Hematopathology Practice Questions

Q: Identify the cell.

Basophil. ***Basophil*** - The cell has **large, coarse, and dense basophilic (dark purple-blue) granules** in its cytoplasm, which often obscure the multi-lobed nucleus. - This characteristic appearance, with the **prominent dark granules that obscure the nucleus**, is distinctive of a **basophil** on a peripheral blood smear. - Basophils contain histamine and heparin, and their granules stain intensely with basic dyes. *Eosinophil* - Would have **bright red-orange granules** that are uniform in size and do NOT obscure the nucleus. - The nucleus is typically bilobed and clearly visible. *Neutrophil* - Would have a **multilobed nucleus** (2-5 lobes) that is clearly visible. - Contains fine, light pink or neutral-staining granules in the cytoplasm. - Most common white blood cell (50-70% of WBCs). *Monocyte* - Largest white blood cell with abundant **grayish-blue cytoplasm**. - Has a **kidney-shaped or horseshoe-shaped nucleus** that is clearly visible. - Lacks prominent granules. *Lymphocyte* - Small cell with a **large, round, dark-staining nucleus** that occupies most of the cell. - Scant cytoplasm, typically appearing as a thin rim around the nucleus. - No cytoplasmic granules.

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 65-year-old man presents with pancytopenia and dry tap on bone marrow aspiration. Peripheral smear is given. The diagnosis is:

Hairy cell leukemia. ***Hairy cell leukemia*** - **Pancytopenia** and **dry tap** on bone marrow aspiration are classic features of hairy cell leukemia due to extensive marrow fibrosis [1]. - The peripheral smear would show characteristic **hairy cells** with cytoplasmic projections, confirming the diagnosis [1]. *Myelophthisic anemia* - While it can cause **pancytopenia** and sometimes a dry tap, it's due to marrow infiltration by fibrosis, granulomas, or metastatic cancer. - The peripheral smear would show **leukoerythroblastosis** (immature myeloid and erythroid precursors) and **teardrop cells**, which are not the primary diagnostic feature here. *Aplastic anemia* - Presents with **pancytopenia** and a **dry tap** due to severely hypocellular bone marrow [3]. - However, the peripheral smear would typically show only a reduction in all cell lines without the presence of abnormal cells like hairy cells [3]. *Myelodysplastic syndrome* - Can cause **pancytopenia** but typically presents with a **hypercellular or normocellular marrow** with dysplastic features, not a dry tap due to fibrosis [2]. - The peripheral smear would show **dysplastic changes** in one or more cell lines, but not the specific hairy cells seen in this case [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. 612. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 613-614. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 595-596.

Q: A 70-year-old man presents with painless cervical lymphadenopathy with progressive pallor and petechiae on ankles. The peripheral smear is shown. What is the most likely diagnosis?

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.

Q: Which is correct about the translocation associated with the neoplasm suggested by these findings in a 25-year-old man who presents with painless cervical lymphadenopathy with progressive pallor and petechiae on ankles. Immunohistochemistry shows nuclear and cytoplasmic ALK staining. Histopathology image is shown below:

t(2: 5). ***t(2: 5)*** - The clinical presentation of painless cervical lymphadenopathy, progressive pallor, and petechiae in a young man, along with nuclear and cytoplasmic ALK staining on immunohistochemistry confirming ALK-positive disease, is highly suggestive of **Anaplastic Large Cell Lymphoma (ALCL)**. - **t(2;5)** translocation, leading to the **NPM-ALK fusion gene**, is the hallmark cytogenetic abnormality found in approximately 75–80% of ALK-positive ALCL cases [1]. *t(14: 15)* - This translocation is not a commonly recognized or significant cytogenetic abnormality associated with a specific hematological malignancy in the context provided. - It does not correspond to the typical translocations seen in lymphomas or leukemias that would present with these symptoms. *t(9: 22)* - This translocation, known as the **Philadelphia chromosome**, is characteristic of **Chronic Myeloid Leukemia (CML)** [2]. - While CML can cause pallor and petechiae, it typically presents with **splenomegaly** and a very high white blood cell count with myeloid precursors, not primarily painless cervical lymphadenopathy as the initial prominent symptom. *t(1: 19)* - This translocation, **t(1;19)**, is primarily associated with **Pre-B cell Acute Lymphoblastic Leukemia (ALL)** [3]. - While ALL can present with pallor and petechiae, the specific presentation of painless cervical lymphadenopathy as a prominent feature along with ALK-positive staining points away from typical ALL. **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. 612-613. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 605-607. [3] 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. 599-600.

Q: A 25-year-old male presents with acute hemolytic anemia after taking primaquine. His peripheral blood smear shows bite cells and blister cells. The pattern of inheritance of the hematological disorder shown is:

X-linked recessive. ***X-linked recessive*** - The smear findings suggest G6PD deficiency, which is inherited in an X-linked recessive pattern. - This pattern is characterized by affected males, unaffected females who can be carriers, and the absence of male-to-male transmission [1]. - The disorder is passed from an affected father to all his daughters (who become carriers) and from a carrier mother to 50% of her sons (who are affected) and 50% of her daughters (who are carriers) [1]. *Autosomal recessive* - In this pattern, affected individuals typically have unaffected parents, and both males and females are affected equally. - The disorder often skips generations, and consanguinity increases the risk. *Autosomal dominant* - This pattern shows affected individuals in every generation, with affected individuals having at least one affected parent. - Both males and females are affected equally, and male-to-male transmission can occur. *X-linked dominant* - This pattern is characterized by affected fathers passing the trait to all their daughters but none of their sons. - Affected mothers have a 50% chance of passing the trait to each child, regardless of sex. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Genetic Disorders, p. 151.

