat cells (adipocytes)** as seen in the specimen. - This condition leads to **pancytopenia**, affecting all three cell lines (red blood cells, white blood cells, and platelets). - Bone marrow cellularity is typically **<25%** (normal ~50%), with the remaining space occupied by fat and stroma. *Pure red cell aplasia* - Pure red cell aplasia primarily affects **erythroid precursors** in the bone marrow, leading to severe anemia. - Unlike aplastic anemia, the **myeloid and megakaryocytic lineages** are typically preserved, and overall marrow cellularity is not severely reduced. *Myelodysplasia* - Myelodysplastic syndromes (MDS) are characterized by **dysplastic changes** in one or more hematopoietic cell lines and **ineffective hematopoiesis**. - The bone marrow in MDS can be **normocellular or hypercellular** with morphological dysplasia (abnormal cell forms), not simply hypocellular with fat replacement. *Normal marrow* - A normal bone marrow is **cellular for the patient's age**, with a healthy mix of hematopoietic cells from all lineages and appropriate fat content (~50% cellularity in adults). - It would not show the profound **hypocellularity and fat replacement** seen in the provided specimen. *Hairy cell leukemia* - Hairy cell leukemia (HCL) shows bone marrow infiltration by **lymphoid cells with characteristic cytoplasmic hair-like projections** (best seen on peripheral smear). - Bone marrow biopsy in HCL typically shows **"fried egg" appearance** due to widely spaced hairy cells with pale cytoplasm — not a simple hypocellular, fat-replaced marrow. - HCL causes **dry tap** on aspiration but the trephine shows infiltration, not the pure hypocellularity seen in aplastic anemia. **References:** [1] Kumar V, Abbas AK, et al. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, p. 662. [2] Kumar V, Abbas AK, et al. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 662-663. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 595-596. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 613-614.

Question 20: A 70-year-old man presents with painless cervical lymphadenopathy with progressive pallor and petechiae on ankles. Peripheral smear shows presence of:

A. Acute ITP
B. Chronic ITP
C. CLL (Correct Answer)
D. Richter syndrome
E. Hairy cell leukemia

Explanation: ***CLL*** - The presentation of **painless cervical lymphadenopathy**, progressive **pallor** (due to anemia), and **petechiae** (due to thrombocytopenia) in an elderly patient is highly suggestive of **Chronic Lymphocytic Leukemia (CLL)** [2]. - Peripheral smear in CLL typically shows a proliferation of mature-appearing **small lymphocytes** and characteristic **smudge cells** [1]. *Acute ITP* - Acute ITP is characterized by sudden onset of **thrombocytopenia** and bleeding, often following a viral infection, and is more common in children. - It does not typically present with **lymphadenopathy** or progressive pallor as a primary feature. *Chronic ITP* - Chronic ITP is characterized by isolated **thrombocytopenia** and bleeding symptoms, usually without lymphadenopathy or significant anemia unless bleeding is severe. - The presence of **lymphadenopathy** points away from isolated ITP and towards a systemic hematological malignancy. *Richter syndrome* - Richter syndrome is the transformation of CLL into a more aggressive lymphoma, most commonly **diffuse large B-cell lymphoma (DLBCL)**. - While it can present with rapidly enlarging lymph nodes and systemic symptoms, the initial presentation described (painless lymphadenopathy, progressive pallor, petechiae) is more typical of **untreated CLL** before transformation [2]. **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, p. 602. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 612-613.

Practice by Chapter

Red blood cell disorders

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White blood cell disorders

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Platelet disorders

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Coagulation disorders

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Acute leukemias

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Chronic leukemias

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Myeloproliferative neoplasms

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Myelodysplastic syndromes

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Hodgkin lymphoma

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Non-Hodgkin lymphomas

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Plasma cell disorders

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Bone marrow failure syndromes

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Splenic pathology

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