Hematology Practice Questions

Q: Comment on the diagnosis in the patient shown below?

Hand and foot syndrome. ***Hand and foot syndrome*** - The image shows **swelling and dactylitis** of the fingers, along with a peripheral blood smear demonstrating **sickle cells** (indicated by arrows). This combination is characteristic of hand-foot syndrome, also known as **dactylitis**, which is often the first manifestation of **sickle cell disease** in infants and young children. - **Dactylitis** results from **vaso-occlusion** in the small bones of the hands and feet, leading to painful swelling. *Squaring of metacarpals* - **Squaring of metacarpals** is not a typical finding in sickle cell disease and does not correlate with the observed hand swelling and erythrocyte morphology. - This term is sometimes used to describe changes seen in conditions like **rheumatoid arthritis**, but not in the context of dactylitis associated with sickle cells. *Sub-periosteal resorption* - **Sub-periosteal resorption** is a hallmark radiological finding in **hyperparathyroidism**, affecting bones, typically in the phalanges. - It is not directly suggested by the hand swelling (which is soft tissue/marrow oedema) or the presence of sickle cells in the blood smear. *Peripheral oedema with iron deficiency anemia* - While the picture shows **peripheral oedema** (swelling), the concomitant finding of **sickle cells** in the blood smear strongly indicates **sickle cell disease**, not iron deficiency anemia. - **Iron deficiency anemia** typically presents with microcytic hypochromic red cells, not sickle-shaped cells, and while it can cause fatigue and pallor, it does not directly lead to the dactylitis seen here.

Q: An 8-year-old child of migrant construction worker presents with fever for last 2 weeks with progressive pallor. Complete blood counts reveal pancytopenia, malaria work up is negative, Total serum protein is 7 gm% with Serum Globulin of 4.5 gm%, serum albumin 3.5 mg%. Bone marrow study shows?

L.D bodies. ***L.D bodies*** - The image provided shows **macrophages** laden with numerous **Leishman-Donovan bodies**, which are intracellular amastigotes of *Leishmania* parasites. This bone marrow finding, in conjunction with **pancytopenia** and **fever with progressive pallor** in a child from a region where migrant workers live (suggesting possible exposure to endemic diseases), points strongly to **visceral leishmaniasis (kala-azar)**. - The elevated serum globulin and positive total serum protein differentiate from conditions like aplastic anemia. *Aplastic crisis* - An aplastic crisis results in **pancytopenia** but is characterized by a **hypocellular bone marrow** with a severe reduction in hematopoietic precursors. - It would not show the presence of **L.D. bodies** or hypergammaglobulinemia. *Myelofibrosis* - Myelofibrosis is characterized by **fibrotic bone marrow** and usually presents with cytopenias, but also often with **splenomegaly** and a leukoerythroblastic peripheral smear. - The bone marrow would show *fibrosis* and not parasitic inclusions. *Myeloid metaplasia* - Myeloid metaplasia (extramedullary hematopoiesis) is the presence of hematopoietic tissue outside the bone marrow, typically in the spleen or liver, and occurs in response to severe bone marrow dysfunction (e.g., myelofibrosis). - While it can be associated with pancytopenia, the primary bone marrow pathology here is parasitic infection, not a compensatory shift in hematopoiesis.

Q: What is the threshold for prophylactic administration of the following blood product?

$<10,000$. ***<10,000*** - The image clearly shows a bag labeled "PLATELETS." Prophylactic platelet transfusions are generally recommended when the **platelet count drops below 10,000/µL** in hemodynamically stable patients without additional risk factors for bleeding. - This threshold helps prevent **spontaneous hemorrhage**, especially in critically ill patients, as severe thrombocytopenia significantly increases the risk of serious bleeding events like intracranial hemorrhage. *<5,00* - A platelet count of **less than 5,000/µL** is an extremely low threshold, indicating a very high risk of spontaneous bleeding. - While transfusion would certainly be indicated at this level, the typical prophylactic threshold to prevent bleeding in stable patients is higher, at 10,000/µL. *<20,000* - A platelet count of **less than 20,000/µL** is a common threshold for prophylactic platelet transfusion when there are additional risk factors for bleeding, such as fever, sepsis, or certain medications. - However, for general prophylactic transfusion in *stable* patients without these additional risk factors, the lower threshold of <10,000/µL is usually applied. *<50,000* - A platelet count of **less than 50,000/µL** is typically the threshold for prophylactic platelet transfusion in patients who are undergoing (or about to undergo) an **invasive procedure** or surgery where hemostasis is critical. - It is not the general prophylactic threshold for preventing spontaneous bleeding in stable, non-surgical patients.

