Hematopathology Practice Questions

Q: Which of the following is true about iron deficiency anemia?

Microcytic hypochromic anemia. ***Microcytic hypochromic anemia*** - **Iron deficiency anemia** is characterized by red blood cells that are **smaller than normal (microcytic)** and **paler than normal (hypochromic)** due to insufficient hemoglobin [1]. - This morphology is a classic finding on a **peripheral blood smear** and reflects the impaired heme synthesis caused by iron depletion [1]. *Bone marrow iron stores are depleted before serum iron levels drop* - This statement is incorrect because **serum ferritin levels**, which reflect **iron stores**, are typically the first to decrease, even before changes in serum iron or hemoglobin are evident. - **Bone marrow iron stores** (assessed by biopsy) would also be depleted early on, but changes in serum ferritin and iron saturation can be detected before a significant drop in serum iron. *TIBC is typically decreased in this condition* - This is incorrect; **total iron-binding capacity (TIBC)** is typically **increased** in iron deficiency anemia, not decreased. - The liver produces more **transferrin** (the protein that binds iron) in an attempt to capture any available iron, leading to a higher TIBC. *Ferritin levels are elevated in this condition* - This is incorrect; **ferritin levels** are typically **decreased** in iron deficiency anemia. - **Ferritin** is a storage protein for iron, and its levels correlate with the body's iron stores, so a low ferritin is indicative of iron deficiency.

Q: Which of the following stains is used for reticulocyte staining?

Brilliant cresyl blue. **Correct Answer: Brilliant cresyl blue** - **Brilliant cresyl blue** is a **supravital stain** commonly used to visualize **reticulocytes** [1] - It precipitates the **ribosomal RNA** and other organelles present in reticulocytes, making them visible as a **reticular network** within the cell - This is one of the two most common stains used for reticulocyte counting (along with New methylene blue) *Incorrect: Indigo carmine* - **Indigo carmine** is a vital dye used for diagnostic procedures in **gastroenterology and urology** (e.g., to detect mucosal lesions or assess kidney function) - Used in endoscopic procedures as a **chromoscopic agent** to enhance visualization, but not for reticulocyte staining *Incorrect: Sudan black* - **Sudan black B** is a stain primarily used for detecting **lipids** and **lipofuscin** in various cells and tissues - Often utilized in **hematology** to differentiate myeloid cells from lymphoid cells based on their granule content, but not for reticulocytes *Incorrect: Methyl violet* - **Methyl violet** is a basic dye used as a **histological stain** and for staining **Gram-positive bacteria** in bacteriology - While it can stain cellular components, it is not specifically used for the identification or enumeration of reticulocytes **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 578-579.

Q: ALL L3 morphology is a malignancy arising from which cell lineage –

Mature B cell. ***Mature B cell*** - ALL L3, also known as **Burkitt-type ALL**, arises from a **mature B-cell lineage**. [1] - This is characterized by specific immunophenotypic markers (e.g., strong expression of **surface immunoglobulin** and **CD20**) and frequent chromosomal translocations involving the **MYC oncogene**, typically t(8;14). [1] *Mixed B cell & T cell* - This refers to **mixed phenotype acute leukemia (MPAL)**, which exhibits features of both B-cell and T-cell lineages. - MPAL is distinct from ALL L3, which is definitively B-cell in origin based on morphology and immunophenotype. *Immature T cell* - Malignancies arising from immature T cells are classified as **T-cell ALL**, which have a different morphology (L1 or L2) and distinct immunophenotype (e.g., expression of **cytoplasmic CD3**, CD1a, CD2, CD5, CD7). [1] - T-cell ALL is characterized by **T-cell receptor gene rearrangements** and typically presents with a mediastinal mass, unlike ALL L3. [1] *Precursor B cell* - Most cases of ALL (ALL L1 and L2) arise from **precursor B cells**, also known as B-lymphoblastic leukemia. [2] - These are characterized by lack of surface immunoglobulin expression and generally express **CD10, CD19, CD22**, and **TdT**, contrasting with the mature B-cell immunophenotype of ALL L3. [2] **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. 606. [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. 596-598.

Q: Packed red cells are commonly stored in which preservative solution?

CPDA-1 solution. ***Correct: CPDA-1 solution*** - **CPDA-1** (Citrate-Phosphate-Dextrose-Adenine) is the standard anticoagulant and preservative solution taught in Indian medical curricula - Allows storage of packed red cells for **35 days** at 1-6°C - Contains citrate (anticoagulant), phosphate (buffer), dextrose (RBC energy), and adenine (ATP synthesis) - Most commonly referenced in NEET-PG examinations as the standard storage solution *AS-1 (Adsol) solution* - Additive solution used primarily in the United States for extended PRBC storage (42 days) - Added to red cells after plasma removal to maintain viability - While effective, it is not the primary solution taught in standard Indian medical education *SAG-M solution* - **SAG-M** (Saline-Adenine-Glucose-Mannitol) is an additive solution used primarily in Europe - Extends packed red cell storage to **42 days** - Functionally similar to other additive solutions but less commonly referenced in Indian medical curriculum *AS-3 (Nutricel) solution* - Another additive solution for red blood cell storage used in the US - Designed to extend shelf life to 42 days - Like AS-1, it is not the standard preservative solution taught in Indian medical education **Note:** Modern blood banking increasingly uses additive solutions (AS-1, AS-3, SAG-M) for extended storage, but CPDA-1 remains the fundamental preservative solution taught in medical education.

