Hematopathology Practice Questions

Q: The Hb is 5 g/dL and the reticulocyte count is 9%. What is the corrected reticulocyte count?

3. ***3*** - The **corrected reticulocyte count (CRC)** is calculated to adjust for varying degrees of anemia, providing a more accurate assessment of bone marrow erythropoietic activity. The formula is: **CRC = observed reticulocyte % × (patient's HCT / normal HCT)**. - Assuming a normal hematocrit (HCT) of 45% and a direct hemoglobin to hematocrit conversion of 1:3 for 5 g/dL Hb (so HCT = 15%), then CRC = 9% × (15/45) = 9% × 1/3 = **3%**. *5* - This value is likely obtained by an **incorrect calculation** or by applying an inappropriate correction factor. - It does not properly account for the **severity of anemia** in the calculation of the corrected reticulocyte count [2]. *1.8* - This result may represent confusion with the **Reticulocyte Production Index (RPI)**, which further corrects for premature reticulocyte release by dividing CRC by a maturation time factor (typically 1.5-2 in severe anemia) [1]. - However, the question specifically asks for the **corrected reticulocyte count**, not the RPI, making this an inappropriate over-correction. *4.5* - This value might be a result of **dividing the observed reticulocyte count by a factor of 2**, which is not the standard correction for anemia. - It does not accurately reflect the **bone marrow's response** to the severe anemic state. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 586-587. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 590-591.

Q: Identify the given bone marrow biopsy instrument

Jamshidi needle. ***Jamshidi needle*** - The image displays a **Jamshidi needle**, characterized by its **tapered, beveled tip** designed to facilitate entry into the bone and procure an intact core of bone marrow. - This needle is widely considered the **gold standard** for bone marrow biopsy due to its effectiveness in obtaining high-quality trephine samples. *Salah needle* - A Salah needle is primarily used for **bone marrow aspiration**, not typically for a trephine biopsy, and it has a different design meant for aspirating liquid marrow. - It features a **shorter, sturdier design** with a sharp bevel, optimized for safely extracting marrow fluid. *Tru-cut needle* - The Tru-cut needle is primarily designed for obtaining **soft tissue biopsies** (e.g., liver, kidney, prostate) and is not typically used for bone marrow biopsies. - Its mechanism involves an inner cutting stylet and an outer cutting cannula, which is unsuitable for penetrating dense bone and retrieving a bone core. *Vim Silverman needle* - The Vim Silverman needle is also designed for **soft tissue biopsies**, similar to the Tru-cut, and not specifically for bone marrow. - It utilizes a split needle design to capture tissue, which is not appropriate for obtaining a solid bone marrow core.

Q: Which of the following cells is shown in the given image?

Hairy cell. ***Hairy cell*** - The image displays prominent **cytoplasmic projections** or "hairs" on the cell surface, which are characteristic features of **hairy cells** (lymphocytes seen in hairy cell leukemia) [1]. - These cells typically have an irregularly shaped nucleus and cytoplasm rich in ribosomes, as suggested by the granular appearance [1]. *Sickle cell* - **Sickle cells** are **red blood cells** that have a characteristic crescent or sickle shape due to abnormal hemoglobin polymerization. - The cell in the image is a **white blood cell** with a large nucleus and cytoplasmic extensions, clearly not a red blood cell. *Gaucher cell* - **Gaucher cells** are **macrophages** that accumulate glucocerebroside, giving them a characteristic **"crinkled paper"** or **"chicken scratch"** cytoplasm. - While they are large cells, they lack the distinct, fine, hair-like projections seen in the provided image. *Target cell* - **Target cells** are **red blood cells** with a central bullseye appearance due to an abnormal distribution of hemoglobin, often seen in thalassemia or liver disease. - The presented image is not a red blood cell and does not demonstrate the morphology of a target cell. **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.

