Hematopathology Practice Questions

Q: A 42-year-old male after ileal resection complains of peripheral neuropathy with dizziness and fatigue on rest. His peripheral smear is given in the image below. What is the most likely diagnosis?

Megaloblastic anemia. ***Megaloblastic anemia*** - **Ileal resection** can lead to **Vitamin B12 malabsorption** [1], which is a common cause of **megaloblastic anemia** [2,3]. - **Peripheral neuropathy**, dizziness, and fatigue are classic symptoms of **Vitamin B12 deficiency** [3]. *Autoimmune hemolytic anemia* - This condition is characterized by **hemolysis** and would typically present with **jaundice**, **splenomegaly**, and a positive **Coombs test**, which are not mentioned. - The peripheral smear would show **spherocytes** and **reticulocytosis**, not necessarily the features of megaloblastic anemia. *Immune thrombocytopenic purpura* - This disorder primarily affects **platelets**, leading to **bleeding manifestations** like petechiae and purpura. - It does not typically cause **peripheral neuropathy** or the specific red blood cell changes seen in megaloblastic anemia. *PNH* - **Paroxysmal nocturnal hemoglobinuria (PNH)** is characterized by **hemolytic anemia**, **thrombosis**, and **bone marrow failure**. - While it can cause fatigue, the clinical picture of **peripheral neuropathy** and a history of **ileal resection** are not typical for PNH. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 654-655. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, p. 654. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 593-594.

Q: Which defect in RBC is shown below?

Basophilic stippling. ***Basophilic stippling*** - This refers to the presence of **small, dark-blue granules** within red blood cells, which are aggregates of **ribosomal RNA**. - It is classically associated with **lead poisoning**, but can also be seen in severe anemias like **thalassemia** and **myelodysplastic syndromes**. *Cabot ring* - These are **thin, reddish-purple, ring-shaped or figure-of-eight inclusions** within red blood cells. - They are thought to be remnants of the **mitotic spindle** or nuclear membrane and are seen in conditions like **megaloblastic anemia** and **lead poisoning**. *Heinz bodies* - These are **denatured hemoglobin precipitates** that appear as small, round inclusions attached to the inner surface of the red blood cell membrane [1]. - They are typically seen in conditions causing **oxidative stress** to red blood cells, such as **G6PD deficiency** and unstable hemoglobinopathies [1]. *Toxic granules* - These are **prominent, dark-staining granules** found within the cytoplasm of **neutrophils**, not red blood cells. - They are an indicator of **severe infection** or inflammation, representing increased lysosomal enzyme activity. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 642-643.

Q: Peripheral smear shown below depicts:

Hairy WBC. ***Hairy WBC*** - The image depicts a lymphocyte with **fine, hair-like cytoplasmic projections**, which are characteristic of **hairy cell leukemia** [1,4]. - These cells are typically **B-lymphocytes** and are seen in the peripheral blood, bone marrow, and spleen in this condition [1]. *Schistocytes* - These are **fragmented red blood cells** resulting from mechanical damage within the circulation. - They are typically seen in conditions like **microangiopathic hemolytic anemia (MAHA)**, disseminated intravascular coagulation (DIC), or prosthetic heart valves. *Acanthocytes* - These are **red blood cells with irregular, spiny projections** of varying length and width, often due to abnormal lipid content in the cell membrane. - They are classically associated with **abetalipoproteinemia** and severe liver disease. *Smudge cells* - These are **fragile white blood cells** that rupture during the preparation of a peripheral blood smear, appearing as nuclear remnants without intact cytoplasm [2]. - They are a hallmark finding in **chronic lymphocytic leukemia (CLL)** due to the fragility of the neoplastic lymphocytes [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] 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. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 569-570.

Q: Spot the diagnosis.

Dimorphic anemia. ***Dimorphic anemia*** - This term refers to the coexistence of two types of anemia, typically **iron deficiency anemia** (microcytic, hypochromic) [2] and **megaloblastic anemia** (macrocytic) [1]. - This can occur when there is a deficiency of both **iron** and **vitamin B12** or **folate** [1][2]. *Thalassemia* - Thalassemia is a **genetic disorder** characterized by reduced or absent synthesis of globin chains, leading to **microcytic, hypochromic anemia** [3]. - It is not typically associated with the presence of two distinct red cell populations (microcytic and macrocytic) simultaneously. *Megaloblastic anemia* - Megaloblastic anemia is caused by impaired DNA synthesis, most commonly due to **vitamin B12** or **folate deficiency**, leading to **macrocytic red blood cells** [1]. - While it explains the macrocytic component, it does not account for the presence of a microcytic, hypochromic population. *G6PD deficiency* - G6PD deficiency is an **X-linked genetic disorder** that causes **hemolytic anemia** due to oxidative stress, often triggered by certain drugs, foods, or infections. - It typically presents with **normocytic or macrocytic anemia** during hemolytic episodes, and is not characterized by a dimorphic picture of microcytic and macrocytic cells. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 593-594. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 590-591. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 587-588.