Q: Glycoprotein IIb-IIIa complex is deficient in

Glanzmann disease. ***Glanzmann disease*** - This condition is characterized by a deficiency or qualitative defect of the **glycoprotein IIb-IIIa (GPIIb-IIIa) complex** on the platelet surface [1]. - The GPIIb-IIIa complex is crucial for **platelet aggregation** as it acts as a receptor for **fibrinogen**, connecting platelets [1], [2]. *Bernard-Soulier syndrome* - This syndrome involves a deficiency of the **glycoprotein Ib-IX-V complex**, which is responsible for **platelet adhesion** to **von Willebrand factor (vWF)** on the subendothelium [1], [2]. - Patients present with **large platelets** and impaired platelet adhesion. *Gray platelet syndrome* - This is a rare bleeding disorder characterized by a deficiency of **alpha-granules** in platelets [4]. - Platelets in this condition appear 'gray' on a blood smear due to the lack of alpha-granules that contain growth factors and adhesion proteins [4]. *von Willebrand disease* - This is primarily a deficiency or dysfunction of **von Willebrand factor (vWF)**, which is essential for **platelet adhesion** and stability of **factor VIII** [3]. - It does not directly involve a deficiency of the GPIIb-IIIa complex itself. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 668-669. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, p. 128. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 669-670. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 581-582.

Q: The removal of malarial parasites from the red blood cells is called:

Pitting. ***Pitting*** - **Pitting** is the process by which the spleen removes intraerythrocytic inclusions, such as malarial parasites, Howell-Jolly bodies, or Heinz bodies, from red blood cells while leaving the cell intact. - This function is critical in controlling **parasitemia** in malaria, as the spleen filters infected red blood cells and extracts the parasites, often resulting in uninfected, but slightly deformed, red blood cells returning to circulation. *Binding* - **Binding** refers to the adhesion of malarial parasites to red blood cells or endothelial cells, a process involved in parasite invasion or sequestration. - It does not describe the specific removal of the parasite from an already infected red blood cell. *Culling* - **Culling** is the process by which the spleen removes and destroys senescent (old) or damaged red blood cells from circulation. - While related to red blood cell removal, it specifically targets entire dysfunctional cells and doesn't describe the removal of an inclusion from an otherwise viable red blood cell. *Phagocytosis* - **Phagocytosis** is the process by which phagocytic cells (e.g., macrophages) engulf and digest foreign particles, microorganisms, or cellular debris. - While phagocytosis is crucial in clearing infected whole red blood cells, it is distinct from "pitting," where the parasite is "pitted out" of an intact red blood cell.

Q: In infectious mononucleosis, which cell type shows the most significant pathological changes?

T-cells. ***Correct: T-cells*** - In response to **Epstein-Barr virus (EBV)** infection of B-cells, there is a massive proliferation of **CD8+ cytotoxic T-lymphocytes** which are responsible for controlling the infection and mediating many of the symptoms. - These activated T-cells, known as **atypical lymphocytes** or **Downey cells**, are the characteristic pathological finding in peripheral blood smears of patients with infectious mononucleosis. - The **lymphocytosis with atypical lymphocytes** (>10% of total WBCs) is the hallmark laboratory finding. *Incorrect: B-cells* - **EBV directly infects B-cells**, leading to their proliferation, but the most significant pathological changes observed in the blood smear are due to the host's immune response. - While B-cells are the primary target of EBV, the hallmark feature of infectious mononucleosis on a peripheral blood smear is the presence of reactive T-cells, not the infected B-cells themselves. *Incorrect: Macrophages* - Macrophages play a role in clearing cellular debris and presenting antigens during an infection, but they do not show the most significant **pathological changes** or proliferative response characteristic of infectious mononucleosis. - They are generally not the predominant cell type exhibiting **atypical morphology** in the peripheral blood during this condition. *Incorrect: NK cells* - **Natural killer (NK) cells** are part of the innate immune response and contribute to controlling viral infections, including EBV. - However, they do not undergo the distinct and extensive **morphological changes** and proliferation seen in T-cells during infectious mononucleosis.

Q: 24 years old female patient presents with acute blood loss secondary to bilateral fracture femur. Reticulocytosis is evident on peripheral smear examination. Patient's anemia can be categorized into which of the following types?