Q: The image shows presence of:

Extravascular hemolysis. ***Extravascular hemolysis*** - The image likely depicts **spherocytes** or other red blood cell abnormalities characteristic of extravascular hemolysis, where red cells are destroyed in the **spleen** or **liver** [1]. - This process leads to increased **unconjugated bilirubin** and often **splenomegaly** [2]. *Intravascular hemolysis* - This type of hemolysis occurs within blood vessels, leading to the release of **hemoglobin** into the plasma [3]. - It is characterized by **hemoglobinemia**, **hemoglobinuria**, and decreased **haptoglobin**, which are not directly visible in a typical blood smear image [3]. *Myelophthisic anemia* - This condition results from the **replacement of bone marrow** by abnormal tissue, such as fibrosis, tumors, or granulomas. - It is characterized by **leukoerythroblastosis** (immature white and red blood cells in peripheral blood) and **teardrop cells**, which are not the primary feature suggested by the term "hemolysis." *Extramedullary hematopoiesis* - This refers to the formation of blood cells outside the bone marrow, typically in the **spleen** or **liver**. - While it can be a compensatory mechanism in severe anemias, including some hemolytic anemias, it is a process of blood cell production, not directly a type of hemolysis itself. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 602-603. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, p. 640. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 639-640.

Q: The following image shows presence of:

Ovalocytes/Elliptocytes. ***Ovalocytes/Elliptocytes*** - The image shows a predominance of **oval or elongated red blood cells**, which are characteristic of ovalocytes or elliptocytes - These cells have an **elliptical shape with a length-to-width ratio greater than 1.3:1** - Commonly seen in **hereditary elliptocytosis** (genetic defect in RBC membrane proteins like spectrin or protein 4.1) - Also found in **iron deficiency anemia, thalassemias, myelodysplastic syndromes**, and occasionally in normal individuals *Spherocytes* - These are **small, round RBCs lacking central pallor** due to loss of membrane surface area - Seen in **hereditary spherocytosis** and **autoimmune hemolytic anemia** - The image does not show spherical cells with absent central pallor *Acanthocytes* - These are **irregularly spiculated RBCs** with 3-12 projections of varying length distributed unevenly - Associated with **liver disease, abetalipoproteinemia**, and **neuroacanthocytosis** - The cells in the image are oval/elongated, not irregularly spiculated *Target cells* - Also called **codocytes**, these cells show a **central dense area surrounded by pale zone and peripheral rim of hemoglobin** (bull's-eye appearance) - Seen in **thalassemia, liver disease, hemoglobin C disease**, and **post-splenectomy** - The image does not demonstrate the characteristic target appearance *Schistocytes* - These are **fragmented RBCs (helmet cells, triangular cells)** resulting from mechanical damage - Characteristic of **microangiopathic hemolytic anemia (MAHA)**, including DIC, TTP, HUS - The cells shown are intact oval cells, not fragmented

Question 1

Identify the cell.

Accepted Answer

Basophil

Answer

Eosinophil

Answer

Neutrophil

Answer

Monocyte

Answer

Lymphocyte

Question 2

Identify the cell.

Accepted Answer

Monocyte

Answer

Eosinophil

Answer

Basophil

Answer

Lymphocyte

Answer

Neutrophil

Question 3

A 65-year-old man presents with pancytopenia and dry tap on bone marrow aspiration. Peripheral smear is given. The diagnosis is:

Accepted Answer

Hairy cell leukemia

Answer

Myelophthisic anemia

Answer

Aplastic anemia

Answer

Myelodysplastic syndrome

Answer

Chronic lymphocytic leukemia

Question 4

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

Mycosis fungoides/Cutaneous T-cell lymphoma

Answer

Lymphoplasmacytic lymphoma

Answer

Immunoblastic lymphoma

Answer

DLBCL

Answer

Hodgkin lymphoma

Question 5

The following bone marrow specimen is suggestive of diagnosis of:

Accepted Answer

Aplastic anemia

Answer

Pure red cell aplasia

Answer

Normal marrow

Answer

Myelodysplasia

Answer

Hairy cell leukemia

Question 6

A 70-year-old man presents with painless cervical lymphadenopathy with progressive pallor and petechiae on ankles. The peripheral smear is shown. What is the most likely diagnosis?

Accepted Answer

CLL

Answer

Chronic ITP

Answer

Richter syndrome

Answer

Acute ITP

Answer

Hairy cell leukemia

Question 7

Which is correct about the translocation associated with the neoplasm suggested by these findings in a 25-year-old man who presents with painless cervical lymphadenopathy with progressive pallor and petechiae on ankles. Immunohistochemistry shows nuclear and cytoplasmic ALK staining. Histopathology image is shown below:

Accepted Answer

t(2: 5)

Answer

t(9: 22)

Answer

t(1: 19)

Answer

t(14: 15)

Answer

t(11: 14)

Question 8

A 25-year-old male presents with acute hemolytic anemia after taking primaquine. His peripheral blood smear shows bite cells and blister cells. The pattern of inheritance of the hematological disorder shown is:

Accepted Answer

X-linked recessive

Answer

Autosomal dominant

Answer

Mitochondrial inheritance

Answer

Autosomal recessive

Answer

X-linked dominant

Question 9

The image shows presence of:

Accepted Answer

Extravascular hemolysis

Answer

Intravascular hemolysis

Answer

Myelophthisic anemia

Answer

Extramedullary hematopoiesis

Answer

Microangiopathic hemolytic anemia

Question 10

The following image shows presence of:

Accepted Answer

Ovalocytes/Elliptocytes

Answer

Spherocytes

Answer

Acanthocytes

Answer

Target cells

Answer

Schistocytes

Hematopathology — MCQs

Hematopathology — MCQs

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