Hematology Practice Questions

Q: Macrocytic anemia occurs in all except?

Copper deficiency. **Explanation:** The correct answer is **Copper deficiency**. In hematology, macrocytic anemia (MCV >100 fL) is broadly divided into megaloblastic and non-megaloblastic causes. **1. Why Copper Deficiency is the correct answer:** Copper is an essential cofactor for **hephaestin** and **ceruloplasmin**, which are required for iron transport and utilization. Copper deficiency typically presents as **Microcytic Hypochromic Anemia** (due to defective iron mobilization) or **Normocytic Anemia**. A classic high-yield finding in copper deficiency is **sideroblastic changes** and **neutropenia**, often mimicking Myelodysplastic Syndrome (MDS). **2. Analysis of Incorrect Options:** * **Thiamine (B1) Deficiency:** Specifically, **Thiamine-Responsive Megaloblastic Anemia (TRMA)** or Rogers Syndrome is a rare genetic disorder characterized by megaloblastic anemia, non-type 1 diabetes, and sensorineural deafness. * **Liver Disease:** This is a classic cause of **non-megaloblastic macrocytosis**. Increased cholesterol deposition on the RBC membrane leads to increased surface area (target cells) and macrocytosis. * **Orotic Aciduria:** This is an autosomal recessive disorder of pyrimidine synthesis. It presents with **megaloblastic anemia** [1] that does not respond to B12 or Folate [2], along with failure to thrive and orotic acid crystals in the urine. **Clinical Pearls for NEET-PG:** * **Megaloblastic Macrocytosis:** B12/Folate deficiency [2], Drugs (Methotrexate, Phenytoin, Hydroxyurea), Orotic aciduria. * **Non-Megaloblastic Macrocytosis:** Alcoholism (most common), Liver disease, Hypothyroidism, Pregnancy, and Reticulocytosis. * **Copper Deficiency Clue:** Look for a history of gastric bypass surgery or excessive zinc ingestion (zinc induces metallothionein which sequesters copper).

Q: Which of the following is NOT true about multiple myeloma?

Increased alkaline phosphatase. In Multiple Myeloma (MM), the characteristic bone lesions are purely **osteolytic**. This is due to the activation of osteoclasts (via RANKL) and the simultaneous inhibition of osteoblasts [1]. Since **Alkaline Phosphatase (ALP)** is a marker of osteoblastic activity (bone formation), its levels typically remain **normal** in MM, despite extensive bone destruction [1]. This is a classic "trap" in NEET-PG questions, as most other bone-destroying pathologies (like bony metastases or Paget’s disease) show elevated ALP. **Explanation of Options:** * **Option D (Correct):** ALP is not increased because there is no compensatory osteoblastic activity in MM. If ALP is elevated in a myeloma patient, one should suspect a pathological fracture or an alternative diagnosis. * **Option A (Incorrect):** Hyperuricemia is common due to high cell turnover and increased nucleic acid breakdown, especially during treatment (Tumor Lysis Syndrome). * **Option B (Incorrect):** Increased urea (Azotemia) occurs due to **Myeloma Kidney**. Renal failure is caused by Bence-Jones proteinuria (cast nephropathy), hypercalcemia, and amyloidosis [1]. * **Option C (Incorrect):** Hypercalcemia is a hallmark of MM (part of the **CRAB** criteria), resulting from massive osteoclast-mediated bone resorption. **High-Yield Clinical Pearls for NEET-PG:** 1. **CRAB Criteria:** **C**alcium (↑), **R**enal failure, **A**nemia, **B**one lesions [1]. 2. **Radiology:** "Punched-out" lytic lesions on a skeletal survey; **Technetium-99m bone scans are often negative** (as they detect osteoblastic activity) [1]. 3. **Diagnosis:** M-spike on Serum Protein Electrophoresis (SPEP) and >10% clonal plasma cells on bone marrow biopsy [1]. 4. **Blood Film:** Rouleaux formation due to high globulin levels [1].

Q: A 67-year-old male presents with severe pain in the right foot and paleness of the right toe. He received unfractionated heparin 7 days prior. His hemogram shows: Hb – 13.2 g/dL, WBC – 10000/mm³, Platelet – 50000/mm³. Which of the following should be used to treat this condition?

