Hematology Practice Questions

Q: A 40-year-old man with a 10-year history of diabetes, currently on medication, presents with abdominal pain, weakness, lightheadedness, palpitations, and shortness of breath. On examination, he has glossitis, hyperpigmentation of the skin on the dorsum of his hands and feet, and abnormal hair pigmentation. His family reports increased irritability over the past year. Laboratory findings include Hb: 9 gm%, MCV: 110 fl, MCH: 36 Pg, MCHC: 34 gm/dl, Reticulocyte count: 0.1 x 10^9/L, LDH: 600 U/L, Indirect bilirubin: 1 mg/dL, S. iron: Normal, S. Ferritin: Normal, WBC: 2 x 10^9/L, and Platelet count: 90 x 10^9/L. Peripheral blood smear and bone marrow aspiration findings are also noted. Which of the following drugs is the patient most likely taking?

Metformin. The patient presents with classic features of **Megaloblastic Anemia** due to **Vitamin B12 (Cobalamin) deficiency**. **1. Why Metformin is the Correct Answer:** Metformin is a first-line oral hypoglycemic agent known to cause Vitamin B12 deficiency in up to 30% of patients, especially with long-term use (as seen in this 10-year history). It interferes with the **calcium-dependent absorption** of the B12-intrinsic factor complex in the terminal ileum. * **Clinical Clues:** Glossitis, hyperpigmentation (a high-yield dermatological finding in B12 deficiency), and neuropsychiatric symptoms (irritability). * **Laboratory Clues:** Macrocytic anemia (MCV 110 fl), pancytopenia (low WBC and Platelets), and markers of **ineffective erythropoiesis** (elevated LDH and indirect bilirubin due to intramedullary hemolysis) [1]. **2. Why Other Options are Incorrect:** * **Pioglitazone (Thiazolidinedione):** Primarily associated with fluid retention, weight gain, and heart failure exacerbation; it does not cause macrocytic anemia. * **Vildagliptin (DPP-4 Inhibitor):** Generally weight-neutral and does not affect B12 absorption or hematological parameters. * **Exenatide (GLP-1 Agonist):** Associated with gastrointestinal side effects and weight loss, but not specifically linked to B12 deficiency or pancytopenia. **3. NEET-PG High-Yield Pearls:** * **Hyperpigmentation:** While B12 deficiency is usually associated with pallor, skin hyperpigmentation (knuckles/dorsum of hands) is a characteristic board-exam finding. * **Ineffective Erythropoiesis:** High LDH + Low Reticulocyte Count + Macrocytosis = Think B12/Folate deficiency [1]. * **Metformin Monitoring:** ADA guidelines suggest periodic monitoring of B12 levels in metformin-treated patients, especially those with anemia or peripheral neuropathy.

Q: A patient presents with microcytic hypochromic anemia, Hb of 9 g/dL, serum iron of 20 µg/dL, ferritin level of 800 ng/mL, and transferrin saturation of 64%. What is the most likely diagnosis?

Atransferrinemia. **Explanation:** The clinical presentation of microcytic hypochromic anemia with paradoxical iron overload (high ferritin and high transferrin saturation) is the hallmark of **Atransferrinemia** (Congenital Hypotransferrinemia). **1. Why Atransferrinemia is correct:** In this rare autosomal recessive disorder, there is a deficiency of transferrin, the primary protein responsible for transporting iron to the bone marrow for erythropoiesis [1]. * **Anemia:** Without transferrin, iron cannot be delivered to developing RBCs, leading to iron-deficient erythropoiesis and **microcytic hypochromic anemia** [1]. * **Iron Overload:** Because iron is not being utilized by the marrow, it deposits in peripheral tissues (liver, heart, pancreas). This results in **very high serum ferritin** and **high transferrin saturation** (since the total iron-binding capacity is extremely low, even a small amount of iron saturates the available protein). **2. Why other options are incorrect:** * **Iron Deficiency Anemia:** Characterized by **low** ferritin and **low** transferrin saturation [2]. * **DMT1 Mutation:** While it causes microcytic anemia and systemic iron overload, the serum iron and transferrin saturation are typically normal or low because the defect lies in iron transport *into* the cell, not transport *in the plasma*. * **Sideroblastic Anemia:** While it shows high ferritin and saturation, the primary defect is in heme synthesis within the mitochondria (often showing ring sideroblasts). Atransferrinemia is a more specific fit for the combination of profound transferrin deficiency and systemic overload. **Clinical Pearls for NEET-PG:** * **Atransferrinemia** is a "Paradoxical Iron State": Tissue iron overload + Erythroid iron deficiency. * **Treatment:** Periodic infusions of plasma or purified transferrin. * **Differential for High Ferritin + Microcytic Anemia:** Sideroblastic anemia, Thalassemia, Lead poisoning, and Atransferrinemia [2].

