Hematology Practice Questions

Q: An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 69 g/dl - WBC 4000/cm3 with normal differential count - Serum calcium 13 mg/dl - Creatinine 2.3 mg/dl - Total protein 9 g/dl - Albumin 2.4 g/dl

Multiple myeloma. ***Multiple myeloma*** - The combination of **anemia** (Hb - 69 g/dl), **renal insufficiency** (creatinine 2.3 mg/dl), **hypercalcemia** (serum calcium 13 mg/dl), and **osteolytic lesions** on X-ray spine is highly characteristic of multiple myeloma, often remembered by the acronym **CRAB** (Calcium elevation, Renal failure, Anemia, Bone lesions) [1]. - The **elevated total protein** (9 g/dl) with a relatively low albumin (2.4 g/dl) suggests a **paraproteinemia**, a hallmark of multiple myeloma caused by the overproduction of monoclonal antibodies [1]. *Milk alkali syndrome* - This syndrome is characterized by **hypercalcemia**, **metabolic alkalosis**, and **renal insufficiency**, usually due to excessive intake of calcium and absorbable alkali. While hypercalcemia and renal dysfunction are present, the absence of metabolic alkalosis and the presence of osteolytic lesions make this less likely. - It does not typically cause **anemia** or **osteolytic lesions**, and the high total protein is not a feature. *Metastatic breast cancer* - While metastatic breast cancer can cause **osteolytic lesions** and **hypercalcemia**, it typically presents with a primary breast mass or a history of breast cancer [2]. - The **elevated total protein** with a narrowed albumin-globulin gap is not a characteristic feature of metastatic breast cancer unless it also involves multiple myeloma, which is less common. *Primary hyperparathyroidism* - This condition is characterized by **elevated parathyroid hormone (PTH)** leading to **hypercalcemia** and, in severe cases, bone disease (osteitis fibrosa cystica). - Unlike the patient's presentation, primary hyperparathyroidism typically does not cause **anemia** or such pronounced **renal failure** (though kidney stones are common), nor does it lead to significantly elevated total protein with a low albumin.

Q: An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 6.9 g/dl

Multiple myeloma. ***Multiple myeloma*** - The combination of **osteolytic lesions** (bone pain, tenderness), **hypercalcemia** (confusion, thirst), **anemia** (Hb 69 g/dl, pallor), and **renal insufficiency** (confusion, thirst from dehydration) is highly suggestive of **multiple myeloma** [1]. - This plasma cell malignancy leads to excessive production of monoclonal antibodies and bone destruction [1]. *Vertebral compression fracture* - While **thoracic spine tenderness** and osteolytic lesions could be a component, it doesn't fully explain the systemic symptoms such as **anemia**, **confusion**, and **hypercalcemia**. - A simple compression fracture would not account for the profound **anemia** (Hb 69 g/dl) seen in this patient. *Metastatic carcinoma* - While metastatic carcinoma can cause **osteolytic lesions**, **anemia**, and sometimes **hypercalcemia**, the specific constellation of symptoms, particularly the severity of anemia and rapid progression, makes **multiple myeloma** a more fitting diagnosis. - Absence of primary tumor indicates that it is not a metastatic disease [1]. *Osteoporosis* - **Osteoporosis** can cause vertebral fractures and bone pain but typically does not lead to **osteolytic lesions**, **severe anemia**, or **hypercalcemia** [2]. - The bone changes in osteoporosis are primarily due to decreased bone density, not destructive lesions [2].

Q: A 19-year-old woman comes to the physician because of a 1-month history of mild fatigue and weakness. Physical examination shows no abnormalities. Her hemoglobin concentration is 11 g/dL and mean corpuscular volume is 74 μm3. Hemoglobin electrophoresis shows 10% HbA2 (normal < 3.5%). Which of the following is the most likely diagnosis?