Q: A patient in ICU was given blood transfusion. 3 hours later SpO2 is reduced to 75% with respiratory difficulty. CVP is 15 cm water and PCWP is 25 mm Hg . CXR is shown below. What is the diagnosis?

Transfusion associated circulatory overload. ***Transfusion associated circulatory overload*** - The combination of **respiratory difficulty**, **reduced SpO2**, **elevated CVP (15 cm water)**, and **markedly elevated PCWP (25 mm Hg)** after a blood transfusion strongly indicates hydrostatic pulmonary edema due to fluid overload. - The CXR image showing **diffuse bilateral infiltrates** (pulmonary edema) further supports this diagnosis, especially with the elevated cardiac filling pressures. *Tension pneumothorax* - A tension pneumothorax would present with **unilateral lung collapse**, **tracheal deviation**, and potentially **hypotension**, none of which are explicitly described or suggested by the CXR. - While it causes respiratory distress, the hemodynamic parameters (CVP and PCWP) and bilateral CXR findings are inconsistent with a pneumothorax. *Transfusion related acute lung injury* - TRALI also causes acute respiratory distress and hypoxemia after transfusion, but it is characterized by **non-cardiogenic pulmonary edema** with a **normal or low CVP** and **normal or mildly elevated PCWP** (<18 mm Hg), differentiating it from TACO. - The elevated CVP and PCWP strongly point away from TRALI, which is immune-mediated and involves capillary leakage. *Mismatched blood transfusion* - An acute hemolytic transfusion reaction (mismatched blood transfusion) typically presents with symptoms such as **fever, chills, flank pain, hemoglobinuria**, and potentially **DIC** or **renal failure**. - While it's a serious transfusion reaction, the primary clinical presentation and elevated cardiac filling pressures are not characteristic of an acute hemolytic reaction.

Q: Which of the following is a prognostic marker for the patient whose urinary and serum electrophoresis report is given below?

Beta 2 microglobulin. ***Beta 2 microglobulin*** - The serum/urine electrophoresis shows a **monoclonal gamma spike**, which is characteristic of a **monoclonal gammopathy**, such as **multiple myeloma**. - **Beta 2 microglobulin** is a prognostic marker for multiple myeloma, reflecting **tumor burden** and **renal function**. *Beta 2 transferrin* - **Beta 2 transferrin** is a unique isoform of transferrin found in **cerebrospinal fluid (CSF)** and is used to detect CSF leaks. - It has no known role as a prognostic marker in **monoclonal gammopathies**. *Beta 2 glycoprotein* - **Beta 2 glycoprotein I** is involved in the coagulation cascade and is primarily associated with **antiphospholipid syndrome**. - It is not a prognostic marker for **monoclonal gammopathies**. *Beta 2 microalbumin* - The term **microalbumin** refers to a small amount of albumin in the urine, indicating **early kidney damage**. - While kidney involvement can occur in multiple myeloma, **beta 2 microalbumin** itself is not the primary prognostic marker in this context.