Q: Blood smear of a patient with G6PD deficiency shows:

Heinz bodies. ***Heinz bodies*** - **Heinz bodies** are inclusions of denatured hemoglobin that precipitate within red blood cells, characteristic of **oxidative stress** seen in G6PD deficiency [1]. - They are typically visualized with **supravital stains** like crystal violet and can lead to hemolysis as the spleen removes these rigid inclusions [1]. *Howell jolly bodies* - These are **nuclear remnants** (DNA) in red blood cells, indicating **hyposplenism** or **asplenia**, not directly related to G6PD deficiency [2]. - They are typically seen in conditions like **sickle cell anemia** or after splenectomy [2]. *Cabot rings* - **Cabot rings** are thin, thread-like inclusions forming a loop or figure-of-eight shape within red blood cells, representing **remnants of the mitotic spindle**. - They are non-specific and can be seen in severe anemias, **myelodysplastic syndromes**, or lead poisoning. *Pelger-Huet anomaly* - This is a **hereditary or acquired disorder** characterized by **hyposegmented neutrophils** (bilobed or unsegmented nuclei, often described as "pince-nez" appearance). - It affects white blood cells and is not a feature seen in red blood cells in G6PD deficiency. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 642-643. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 644-645.

Question 1

A 42-year-old male after ileal resection complains of peripheral neuropathy with dizziness and fatigue on rest. His peripheral smear is given in the image below. What is the most likely diagnosis?

Accepted Answer

Megaloblastic anemia

Answer

Autoimmune hemolytic anemia

Answer

Immune thrombocytopenic purpura

Answer

PNH

Answer

Iron deficiency anemia

Question 2

Which of the following is seen in the peripheral smear?

Accepted Answer

Band cells, tear drop cells, hyposegmented neutrophils

Answer

Smudge cells, tear drop cells, hyposegmented neutrophils

Answer

Lacunar cells, tear drop cells, atypical lymphocytes

Answer

Reed-Sternberg cells, tear drop cells, atypical monocytes

Answer

Auer rods, schistocytes, hypersegmented neutrophils

Question 3

Which defect in RBC is shown below?

Accepted Answer

Basophilic stippling

Answer

Cabot ring

Answer

Heinz bodies

Answer

Toxic granules

Answer

Howell-Jolly bodies

Question 4

Peripheral smear shown below depicts:

Accepted Answer

Hairy WBC

Answer

Schistocytes

Answer

Acanthocytes

Answer

Smudge cells

Answer

Atypical lymphocytes

Question 5

Spot the diagnosis.

Accepted Answer

Dimorphic anemia

Answer

Thalassemia

Answer

Megaloblastic anemia

Answer

G6PD deficiency

Answer

Iron deficiency anemia

Question 6

A 6-year-old girl presents with bilateral cervical lymphadenopathy and fever for 3 weeks, night sweats and weight loss. Photomicrograph of lymph node biopsy is given. Diagnosis is:

Accepted Answer

Hodgkin's lymphoma

Answer

Non-Hodgkin's lymphoma

Answer

Chronic lymphocytic leukemia

Answer

Acute lymphocytic leukemia

Answer

Reactive lymphadenitis

Question 7

A 12-year-old boy presents with bilateral cervical lymphadenopathy for the last 2 years. Biopsy from the lymph node shows the following picture. Which of the following is the correct set of diagnosis, etiology and the cell described?

Accepted Answer

Hodgkin's lymphoma; Epstein-Barr virus and Reed-Sternberg cells

Answer

Tuberculosis, Mycobacterium and Tiny granuloma

Answer

Hodgkin's lymphoma; Epstein-Barr virus and orphan annie eye nucleus

Answer

Non-Hodgkin's lymphoma; HIV and popcorn cell

Answer

Infectious mononucleosis; Epstein-Barr virus and Downey cells

Question 8

Blood smear of a patient with G6PD deficiency shows:

Accepted Answer

Heinz bodies

Answer

Howell jolly bodies

Answer

Cabot rings

Answer

Pelger-Huet anomaly

Answer

Bite cells

Question 9

A 35-year-old presented with fever. On examination he had enlarged and ulcerated tonsils. Since peripheral smear shows lymphocytosis, monospot test was done which is negative. Tonsillectomy was done and stained section is shown below. Large cells mixed with lymphocytes are seen. The cells are positive for CD20, EBVLMP-1, MUM1, CD 79a and CD 15 negative. The background cells are positive for CD3. Diagnosis is: (AIIMS May 2017)

Accepted Answer

EBV positive- mucocutaneous ulcer

Answer

Infectious mononucleosis

Answer

Hodgkin lymphoma

Answer

EBV positive- DLBCL

Answer

Burkitt lymphoma

Question 10

A 70-year-old man presents with history of intractable diarrhea. His bone marrow and kidney biopsy are shown below. Which of the following is the most appropriate diagnosis?

Accepted Answer

Multiple myeloma

Answer

Leishmaniasis

Answer

Lymphoma

Answer

Urate nephropathy

Answer

Amyloidosis

Hematopathology — MCQs

Hematopathology — MCQs

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