Beta thalassemia minor. ***Beta thalassemia minor*** - The combination of **microcytic anemia** (MCV 74 µm3), mild fatigue, and significantly **elevated HbA2** (10%) is highly characteristic of beta thalassemia minor. - In beta thalassemia minor, there is reduced production of beta-globin chains, leading to a compensatory increase in **alpha-globin chains** [1] that combine with delta-globin chains to form more **HbA2**. *Hemoglobin Barts disease* - **Hemoglobin Barts disease** is a severe form of alpha thalassemia, where all four alpha-globin genes are deleted. - It results in **hydrops fetalis** and is incompatible with life, presenting in the perinatal period, not in a 19-year-old with mild symptoms. *Hemoglobin H disease* - **Hemoglobin H disease** is another form of alpha thalassemia caused by the deletion of three alpha-globin genes. - Patients typically present with **moderate to severe microcytic hypochromic anemia**, and **HbH** (beta-4 tetramers) is usually detectable on electrophoresis [2], not elevated HbA2. *Alpha thalassemia minima* - **Alpha thalassemia minima** (silent carrier) involves the deletion of only one alpha-globin gene and is usually **asymptomatic**, often presenting with no or very mild microcytosis. - It does not cause a significant increase in **HbA2** or noticeable anemia as described. *Sickle cell trait* - **Sickle cell trait** is characterized by the presence of both **HbA** and **HbS** (usually 35-45% HbS) on electrophoresis [2], and typically does not cause anemia or microcytosis. - While it can sometimes be associated with a slightly elevated HbA2, the 10% HbA2 level is more indicative of **beta thalassemia minor** in the context of microcytic anemia.

Q: Which type of anemia is seen in patients of rheumatoid arthritis?

Normocytic and normochromic anemia. The anemia seen in **rheumatoid arthritis (RA)** is typically **anemia of chronic disease**, characterized by **normal-sized red blood cells (normocytic)** and **normal hemoglobin content (normochromic)**. This type of anemia is caused by **chronic inflammation** leading to impaired iron utilization and reduced erythropoiesis [1], [2]. This type of anemia is associated with inflammation-mediated upregulation of hepcidin [1]. Although iron deficiency can coexist in RA patients, the primary anemia of chronic disease mechanism generally results in normochromic cells [2].

Q: Which type of anaemia is seen in vitamin B12 deficiency?

Macrocytic anemia. ***Macrocytic anemia*** - Vitamin B12 is essential for **DNA synthesis**, and its deficiency leads to impaired nuclear maturation and delayed cell division in erythroid precursors, resulting in abnormally large red blood cells called **megaloblasts**. - This impaired maturation process leads to the production of **macrocytic red blood cells** (high MCV) which are also often prematurely destroyed, contributing to the anemia. *Dimorphic anemia* - This term describes the presence of **two distinct red cell populations**, typically microcytic and macrocytic, which can occur with combined deficiencies such as iron and vitamin B12. - While vitamin B12 deficiency primarily causes macrocytic anemia, dimorphic anemia is not its standalone feature unless accompanied by another deficiency. *Microcytic anemia* - Characterized by **abnormally small red blood cells** (low MCV), typically seen in conditions like **iron deficiency anemia** or thalassemia. - Vitamin B12 deficiency causes large red blood cells, thus ruling out microcytic anemia. *Normocytic anemia* - Red blood cells are of **normal size** (normal MCV) but are reduced in number, often seen in conditions like **anemia of chronic disease** or acute blood loss. - Since vitamin B12 deficiency directly impacts red blood cell size by causing megaloblastic changes, normocytic anemia is not the primary presentation.

Q: Which type of gout is seen in a patient who is on treatment of CML?