Q: The patient with the following hematological abnormality presents with severe chest pain and difficulty in breathing. All are useful for managing this emergency except:

Packed RBC. ***Packed RBC*** - Transfusing **packed red blood cells** will increase the overall hemoglobin concentration, which can paradoxically increase blood viscosity and worsen vaso-occlusion in sickle cell crisis, especially in the setting of acute chest syndrome where fluid overload is a concern. - This is generally avoided as a first-line treatment for acute chest syndrome in sickle cell anemia unless the patient has severe anemia with a hemoglobin level significantly below their baseline. *Partial exchange transfusion* - **Partial exchange transfusion** is a critical intervention during sickle cell crises with severe complications like acute chest syndrome. - It rapidly reduces the percentage of **sickle hemoglobin (HbS)** and concurrently provides normal red blood cells, improving oxygen-carrying capacity and reducing blood viscosity without significantly increasing total red blood cell mass. *Morphine* - **Morphine** is essential for effective pain management in sickle cell crisis, including the severe chest pain associated with acute chest syndrome. - Adequate pain control helps reduce patient distress and can indirectly prevent worsening of the crisis by reducing stress-induced sympathetic activation. *Hydroxyurea* - **Hydroxyurea** is a long-term disease-modifying therapy for sickle cell anemia, increasing the production of **fetal hemoglobin (HbF)**, which reduces sickling. - While crucial for preventing future crises and complications, it is not an acute treatment for an emergency like acute chest syndrome, as its effects take weeks to months to manifest.

Q: A patient with following peripheral smear and X-ray spine will present with:

Hand-foot syndrome. ***Hand-foot syndrome*** - The peripheral smear shows numerous **sickle cells** (elongated, crescent-shaped red blood cells), indicating **sickle cell anemia**. The X-ray depicts **H-shaped vertebrae** or "fish-mouth vertebrae", which is a characteristic finding in sickle cell disease due to chronic bone infarcts. - **Hand-foot syndrome (dactylitis)** is an initial presentation of sickle cell anemia in infants and young children, characterized by painful swelling of the hands and feet caused by **vaso-occlusion** in the small bones. *Black urine* - **Black urine (alkaptonuria)** is associated with an inborn error of metabolism where homogentisic acid accumulates, leading to ochronosis, not sickle cell disease. - This symptom is not typical for the peripheral smear and X-ray findings presented. *Elevated haptoglobin* - Haptoglobin binds to **free hemoglobin** and is *decreased* in hemolytic anemias like sickle cell disease, as accelerated red blood cell destruction leads to its consumption. - Therefore, an elevated haptoglobin level would argue against **hemolytic anemia**. *Splenomegaly with gallstones* - While chronic hemolysis in sickle cell disease can lead to **gallstones** (pigment gallstones), most patients with sickle cell anemia develop **autosplenectomy** (functional asplenia) by childhood or early adulthood due to repeated splenic infarcts, rather than persistent splenomegaly. - Splenomegaly can occur in early childhood but typically regresses as the spleen undergoes fibrosis.

Q: Which is shown in the peripheral smear of patient with metallic heart prosthesis?

MAHA. ***MAHA*** - Metallic heart valve prostheses can cause **Microangiopathic Hemolytic Anemia (MAHA)** due to mechanical shearing of red blood cells as they pass through the turbulent flow around the valve. - The peripheral smear in MAHA typically shows **schistocytes** (fragmented red blood cells), which are represented by the irregular, fragmented pink structures in the image, mixed with intact red blood cells. *AIHA* - **Autoimmune Hemolytic Anemia (AIHA)** is characterized by immune-mediated red blood cell destruction, often showing **spherocytes** on the peripheral smear, which are not depicted here. - The mechanism involves antibodies attacking red blood cells, rather than mechanical destruction. *Echinocytes* - **Echinocytes (burr cells)** are red blood cells with uniformly spaced, short, blunt projections on their surface, often seen in uremia or artifactually. - The fragmented cells shown in the image are distinctly different from echinocytes. *Dimorphic anemia* - **Dimorphic anemia** is a condition where two distinct populations of red blood cells (e.g., microcytic hypochromic and macrocytic) are present, typically due to combined deficiencies like iron and folate/B12. - The image mainly shows fragmented red blood cells and normal red blood cells, not two distinct populations based on size and hemoglobin content.

Q: Which of the following is seen with the peripheral smear shown in the picture below?