Q: Which of the following findings is generally NOT seen in idiopathic thrombocytopenic purpura (ITP)?

Palpable splenomegaly. **Explanation:** **1. Why Palpable Splenomegaly is the Correct Answer:** In Idiopathic Thrombocytopenic Purpura (ITP), platelet destruction occurs via anti-platelet antibodies (IgG) in the reticuloendothelial system, primarily the spleen [1]. However, this process does not typically lead to splenic congestion or hyperplasia significant enough to cause organomegaly. **The presence of a palpable spleen in a patient with thrombocytopenia should prompt a search for alternative diagnoses**, such as leukemia, lymphoma, portal hypertension, or systemic lupus erythematosus (SLE) [3]. In ITP, the spleen is usually normal in size. **2. Analysis of Incorrect Options:** * **A. More common in females:** Chronic ITP is classically seen in young to middle-aged women (female-to-male ratio of approximately 3:1), making this a typical finding. * **B. Petechiae, ecchymosis, and bleeding:** These are the hallmark clinical manifestations of "mucocutaneous bleeding" caused by a low platelet count (thrombocytopenia) [2], [3]. * **D. Increased megakaryocytes in bone marrow:** Since ITP is a peripheral destruction disorder, the bone marrow responds by increasing platelet production. This results in a compensatory increase in the number and size of megakaryocytes. **3. Clinical Pearls for NEET-PG:** * **Diagnosis of Exclusion:** ITP is diagnosed only after ruling out other causes of thrombocytopenia [1]. * **First-line Treatment:** Corticosteroids (e.g., Prednisolone) or IVIG. * **Splenectomy:** Considered the most effective second-line treatment for chronic refractory ITP. * **Key Rule:** If a question mentions "massive splenomegaly" and "thrombocytopenia," think of Myelofibrosis or Malaria/Kala-azar, never ITP.

Q: A 23-year-old asymptomatic female presents with MCV of 70 fL, ferritin of 100 ng/mL, and Hb of 10 gm%. Which of the following is the most likely cause?

Thalassemia trait. ### Explanation The correct answer is **Thalassemia trait**. **1. Why Thalassemia Trait is Correct:** The patient presents with **microcytic anemia** (MCV 70 fL, Hb 10 gm%). The key to distinguishing the cause lies in the **ferritin level (100 ng/mL)**, which is well within the normal range (normal: 15–150 ng/mL). * In **Thalassemia trait**, there is a genetic defect in globin chain synthesis, leading to microcytosis. However, iron stores remain normal or even slightly elevated because the pathology is not iron deficiency. * A classic NEET-PG clue is an **asymptomatic** patient with a disproportionately low MCV relative to a mild anemia, often accompanied by a Mentzer Index (MCV/RBC count) < 13. **2. Why Other Options are Incorrect:** * **Iron Deficiency (B):** This is the most common cause of microcytic anemia, but it is characterized by **low ferritin** ( 100 fL)** (macrocytosis), contrary to the 70 fL seen here [1]. **3. NEET-PG High-Yield Pearls:** * **Mentzer Index:** MCV ÷ RBC count. If ** 13**, suspect Iron Deficiency Anemia (IDA). * **Gold Standard Diagnosis:** For β-Thalassemia trait, the investigation of choice is **Hb Electrophoresis/HPLC**, showing elevated **HbA2 (>3.5%)**. * **RDW (Red Cell Distribution Width):** Usually normal in Thalassemia trait (homogenous cell population) but increased in IDA (anisocytosis). * **Ferritin** is the most sensitive initial lab test for diagnosing Iron Deficiency Anemia.