Q: Which of the following are characteristic laboratory findings in Iron Deficiency Anemia (IDA)? 1. Low serum ferritin 2. Low transferrin saturation 3. Low serum iron 4. Increased TIBC

All of the above. ***All of the above (1, 2, 3, and 4)*** - **All listed parameters are characteristic findings in Iron Deficiency Anemia (IDA):** - **Low serum ferritin** - Indicates depleted iron stores; most specific early marker [1] - **Low serum iron** - Reflects reduced circulating iron availability [1] - **Low transferrin saturation** - Shows decreased percentage of iron-bound transferrin molecules (typically <15%) [1] - **Increased TIBC** - Compensatory increase in total iron-binding capacity as the liver produces more transferrin to capture available iron [1] *Why not just 1, 2, and 3?* - Increased TIBC is also a hallmark finding in IDA, distinguishing it from anemia of chronic disease (where TIBC is typically low) [1] *Why not just 3 and 4?* - Serum ferritin and transferrin saturation are equally important diagnostic parameters [1] *Why not just 1, 3, and 4?* - Low transferrin saturation is a key diagnostic criterion for IDA [1] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 657-660.

Q: The graphical representation for flow cytometry analysis is done by which of the following?

Histogram, dot plot. ***Histogram, dot plot*** - **Histograms** are used in flow cytometry to display the distribution of a single parameter (e.g., cell size, fluorescence intensity) across the cell population. - **Dot plots** are used to visualize the relationship between two or more parameters, allowing for the identification of distinct cell populations based on multiple characteristics. *Pie chart, dot plot* - **Pie charts** are typically used to represent proportions of a whole, which is not the primary way flow cytometry data is presented for detailed cell analysis. - While dot plots are correct, the combination with pie charts makes this option less accurate for typical flow cytometry analysis. *Line diagram, dot plot* - **Line diagrams** are generally used to show trends over time or continuous relationships, which is not the standard graphical representation for direct flow cytometry output. - Although dot plots are used, the inclusion of line diagrams makes this option incorrect in the context of typical flow cytometry data visualization. *Bar diagram, dot plot* - **Bar diagrams** are often used for comparing discrete categories or counting occurrences, not for displaying continuous distributions or multi-parameter relationships in flow cytometry directly. - While dot plots are correct, the pairing with bar diagrams does not represent the common and most informative graphical methods for flow cytometry analysis.

Q: A boy presents with fever, night sweats, and neck swelling. The biopsy of swelling showed a starry sky appearance. What is the most likely genetic abnormality seen in this case?

MYC. ***MYC*** - The clinical presentation of **fever, night sweats, and neck swelling** in a child, coupled with a **starry sky appearance** on biopsy, is highly suggestive of **Burkitt lymphoma** [2, 3]. - **Burkitt lymphoma** is characterized by a **translocation involving the *MYC* gene** on chromosome 8, most commonly t(8;14), which leads to its overexpression and uncontrolled cell proliferation [1]. *RAS* - Mutations in the **RAS family of genes (HRAS, KRAS, NRAS)** are commonly found in a wide variety of cancers, including **leukemias, pancreatic cancer, and colorectal cancer**. - While *RAS* mutations drive proliferation, they are **not the primary genetic driver** of Burkitt lymphoma, nor are they linked to the characteristic starry sky appearance. *BCR-ABL* - The **BCR-ABL fusion gene**, resulting from the **Philadelphia chromosome (t(9;22))**, is the defining genetic abnormality of **chronic myeloid leukemia (CML)**. - CML presents with different symptoms and a distinct peripheral blood and bone marrow morphology, **not the "starry sky" appearance** seen in Burkitt lymphoma. *p53* - The **p53 tumor suppressor gene** is frequently mutated or inactivated in over half of all human cancers, leading to a loss of cell cycle control and apoptosis. - While **p53 mutations can occur in aggressive lymphomas**, including Burkitt lymphoma, the **primary and characteristic genetic abnormality** associated with Burkitt lymphoma and its presentation is the *MYC* translocation, not solely *p53* mutations. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 324-325. [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, pp. 605-606. [3] 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. 606.

Q: A patient with lytic lesions on the skull is suspected of a diagnosis of Langerhans cell histiocytosis. Which of the following is a characteristic finding on electron microscopy?