Argatroban. **Explanation:** The clinical presentation of a patient developing thrombocytopenia and arterial thrombosis (the "white clot" syndrome causing foot pain and paleness) approximately 7 days after starting heparin is classic for **Heparin-Induced Thrombocytopenia (HIT) Type II**. **1. Why Argatroban is correct:** HIT is caused by IgG antibodies against the **Heparin-Platelet Factor 4 (PF4) complex**, leading to massive platelet activation and a paradoxical prothrombotic state. The first step in management is the immediate cessation of all heparin products. To maintain anticoagulation and prevent further thrombosis, a **Direct Thrombin Inhibitor (DTI)** like **Argatroban** (or Lepirudin/Danaparoid) must be started [1]. Argatroban is preferred in patients with renal impairment as it is hepatically cleared. **2. Why the other options are incorrect:** * **High dose Heparin:** This would be catastrophic, as it provides more substrate for the antibody-mediated reaction, worsening the thrombosis. * **Platelet infusions:** Generally contraindicated in HIT. Adding more platelets is like "adding fuel to the fire," potentially increasing the risk of thrombotic events. * **Warfarin:** Should **never** be used as monotherapy in the acute phase of HIT. It can cause a rapid drop in Protein C levels, leading to **venous limb gangrene** or skin necrosis. It should only be started once the platelet count has recovered to >150,000/mm³. **Clinical Pearls for NEET-PG:** * **The 4T Score:** Used clinically to assess the probability of HIT (Thrombocytopenia, Timing, Thrombosis, and oTher causes). * **Timing:** HIT typically occurs **5–10 days** after heparin exposure [1]. * **Diagnosis:** Initial screening with **ELISA (anti-PF4)**; Gold standard confirmatory test is the **Serotonin Release Assay (SRA)**. * **Management Rule:** Stop Heparin → Start DTI (Argatroban) → Delay Warfarin.

Q: Which of the following is NOT true about Idiopathic Thrombocytopenic Purpura (ITP)?

Splenomegaly is not essential for the diagnosis of ITP.. ### Explanation **Understanding the Correct Answer (Option C)** In Immune Thrombocytopenic Purpura (ITP), the pathophysiology involves the peripheral destruction of platelets by anti-platelet antibodies (IgG) [1]. While this destruction occurs primarily in the spleen, the spleen itself is **not typically enlarged**. In fact, the presence of significant splenomegaly should prompt a clinician to look for alternative diagnoses, such as leukemia, lymphoma, or portal hypertension. Therefore, the statement "Splenomegaly is not essential for the diagnosis" is medically accurate, making it the correct choice in the context of this question. **Analysis of Other Options** * **Option A:** This statement is **False**. In pediatric ITP, the majority of cases (approx. 80%) are acute and self-limiting, often following a viral infection. Conservative management or short-term steroids/IVIG are preferred; splenectomy is reserved only for chronic, refractory cases. * **Option B:** This statement is **True**. Splenectomy is a second-line treatment that produces complete remission in about 70% of patients [2]. Many patients respond well to corticosteroids (first-line), Rituximab, or TPO-receptor agonists (Eltrombopag/Romiplostim) [2]. * **Option D:** This statement is **False**. IVIG is highly effective in adults, especially when a rapid rise in platelet count is required (e.g., life-threatening bleed or emergency surgery). **NEET-PG High-Yield Pearls** * **First-line treatment:** Corticosteroids (Prednisolone or high-dose Dexamethasone). * **Bone Marrow Finding:** Increased or normal megakaryocytes (compensatory response to peripheral destruction). * **Diagnosis of Exclusion:** ITP is diagnosed only after ruling out other causes of thrombocytopenia [1]. * **Indication for treatment:** Generally started when platelets are <20,000–30,000/µL or if there is significant mucosal bleeding [1].

Q: A patient presents with renal failure and bone pain. X-rays show evidence of skeletal destruction. Laboratory evaluation reveals hypercalcemia. Serum electrophoresis shows a prominent M spike. Tissue biopsy shows plasmacytoma. Bone marrow shows plasmacytosis with 35 percent plasma cells. What is the most likely diagnosis?