Q: Which of the following indicates the worst prognosis in Chronic Lymphocytic Leukemia (CLL) patients?

Hemoglobin level less than 10 g/dL. The prognosis of Chronic Lymphocytic Leukemia (CLL) is primarily determined by the extent of bone marrow failure and the total tumor burden, as defined by the Rai and Binet staging systems [1]. **Why Option C is Correct:** A hemoglobin level of **<10 g/dL** (or a platelet count <100,000/mm³) signifies **Rai Stage IV** or **Binet Stage C**. This indicates advanced disease where the bone marrow is heavily infiltrated by leukemic lymphocytes, leading to hematopoietic failure [1]. This stage carries the worst prognosis, with a median survival of approximately 1.5 to 3.5 years [1]. **Analysis of Incorrect Options:** * **Options A & B:** Lymphadenopathy (Rai Stage I) and Hepatosplenomegaly (Rai Stage II) represent intermediate-risk disease. While they indicate a higher tumor burden than isolated lymphocytosis (Stage 0), they do not signify bone marrow failure and thus have a significantly better prognosis than anemia or thrombocytopenia [1]. * **Option D:** While a very high White Blood Cell (WBC) count reflects a high tumor burden, the absolute lymphocyte count itself is not a primary staging criterion for prognosis in the Rai or Binet systems. Patients can have very high counts for years without clinical deterioration. **High-Yield Clinical Pearls for NEET-PG:** * **Rai Staging:** Stage 0 (Lymphocytosis only), Stage I (Nodes), Stage II (Spleen/Liver), Stage III (Anemia), Stage IV (Thrombocytopenia). * **Poor Prognostic Markers:** 17p deletion (TP53 mutation), 11q deletion, ZAP-70 expression, and unmutated IGHV. * **Good Prognostic Marker:** 13q deletion (isolated). * **Richter Transformation:** Sudden clinical worsening or rapid lymph node growth in a CLL patient suggests transformation into Diffuse Large B-cell Lymphoma (DLBCL).

Q: A pregnant lady in her second trimester has a hemoglobin level of 6 mg%. The gynecologist suggests IV transfusion of packed red cells. What is the most common oral change due to nutritional anemia?

Atrophic glossitis. The patient presents with severe anemia (Hb 6 g/dL) during pregnancy, which is most commonly due to **Iron Deficiency Anemia (IDA)** [1] or megaloblastic anemia (folate/B12 deficiency) [2]. **Why Atrophic Glossitis is correct:** Nutritional anemias lead to a high turnover rate of the oral mucosal cells. In iron deficiency, there is a depletion of iron-dependent intracellular enzymes, leading to the atrophy of the **filiform papillae** (and later fungiform papillae) on the dorsum of the tongue. This results in **Atrophic Glossitis**, characterized by a smooth, red, and "glazed" appearance of the tongue. It is often accompanied by angular cheilitis and burning sensations (glossodynia). **Analysis of Incorrect Options:** * **A. Enlarged tongue (Macroglossia):** This is typically seen in conditions like amyloidosis, hypothyroidism (myxedema), or acromegaly, rather than nutritional anemia. * **C. Generalized osteolysis:** This refers to bone destruction, commonly seen in Multiple Myeloma or metastatic bone disease, not anemia. * **D. Focal marrow expansion:** While chronic hemolytic anemias (like Thalassemia) cause marrow hyperplasia leading to "crew-cut" appearance on X-ray, it is not a common *oral* mucosal change of nutritional anemia. **High-Yield Clinical Pearls for NEET-PG:** * **Plummer-Vinson Syndrome (Paterson-Kelly Syndrome):** A classic triad of Iron deficiency anemia, Atrophic glossitis, and Esophageal webs. It carries an increased risk of post-cricoid carcinoma. * **Pernicious Anemia:** Often presents with **Hunter’s glossitis** (beefy red tongue). * **Oral manifestations of IDA:** Atrophic glossitis, angular cheilitis, and oral candidiasis.