Birbeck granules. ***Birbeck granules*** - **Birbeck granules** are rod-shaped organelles with a striated core and a dilated end, resembling a "tennis racket," which are pathognomonic for **Langerhans cells** and, by extension, **Langerhans cell histiocytosis** [1]. - Their presence on **electron microscopy** is a definitive diagnostic feature for LCH [1]. *Eosinophils* - While **eosinophils** are often seen infiltrating lesions in **Langerhans cell histiocytosis**, they are not the diagnostic cellular component or ultrastructural finding on electron microscopy [1]. - **Eosinophils** are granulocytes involved in allergic reactions and parasitic infections; their appearance on EM is distinct from Birbeck granules. *Histiocytes* - **Histiocytes** (macrophages) are present in various inflammatory and neoplastic conditions and are the cell lineage from which **Langerhans cells** are derived, but their general presence on **electron microscopy** is not specific enough for diagnosing **LCH** [1]. - Without the characteristic **Birbeck granules**, a generic histiocyte would not distinguish LCH from other histiocytic disorders [1]. *Giant cells* - **Giant cells**, such as **multinucleated giant cells** or **osteoclasts**, can be found in association with bone lesions including **lytic lesions**, but they are not specific to **Langerhans cell histiocytosis** and do not possess Birbeck granules. - Their presence points to bone destruction or inflammation but not the underlying cellular pathology of LCH. **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. 630.

Q: Which of the following can be prevented by transfusing irradiated RBCs?

Graft versus host disease. Graft versus host disease - **Irradiation** of red blood cell (RBC) products inactivates proliferating donor **T-lymphocytes**, which are responsible for mediating transfusion-associated **graft-versus-host disease (TA-GVHD)**. - TA-GVHD is a severe and often fatal complication where donor immune cells attack recipient tissues. *HLA Alloimmunization* - **HLA alloimmunization** is prevented by **leukoreduction**, which removes donor leukocytes expressing HLA antigens, not by irradiation. - Irradiation targets the proliferative capacity of T-lymphocytes, but does not remove the cells themselves or prevent the presentation of HLA antigens. *Transfusion Related Acute Lung Injury (TRALI)* - **TRALI** is primarily associated with **donor antibodies** (anti-HLA or anti-HNA) in plasma that react with recipient neutrophils, leading to lung injury. - It is prevented by selecting plasma donors who have not been pregnant or by using male-only plasma, not by irradiating RBCs. *Immunomodulation* - **Transfusion-related immunomodulation (TRIM)** is a broad effect associated with multiple blood components, including cytokines and biological response modifiers in the transfused products. - While leukoreduction may reduce some aspects of TRIM, irradiation is not specifically used to prevent or reduce this phenomenon.

Q: Which is the cell of origin of Chronic Lymphocytic Leukaemia / Small Lymphocytic Lymphoma?

Naïve B cells. ***Naïve B cells*** - Chronic Lymphocytic Leukaemia (CLL) and Small Lymphocytic Lymphoma (SLL) originate from **CD5-positive B lymphocytes** arrested in a mature but **naïve differentiation stage** [1]. - These cells express both **B-cell markers (CD19, CD20, CD23)** and a T-cell marker (CD5), which is characteristic of the clone [4]. *Mature B cells* - While CLL/SLL are derived from B cells, they are specifically from **naïve, not fully mature, B cells**. - **Other B-cell lymphomas** like follicular lymphoma or mantle cell lymphoma originate from distinct stages of mature B-cell differentiation [2]. *Progenitor T cells* - **Progenitor T cells** are the cells of origin for **T-cell acute lymphoblastic leukaemia (T-ALL)**, not CLL/SLL [3]. - T-ALL involves immature T lymphocytes and presents with different clinical and immunophenotypic features [3]. *Mature T cells* - **Mature T cells** can give rise to various **peripheral T-cell lymphomas**, like peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) or cutaneous T-cell lymphoma (Mycosis Fungoides). - These are distinct from CLL/SLL, which is a B-cell neoplasm [4]. **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, pp. 596-598. [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, pp. 610-612. [3] 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, pp. 598-599. [4] 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. 598.