Multiple Myeloma. The patient presents with the classic triad of **Multiple Myeloma (MM)**: bone destruction, renal insufficiency, and monoclonal protein proliferation. [1] **1. Why Multiple Myeloma is correct:** According to the International Myeloma Working Group (IMWG) criteria, a diagnosis of MM requires: * **Clonal bone marrow plasma cells ≥10%** (Patient has 35%) OR biopsy-proven extramedullary plasmacytoma. * **CRAB features** (Evidence of end-organ damage): **C**alcium elevation, **R**enal insufficiency, **A**nemia, or **B**one lesions. [1] This patient satisfies both criteria with hypercalcemia, renal failure, skeletal destruction, and 35% plasma cells. **2. Why other options are incorrect:** * **Plasmacytoma:** This refers to a solitary mass of neoplastic plasma cells. While the patient has a plasmacytoma, the presence of systemic involvement (bone marrow >10% and CRAB features) upgrades the diagnosis to Multiple Myeloma. * **MGUS (Monoclonal Gammopathy of Undetermined Significance):** Characterized by M-protein <3 g/dL, bone marrow plasma cells <10%, and **no** CRAB features. * **Smoldering Myeloma:** Characterized by M-protein ≥3 g/dL or bone marrow plasma cells 10–60%, but crucially, there is **no** end-organ damage (CRAB features). **Clinical Pearls for NEET-PG:** * **M-Spike:** Usually IgG (most common) or IgA. [1] * **Peripheral Smear:** Look for **Rouleaux formation** due to high protein levels. * **Bence-Jones Proteins:** Free light chains in urine (not detected by routine dipstick). * **Radiology:** "Punched-out" lytic lesions; Bone scans are often negative (as there is no osteoblastic activity). [1] * **Renal Failure:** Most commonly due to "Myeloma Kidney" (cast nephropathy).

Q: A 19-year-old man presents with recurrent knee bleeding during contact sports. He has no history of spontaneous bleeding, but his brother has similar issues. He is diagnosed with "mild" hemophilia A. Which of the following factor abnormalities is consistent with this diagnosis?

Decreased levels of functional factor VIII. **Explanation:** **Hemophilia A** is an X-linked recessive bleeding disorder caused by a deficiency or dysfunction of **Clotting Factor VIII** [1]. The severity of the disease is directly correlated with the plasma levels of functional Factor VIII. 1. **Why Option B is correct:** In Hemophilia A, the primary pathology is a **quantitative or qualitative deficiency of Factor VIII**. "Mild" hemophilia is defined by Factor VIII levels between **5% and 40%** of normal. These patients typically do not bleed spontaneously but experience prolonged bleeding after significant trauma, surgery, or contact sports, as seen in this clinical vignette [1]. 2. **Why other options are incorrect:** * **Option A:** While abnormal function can occur, the standard diagnostic hallmark is the measurement of decreased *levels* of functional factor. Furthermore, "decreased levels" is a more encompassing term for the laboratory diagnosis. * **Option C:** Decreased Factor IX level is the hallmark of **Hemophilia B** (Christmas Disease). While clinically indistinguishable from Hemophilia A, it involves a different factor. * **Option D:** Decreased von Willebrand factor (vWF) characterizes **von Willebrand Disease (vWD)** [4]. While vWF stabilizes Factor VIII, vWD usually presents with mucosal bleeding (epistaxis, menorrhagia) rather than hemarthrosis (joint bleeding) [5]. **High-Yield Clinical Pearls for NEET-PG:** * **Severity Classification:** * Severe: 5–40% factor activity (Bleeding with major trauma/surgery) [1]. * **Lab Findings:** Prolonged **aPTT**, normal PT, and normal bleeding time. * **Treatment:** Recombinant Factor VIII concentrate. For mild cases, **Desmopressin (DDAVP)** can be used to release stored Factor VIII from endothelial cells [2].

Question 1

Macrocytic anemia occurs in all except?