Q: Which of the following is NOT a recognized cause of neutropenia?

Corticosteroid therapy. **Explanation:** The correct answer is **A. Corticosteroid therapy**. **1. Why Corticosteroids cause Neutrophilia (not Neutropenia):** Corticosteroids are a classic cause of **neutrophilia** (increased neutrophil count). This occurs through three primary mechanisms: * **Demargination:** They decrease the expression of adhesion molecules (like L-selectin), causing neutrophils to move from the endothelial walls (marginal pool) into the circulating blood. * **Delayed Apoptosis:** They extend the lifespan of mature neutrophils. * **Marrow Release:** They stimulate the premature release of neutrophils from the bone marrow. * *Note:* While they increase neutrophils, corticosteroids simultaneously cause **lymphopenia** [1] and **eosinopenia**. **2. Analysis of Incorrect Options (Causes of Neutropenia):** * **Typhoid Fever:** Unlike most bacterial infections that cause leukocytosis, enteric fever (Salmonella typhi) is a classic cause of leukopenia and neutropenia due to bone marrow suppression and increased peripheral destruction. * **Aplastic Anemia:** This is characterized by pancytopenia (reduction in RBCs, WBCs, and platelets) due to bone marrow failure. Neutropenia is a core component. * **Viral Infections:** Many viruses (e.g., Hepatitis, HIV, EBV, Influenza) cause transient neutropenia through redistribution or direct marrow suppression [1]. **Clinical Pearls for NEET-PG:** * **Drug-induced Neutropenia:** Common culprits include Clozapine, Antithyroid drugs (Methimazole/PTU), and Chemotherapy [1]. * **Felty’s Syndrome:** A high-yield triad of Rheumatoid Arthritis, Splenomegaly, and **Neutropenia**. * **Kostmann Syndrome:** A severe congenital neutropenia (autosomal recessive). * **Left Shift:** Corticosteroid-induced neutrophilia usually does *not* show a significant "left shift" (immature bands), unlike an acute bacterial infection.

Q: A 70-year-old male has been experiencing intermittent epistaxis, fatigue, and pain in bones for the past 4 months. Laboratory investigations are as follows: Serum Ca++: 12 mg/dL. This patient is likely to develop which complication?

Amyloidosis. **Explanation:** The clinical presentation of a 70-year-old male with **bone pain, fatigue (anemia), epistaxis (bleeding diathesis), and hypercalcemia (12 mg/dL)** is a classic triad for **Multiple Myeloma (MM)**. In MM, the neoplastic proliferation of plasma cells leads to the overproduction of monoclonal light chains (paraproteins). **Why Amyloidosis is the Correct Answer:** In Multiple Myeloma, excess light chains (specifically Lambda or Kappa) can undergo misfolding and deposit in various tissues as insoluble fibrils. This condition is known as **AL (Light Chain) Amyloidosis**. Approximately 10–15% of patients with Multiple Myeloma develop clinical amyloidosis, which can lead to organ dysfunction (macroglossia, restrictive cardiomyopathy, or nephrotic syndrome). **Analysis of Incorrect Options:** * **A & D (Floppy Mitral Valve / Calcific Aortic Valve):** While hypercalcemia can theoretically lead to metastatic calcification, it does not typically manifest as isolated valvular disease in the context of plasma cell dyscrasias. These are degenerative or connective tissue disorders unrelated to MM. * **B (Autoimmune Hemolytic Anemia):** AIHA is more commonly associated with **Chronic Lymphocytic Leukemia (CLL)** or Non-Hodgkin Lymphoma, rather than Multiple Myeloma. Anemia in MM is usually normocytic normochromic due to marrow infiltration and renal failure. **High-Yield Clinical Pearls for NEET-PG:** * **CRAB Criteria for MM:** **C**alcium elevation, **R**enal insufficiency, **A**nemia, **B**one lesions [1]. * **Bleeding in MM:** Epistaxis occurs due to "Platelet Coating" by paraproteins, interfering with aggregation [1]. * **Diagnosis:** Look for "punched-out" lytic lesions on X-ray and M-spike on Serum Protein Electrophoresis (SPEP) [1]. * **Amyloid Staining:** Congo Red stain showing **apple-green birefringence** under polarized light.