Q: Which of the following causes aplastic crisis in hereditary spherocytosis?

Parvovirus. ***Parvovirus*** - **Parvovirus B19** specifically targets and destroys **erythroid precursors** in the bone marrow, leading to a temporary cessation of red blood cell production [1]. - In patients with conditions like **hereditary spherocytosis** who already have chronic hemolysis and increased erythropoiesis, this interruption can cause a sudden and severe drop in hemoglobin, known as an **aplastic crisis** [1]. *Poxvirus* - Poxviruses primarily cause **skin lesions** and systemic symptoms like fever and malaise, with diseases such as smallpox or molluscum contagiosum. - They are not known to directly cause **aplastic crisis** by targeting erythroid progenitors. *Adenovirus* - Adenoviruses commonly cause **respiratory tract infections**, gastroenteritis, and conjunctivitis. - While they can cause various symptoms, they are not typically associated with **aplastic crisis** in the context of hereditary spherocytosis. *Epstein-Barr virus* - **Epstein-Barr virus (EBV)** is known to cause **infectious mononucleosis** and is associated with certain lymphomas and nasopharyngeal carcinoma. - Although it can rarely cause **hemophagocytic lymphohistiocytosis** leading to pancytopenia, it does not typically induce **aplastic crisis** in hereditary spherocytosis by directly targeting erythroid precursors. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 641-642.

Question 1

The Hb is 5 g/dL and the reticulocyte count is 9%. What is the corrected reticulocyte count?

Accepted Answer

3

Answer

5

Answer

1.8

Answer

4.5

Question 2

Identify the given bone marrow biopsy instrument

Accepted Answer

Jamshidi needle

Answer

Salah needle

Answer

Tru-cut needle

Answer

Vim Silverman needle

Question 3

Which of the following cells is shown in the given image?

Accepted Answer

Hairy cell

Answer

Sickle cell

Answer

Gaucher cell

Answer

Target cell

Question 4

Which of the following are characteristic laboratory findings in Iron Deficiency Anemia (IDA)?

1. Low serum ferritin
2. Low transferrin saturation
3. Low serum iron
4. Increased TIBC

Accepted Answer

All of the above

Answer

3 and 4 only

Answer

1, 3, and 4 only

Answer

1 and 2 only

Question 5

The graphical representation for flow cytometry analysis is done by which of the following?

Accepted Answer

Histogram, dot plot

Answer

Pie chart, dot plot

Answer

Line diagram, dot plot

Answer

Bar diagram, dot plot

Question 6

A boy presents with fever, night sweats, and neck swelling. The biopsy of swelling showed a starry sky appearance. What is the most likely genetic abnormality seen in this case?

Accepted Answer

MYC

Answer

RAS

Answer

BCR-ABL

Answer

p53

Question 7

A patient with lytic lesions on the skull is suspected of a diagnosis of Langerhans cell histiocytosis. Which of the following is a characteristic finding on electron microscopy?

Accepted Answer

Birbeck granules

Answer

Eosinophils

Answer

Histiocytes

Answer

Giant cells

Question 8

Which of the following can be prevented by transfusing irradiated RBCs?

Accepted Answer

Graft versus host disease

Answer

HLA Alloimmunization

Answer

Transfusion Related Acute Lung Injury (TRALI)

Answer

Immunomodulation

Question 9

Which is the cell of origin of Chronic Lymphocytic Leukaemia / Small Lymphocytic Lymphoma?

Accepted Answer

Naïve B cells

Answer

Mature B cells

Answer

Progenitor T cells

Answer

Mature T cells

Question 10

Which of the following causes aplastic crisis in hereditary spherocytosis?

Accepted Answer

Parvovirus

Answer

Poxvirus

Answer

Adenovirus

Answer

Epstein-Barr virus

Hematopathology — MCQs

Hematopathology — MCQs

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