Accepted Answer

Copper deficiency

Answer

Thiamine deficiency

Answer

Liver disease

Answer

Orotic aciduria

Question 2

A 72-year-old woman is admitted to the hospital with an acute illness. Her platelet count is incidentally noted to be 800,000/mL. For this patient with a blood-count anomaly, select the corresponding clinical situation and/or laboratory finding.

Accepted Answer

Acute hemorrhage

Answer

Post-splenectomy

Answer

Increased numbers of reticulocytes

Answer

Thiamine deficiency

Question 3

Which of the following is NOT true about multiple myeloma?

Accepted Answer

Increased alkaline phosphatase

Answer

Increased uric acid

Answer

Increased urea

Answer

Increased calcium

Question 4

Which of the following patients would LEAST likely require a bone marrow examination?

Accepted Answer

Adult with fever and a WBC of 20,000 cells/l with a left shift

Answer

Adult with pancytopenia and a normal mean corpuscular volume

Answer

Adult with a myeloproliferative disease

Answer

Adult with a monoclonal spike on a serum protein electrophoresis

Question 5

A 67-year-old male presents with severe pain in the right foot and paleness of the right toe. He received unfractionated heparin 7 days prior. His hemogram shows: Hb – 13.2 g/dL, WBC – 10000/mm³, Platelet – 50000/mm³. Which of the following should be used to treat this condition?

Accepted Answer

Argatroban

Answer

High dose of Heparin

Answer

Platelet infusions

Answer

Warfarin

Question 6

Which of the following is NOT true about Idiopathic Thrombocytopenic Purpura (ITP)?

Accepted Answer

Splenomegaly is not essential for the diagnosis of ITP.

Answer

Splenectomy is the treatment of choice in pediatric patients.

Answer

Splenectomy is not performed in all cases.

Answer

Intravenous immunoglobulin (IVIG) is not useful in adults.

Question 7

A patient presents with renal failure and bone pain. X-rays show evidence of skeletal destruction. Laboratory evaluation reveals hypercalcemia. Serum electrophoresis shows a prominent M spike. Tissue biopsy shows plasmacytoma. Bone marrow shows plasmacytosis with 35 percent plasma cells. What is the most likely diagnosis?

Accepted Answer

Multiple Myeloma

Answer

Plasmacytoma

Answer

MGUS

Answer

Smoldering Myeloma

Question 8

A 19-year-old man presents with recurrent knee bleeding during contact sports. He has no history of spontaneous bleeding, but his brother has similar issues. He is diagnosed with "mild" hemophilia A. Which of the following factor abnormalities is consistent with this diagnosis?

Accepted Answer

Decreased levels of functional factor VIII

Answer

Abnormal factor VIII function

Answer

Decreased factor IX level

Answer

Decreased von Willebrand factor

Question 9

A 48-year-old woman presented with a two-month history of weakness. Examination revealed enlarged cervical lymph nodes and a spleen palpable 2 cm below the costal margin. Her hemoglobin was 10.5 g/dL, platelet count was 237x10^9/L, and total leukocyte count was 40x10^9/L, including 80% mature lymphoid cells with coarse clumped chromatin. Bone marrow revealed nodular lymphoid infiltrate. Peripheral blood lymphoid cells were positive for CD19, CD5, CD20, and negative for CD79B and FMC-7. Which one of the following statements is not true about this disease?

Accepted Answer

A t(11;14) translocation is present in most cases.

Answer

Trisomy 12 correlates with an aggressive clinical course.

Answer

Abnormalities of 13q14 are associated with long-term survival.

Answer

Cases with 11q22-23 deletions have excessive lymphadenopathy.

Question 10

A transplant patient with serologic evidence of previous Epstein-Barr virus infection was on high levels of immunosuppressive medications. The patient presents with generalized lymphadenopathy, fever, night sweats, weight loss, abdominal pain, and tonsillitis. The dosage of immunosuppressive drugs was decreased, leading to regression of the lymphadenopathy. Which of the following is the most likely diagnosis for this patient?

Accepted Answer

Post-transplant lymphoproliferative disorder

Answer

Burkitt lymphoma

Answer

Hodgkin lymphoma

Answer

Infectious mononucleosis

Hematology — MCQs

Hematology — MCQs

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