Question 1

A patient presents with abundant spherocytes in the peripheral blood and a positive family history of anemia and splenectomy. All of the following statements regarding his condition are true, except:

Accepted Answer

The most common mode of inheritance is autosomal recessive.

Answer

Coombs test should be done to exclude an immunological cause.

Answer

Cholecystectomy may be required in the future.

Answer

Splenectomy may be required.

Question 2

A 40-year-old man with a 10-year history of diabetes, currently on medication, presents with abdominal pain, weakness, lightheadedness, palpitations, and shortness of breath. On examination, he has glossitis, hyperpigmentation of the skin on the dorsum of his hands and feet, and abnormal hair pigmentation. His family reports increased irritability over the past year. Laboratory findings include Hb: 9 gm%, MCV: 110 fl, MCH: 36 Pg, MCHC: 34 gm/dl, Reticulocyte count: 0.1 x 10^9/L, LDH: 600 U/L, Indirect bilirubin: 1 mg/dL, S. iron: Normal, S. Ferritin: Normal, WBC: 2 x 10^9/L, and Platelet count: 90 x 10^9/L. Peripheral blood smear and bone marrow aspiration findings are also noted. Which of the following drugs is the patient most likely taking?

Accepted Answer

Metformin

Answer

Pioglitazone

Answer

Vildagliptin

Answer

Exenatide

Question 3

Splenomegaly and reticulocytosis are typically absent in which type of anaemia?

Accepted Answer

Aplastic anaemia

Answer

G-6 PD deficiency anaemia

Answer

Myeloblastic anaemia

Answer

Iron deficiency anaemia

Question 4

A patient presents with microcytic hypochromic anemia, Hb of 9 g/dL, serum iron of 20 µg/dL, ferritin level of 800 ng/mL, and transferrin saturation of 64%. What is the most likely diagnosis?

Accepted Answer

Atransferrinemia

Answer

Iron deficiency anemia

Answer

DMT1 mutation

Answer

Sideroblastic anemia

Question 5

Which of the following findings is generally NOT seen in idiopathic thrombocytopenic purpura (ITP)?

Accepted Answer

Palpable splenomegaly

Answer

More common in females

Answer

Petechiae, ecchymosis, and bleeding

Answer

Increased megakaryocytes in bone marrow

Question 6

A 23-year-old asymptomatic female presents with MCV of 70 fL, ferritin of 100 ng/mL, and Hb of 10 gm%. Which of the following is the most likely cause?

Accepted Answer

Thalassemia trait

Answer

Vitamin B12 deficiency

Answer

Iron deficiency

Answer

Folate deficiency

Question 7

Which of the following indicates the worst prognosis in Chronic Lymphocytic Leukemia (CLL) patients?

Accepted Answer

Hemoglobin level less than 10 g/dL

Answer

Presence of lymphadenopathy

Answer

Presence of hepatosplenomegaly

Answer

WBC count exceeding 1,00,000 cells/mL

Question 8

A pregnant lady in her second trimester has a hemoglobin level of 6 mg%. The gynecologist suggests IV transfusion of packed red cells. What is the most common oral change due to nutritional anemia?

Accepted Answer

Atrophic glossitis

Answer

Enlarged tongue

Answer

Generalized osteolysis

Answer

Focal marrow expansion

Question 9

Which of the following is NOT a recognized cause of neutropenia?

Accepted Answer

Corticosteroid therapy

Answer

Typhoid fever

Answer

Aplastic anemia

Answer

Viral infection

Question 10

A 70-year-old male has been experiencing intermittent epistaxis, fatigue, and pain in bones for the past 4 months. Laboratory investigations are as follows: Serum Ca++: 12 mg/dL. This patient is likely to develop which complication?

Accepted Answer

Amyloidosis

Answer

Floppy mitral valve

Answer

Autoimmune hemolytic anemia

Answer

Calcific aortic valve disease

Hematology — MCQs

Hematology — MCQs

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