Beefy tongue. ***Beefy tongue*** - The peripheral smear shows **hypersegmented neutrophils** and **macrocytic red blood cells**, which are characteristic findings in **megaloblastic anemia**. - **Beefy tongue** (glossitis) is a classic oral manifestation of **vitamin B12 deficiency**, a common cause of megaloblastic anemia. *Magenta tongue* - **Magenta tongue** is typically associated with **riboflavin (vitamin B2) deficiency**, not megaloblastic anemia. - While nutritional deficiencies can coexist, this specific tongue presentation is not directly linked to the red blood cell morphology shown. *Geographic tongue* - **Geographic tongue** (benign migratory glossitis) is a common inflammatory condition of the tongue characterized by irregular, red patches that resemble maps. - It is generally considered benign and not directly associated with the hematological findings seen in the image. *Black hairy tongue* - **Black hairy tongue** is a harmless condition where the papillae on the tongue become elongated and discolored, often due to poor oral hygiene, smoking, or certain medications. - This condition is not related to the hematological abnormalities depicted in the peripheral smear.

Question 1

Comment on the diagnosis in the patient shown below?

Accepted Answer

Hand and foot syndrome

Answer

Squaring of metacarpals

Answer

Sub-periosteal resorption

Answer

Peripheral oedema with iron deficiency anemia

Question 2

An 8-year-old child of migrant construction worker presents with fever for last 2 weeks with progressive pallor. Complete blood counts reveal pancytopenia, malaria work up is negative, Total serum protein is 7 gm% with Serum Globulin of 4.5 gm%, serum albumin 3.5 mg%. Bone marrow study shows?

Accepted Answer

L.D bodies

Answer

Aplastic crisis

Answer

Myelofibrosis

Answer

Myeloid metaplasia

Question 3

What is the threshold for prophylactic administration of the following blood product?

Accepted Answer

$<10,000$

Answer

$<5,000$

Answer

$<20,000$

Answer

$<50,000$

Question 4

A patient in ICU was given blood transfusion. 3 hours later SpO2 is reduced to 75% with respiratory difficulty. CVP is 15 cm water and PCWP is 25 mm Hg . CXR is shown below. What is the diagnosis?

Accepted Answer

Transfusion associated circulatory overload

Answer

Tension pneumothorax

Answer

Transfusion related acute lung injury

Answer

Mismatched blood transfusion

Question 5

Which of the following is a prognostic marker for the patient whose urinary and serum electrophoresis report is given below?

Accepted Answer

Beta 2 microglobulin

Answer

Beta 2 transferrin

Answer

Beta 2 glycoprotein

Answer

Beta 2 microalbumin

Question 6

The patient with the following hematological abnormality presents with severe chest pain and difficulty in breathing. All are useful for managing this emergency except:

Accepted Answer

Packed RBC

Answer

Partial exchange transfusion

Answer

Morphine

Answer

Hydroxyurea

Question 7

A patient with following peripheral smear and X-ray spine will present with:

Accepted Answer

Hand-foot syndrome

Answer

Black urine

Answer

Elevated haptoglobin

Answer

Splenomegaly with gallstones

Question 8

A 45-year-old person has complaints of paresthesia in hand and feet with progressive spastic weakness. On examination, absent ankle jerk with Babinski sign is noted. Peripheral smear and MRI spine were performed. The diagnosis is:

Accepted Answer

Macrocytic anemia

Answer

Lead poisoning

Answer

Miller Fisher syndrome

Answer

Devic's disease

Question 9

Which is shown in the peripheral smear of patient with metallic heart prosthesis?

Accepted Answer

MAHA

Answer

AIHA

Answer

Echinocytes

Answer

Dimorphic anemia

Question 10

Which of the following is seen with the peripheral smear shown in the picture below?

Accepted Answer

Beefy tongue

Answer

Magenta tongue

Answer

Geographic tongue

Answer

Black hairy tongue

Hematology — MCQs

Hematology — MCQs

On this page

Practice by Chapter

Want unlimited practice?