Hematopathology Practice Questions

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

Histiocytosis X. ***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.

Q: The image shows:

Plasma cells. ***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.

Q: Name the anticoagulant used in the following method.

Trisodium citrate. ***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.

Q: Name the inclusions shown in the blast.

Auer rods. ***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**.

Q: This test is used as a screening tool for:

Thalassemia. ***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.

Q: Name the test given.

ESR measurement. ***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.

Q: Identify the cell.

Monocyte. ***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.

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

CLL. ***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.

Question 1

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

Accepted Answer

Histiocytosis X

Answer

Plasmacytoma

Answer

Neuroblastoma

Answer

Chloroma

Answer

Gaucher disease

Question 2

The image shows:

Accepted Answer

Plasma cells

Answer

Langerhans cells

Answer

Reed Sternberg cells

Answer

CMV infected cells

Answer

Mast cells

Question 3

Name the anticoagulant used in the following method.

Accepted Answer

Trisodium citrate

Answer

EDTA

Answer

Heparin

Answer

Dalteparin

Answer

Sodium fluoride

Question 4

Name the inclusions shown in the blast.

Accepted Answer

Auer rods

Answer

Azurophilic granules

Answer

Dohle bodies

Answer

Heinz bodies

Answer

Howell-Jolly bodies

Question 5

This test is used as a screening tool for:

Accepted Answer

Thalassemia

Answer

Hereditary spherocytosis

Answer

G6PD

Answer

Megaloblastic anemia

Answer

Sickle cell disease

Question 6

Name the test given.

Accepted Answer

ESR measurement

Answer

Osmotic fragility

Answer

NESTROFT

Answer

Sickling test

Answer

Packed cell volume (PCV)

Question 7

Identify the cell.

Accepted Answer

Monocyte

Answer

Eosinophil

Answer

Basophil

Answer

Lymphocyte

Answer

Neutrophil

Question 8

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:

Accepted Answer

Peripheral T cell lymphoma

Answer

Immunoblastic lymphoma

Answer

DLBCL

Answer

Lymphoplasmacytic lymphoma

Answer

Hodgkin lymphoma

Question 9

The following bone marrow specimen is suggestive of diagnosis of:

Accepted Answer

Aplastic anemia

Answer

Pure red cell aplasia

Answer

Myelodysplasia

Answer

Normal marrow

Answer

Hairy cell leukemia

Question 10

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

Accepted Answer

CLL

Answer

Acute ITP

Answer

Chronic ITP

Answer

Richter syndrome

Answer

Hairy cell leukemia

Hematopathology — MCQs

Hematopathology — MCQs

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