Normocytic normochromic. ***Normocytic normochromic*** - **Acute blood loss** results in a loss of whole blood, meaning that the remaining red blood cells are still of normal size and hemoglobin content, hence **normocytic normochromic** [1]. - The presence of **reticulocytosis** is a physiological response, indicating that the bone marrow is actively producing new red blood cells to compensate for the acute loss, which also tend to be of normal size initially [1]. *Microcytic hypochromic* - This type of anemia is typically seen in conditions involving **chronic blood loss** or **iron deficiency**, where there is insufficient iron to produce normal hemoglobin, leading to small, pale red blood cells [3]. - While blood loss is present, it is acute, and there hasn't been sufficient time for iron stores to be depleted to this extent [2]. *Microcytic normochromic* - This is not a common classification of anemia; red blood cells that are **microcytic** (small) are almost always **hypochromic** (pale) due to reduced hemoglobin content. - This option does not accurately represent the physiological response to acute blood loss. *Normocytic Hypochromic* - This is also not a common classification; **normocytic** (normal size) red blood cells usually have normal hemoglobin content and thus appear **normochromic** [2]. - Hypochromia typically accompanies microcytosis due to the same underlying issues of impaired hemoglobin synthesis.

Q: All of the following are seen in polycythemia rubra vera except :

Decreased LAP Score. ***Decreased LAP Score*** - **LAP (Leukocyte Alkaline Phosphatase) score** is typically **increased or normal** in polycythemia vera. - A decreased LAP score is characteristic of **chronic myeloid leukemia (CML)**, which must be differentiated from polycythemia vera [2]. *Increased platelets* - **Thrombocytosis** (increased platelets) is a common feature of **polycythemia vera**, often contributing to vascular complications [1], [2]. - The unregulated proliferation of all myeloid cell lines, including megakaryocytes, leads to this increase [1], [3]. *Increased Vit B12 binding capacity (>9000 micromols/dL)* - Polycythemia vera often leads to **increased vitamin B12 levels** and **binding capacity** due to increased production of **transcobalamin I** by proliferating granulocytes. - While not a direct diagnostic criterion, it is a frequent finding supportive of the diagnosis. *Leucocytosis* - **Leukocytosis** (increased white blood cell count), particularly granulocytosis, is a common feature of polycythemia vera [1], [2]. - It results from the **clonal proliferation** of myeloid stem cells, leading to an overproduction of all myeloid lineage cells [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 614-615. [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. 626-627. [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. 627-628.

Question 1

Which of the following is true about iron deficiency anemia?

Accepted Answer

Microcytic hypochromic anemia

Answer

Bone marrow iron stores are depleted before serum iron levels drop

Answer

TIBC is typically decreased in this condition

Answer

Ferritin levels are elevated in this condition

Question 2

Which of the following stains is used for reticulocyte staining?

Accepted Answer

Brilliant cresyl blue

Answer

Indigo carmine

Answer

Sudan black

Answer

Methyl violet

Question 3

ALL L3 morphology is a malignancy arising from which cell lineage –

Accepted Answer

Mature B cell

Answer

Mixed B cell & T cell

Answer

Immature T cell

Answer

Precursor B cell

Question 4

Packed red cells are commonly stored in which preservative solution?

Accepted Answer

CPDA-1 solution

Answer

AS-1 (Adsol) solution

Answer

SAG-M solution

Answer

AS-3 (Nutricel) solution

Question 5

Glycoprotein IIb-IIIa complex is deficient in

Accepted Answer

Glanzmann disease

Answer

Gray platelet syndrome

Answer

von Willebrand disease

Answer

Bernard-Soulier syndrome

Question 6

The removal of malarial parasites from the red blood cells is called:

Accepted Answer

Pitting

Answer

Binding

Answer

Culling

Answer

Phagocytosis

Question 7

In infectious mononucleosis, which cell type shows the most significant pathological changes?

Accepted Answer

T-cells

Answer

B-cells

Answer

Macrophages

Answer

NK cells

Question 8

24 years old female patient presents with acute blood loss secondary to bilateral fracture femur. Reticulocytosis is evident on peripheral smear examination. Patient's anemia can be categorized into which of the following types?

Accepted Answer

Normocytic normochromic

Answer

Microcytic hypochromic

Answer

Microcytic normochromic

Answer

Normocytic Hypochromic

Question 9

Which among the following statements is wrong?

Accepted Answer

M components are detected in chronic myeloid leukemia.

Answer

In 20% of myelomas, only light chains are produced.

Answer

Light chains are synthesized in slight excess normally in plasma cells.

Answer

Qualitative assessment of M component can be done by electrophoresis.

Question 10

All of the following are seen in polycythemia rubra vera except :

Accepted Answer

Decreased LAP Score

Answer

Increased platelets

Answer

Increased Vit B12 binding capacity (>9000 micromols/dL)

Answer

Leucocytosis

Hematopathology — MCQs

Hematopathology — MCQs

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