Secondary gout. ***Secondary gout*** - **Secondary gout** occurs when a high uric acid level is a consequence of another medical condition or its treatment, such as **chronic myelogenous leukemia (CML)** [1]. - The increased cell turnover in CML, especially during treatment, leads to a significant release of **purines**, which are then metabolized into **uric acid**, causing hyperuricemia and gout [1]. *Pseudogout* - **Pseudogout** is caused by the deposition of **calcium pyrophosphate dihydrate (CPPD)** crystals, not uric acid crystals, in the joints [2]. - While it can mimic gout attacks, it has a different underlying pathophysiology and is not directly linked to CML or its treatment. *Acute gout* - **Acute gout** describes the sudden onset of severe pain, swelling, and redness in a joint, which is a common presentation of any type of gout, whether primary or secondary. - This term refers to a **gout flare** rather than the underlying cause of the hyperuricemia. *Primary gout* - **Primary gout** occurs due to an intrinsic metabolic defect in purine metabolism or renal excretion of uric acid, without an identifiable underlying disease [1]. - In this scenario, the gout is secondary to CML and its treatment, making **primary gout** an incorrect classification [1].

Q: What is the most likely diagnosis in an individual with normal serum alkaline phosphatase, normal PTH, normal Vitamin D3, and elevated serum calcium?

Multiple myeloma. ***Multiple myeloma*** [4] - This condition is often associated with **osteolytic lesions** that lead to the release of calcium into the blood, causing **hypercalcemia**. - **PTH**, **alkaline phosphatase**, and **Vitamin D3** levels are typically normal in this scenario because their regulatory pathways are not primarily affected [1]. *Nutritional rickets* [2] - Characterized by **low calcium** and **phosphate levels**, usually with **elevated alkaline phosphatase** and **PTH** due to inadequate vitamin D or calcium intake [3]. - This patient exhibits **elevated serum calcium**, ruling out rickets. *Hyperparathyroidism* - Both **primary** and **secondary hyperparathyroidism** would present with **elevated PTH** levels, which is stated as normal in the case description [1]. - **Hypercalcemia** in hyperparathyroidism is caused by bone resorption and increased renal reabsorption of calcium, driven by high PTH [5]. *Vitamin D intoxication* - Would lead to **hypercalcemia** and **elevated Vitamin D3** levels, alongside **suppressed PTH** levels, which contradicts the described normal PTH and normal Vitamin D3 [1]. - The excessive vitamin D would increase calcium absorption from the gut and bone resorption not seen here.

Q: Complication of blood transfusion can be all except -

Metabolic alkalosis. ***Metabolic alkalosis*** - **Metabolic alkalosis** is generally not a direct complication of blood transfusion, as transfused blood typically has a buffering effect or contributes to acidosis due to stored products. - While citrate, a component of transfused blood, is metabolized to bicarbonate, leading to a theoretical alkalosis, clinically significant metabolic alkalosis is rare and overshadowed by other potential imbalances. *Hyperkalemia* - **Hyperkalemia** can occur, especially with massive transfusions or in patients with impaired renal function, due to the leakage of potassium from red blood cells during storage. - The breakdown of stored red blood cells releases intracellular potassium into the plasma of the stored blood product. *Citrate toxicity* - **Citrate toxicity** is a known complication, particularly with rapid or massive transfusions, as citrate in stored blood binds to calcium, leading to hypocalcemia. - This can result in symptoms such as paresthesias, tetany, and cardiac arrhythmias if not managed appropriately. *Hypothermia* - **Hypothermia** is a common complication, especially with rapid or massive transfusions of refrigerated blood products. - Administering large volumes of cold intravenous fluids can significantly lower the patient's core body temperature.

Q: Treatment of choice in intracranial ALL is:

Intrathecal methotrexate. ***Intrathecal methotrexate*** - **Intrathecal methotrexate** is the cornerstone of central nervous system (CNS) prophylaxis and treatment for **intracranial acute lymphoblastic leukemia (ALL)** due to its ability to reach high concentrations in the cerebrospinal fluid (CSF). - It is highly effective in eradicating leukemic cells in the **CNS**, preventing leptomeningeal relapse, and is often combined with other intrathecal agents or cranial radiation. *Intrathecal vincristine* - **Vincristine** is primarily an intravenous chemotherapeutic agent and is **neurotoxic** when administered intrathecally, potentially causing severe and irreversible neurological damage, including paralysis and death. - Therefore, **intrathecal vincristine** is contraindicated due to its severe adverse effects on the CNS. *Vincristine and prednisolone* - **Vincristine** and **prednisolone** are systemic agents typically administered intravenously and orally, respectively, and are crucial components of **induction and consolidation therapy** for ALL. - However, their ability to penetrate the **blood-brain barrier** is limited, making them ineffective for directly treating or preventing intracranial ALL. *Prednisolone* - **Prednisolone** is a corticosteroid used systemically for its **anti-inflammatory** and **cytotoxic effects** on leukemic cells, particularly in inducing remission in ALL. - While it can partially penetrate the **blood-brain barrier**, its concentration in the CSF is usually insufficient to effectively treat or prevent established **intracranial ALL** on its own.

Question 1

An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis?

- Hb - 69 g/dl
- WBC 4000/cm3 with normal differential count
- Serum calcium 13 mg/dl
- Creatinine 2.3 mg/dl
- Total protein 9 g/dl
- Albumin 2.4 g/dl

Accepted Answer

Multiple myeloma

Answer

Milk alkali syndrome

Answer

Metastatic breast cancer

Answer

Primary hyperparathyroidism

Question 2

An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis?

- Hb - 6.9 g/dl

Accepted Answer

Multiple myeloma

Answer

Vertebral compression fracture

Answer

Metastatic carcinoma

Answer

Osteoporosis

Question 3

A 19-year-old woman comes to the physician because of a 1-month history of mild fatigue and weakness. Physical examination shows no abnormalities. Her hemoglobin concentration is 11 g/dL and mean corpuscular volume is 74 μm3. Hemoglobin electrophoresis shows 10% HbA2 (normal < 3.5%). Which of the following is the most likely diagnosis?

Accepted Answer

Beta thalassemia minor

Answer

Hemoglobin Barts disease

Answer

Hemoglobin H disease

Answer

Alpha thalassemia minima

Answer

Sickle cell trait

Question 4

A 63-year-old man with a history of diabetes mellitus presents with complaints of fatigue. He lives alone and has not seen a doctor in 10 years. He does not exercise, eats a poor diet, and drinks 1-2 beers per day. He does not smoke. He has never had a colonoscopy. Labs show a hemoglobin of 8.9 g/dL (normal 13.5 - 17.5), mean corpuscular volume of 70 fL (normal 80-100), serum ferritin of 400 ng/mL (normal 15-200), TIBC 200 micrograms/dL (normal 250-420), and serum iron 50 micrograms/dL (normal 65-150). Which of the following is the cause of his abnormal lab values?

Accepted Answer

Chronic inflammation

Answer

Vitamin deficiency

Answer

Mineral deficiency

Answer

Occult bleeding

Answer

Mineral excess

Question 5

Which type of anemia is seen in patients of rheumatoid arthritis?

Accepted Answer

Normocytic and normochromic anemia

Answer

Normocytic and hypochromic anemia

Answer

Sideroblastic anemia

Answer

Macrocytic anemia

Question 6

Which type of anaemia is seen in vitamin B12 deficiency?

Accepted Answer

Macrocytic anemia

Answer

Dimorphic anemia

Answer

Microcytic anemia

Answer

Normocytic anemia

Question 7

Which type of gout is seen in a patient who is on treatment of CML?

Accepted Answer

Secondary gout

Answer

Pseudogout

Answer

Acute gout

Answer

Primary gout

Question 8

What is the most likely diagnosis in an individual with normal serum alkaline phosphatase, normal PTH, normal Vitamin D3, and elevated serum calcium?

Accepted Answer

Multiple myeloma

Answer

Nutritional rickets

Answer

Hyperparathyroidism

Answer

Vitamin D intoxication

Question 9

Complication of blood transfusion can be all except -

Accepted Answer

Metabolic alkalosis

Answer

Hyperkalemia

Answer

Citrate toxicity

Answer

Hypothermia

Question 10

Treatment of choice in intracranial ALL is:

Accepted Answer

Intrathecal methotrexate

Answer

Intrathecal vincristine

Answer

Vincristine and prednisolone

Answer

Prednisolone

Hematology — MCQs

Hematology — MCQs

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