Hematopathology Practice Questions

Q: A 30-year-old female with anemia, unresponsive to iron, folic acid, and B12 supplementation, underwent further evaluation. Her CBC profile showed Hb-4.7 g/dL, total WBC count-4,000/mm3, and platelet count-70,000/mm3. Peripheral smear findings are provided. Her bone marrow aspirate revealed a dry tap, and a bone marrow biopsy confirmed the diagnosis. Which of the following stains would have been useful in confirming the bone marrow biopsy findings?

Reticulin stain. ***Reticulin stain*** - **Reticulin stain** is the **gold standard** for demonstrating increased **reticulin fibers** in bone marrow, confirming **myelofibrosis** diagnosis. - The **WHO grading system** (MF-0 to MF-3) uses reticulin stain to assess **fibrosis severity** and guide treatment decisions. *Myeloperoxidase (MPO)* - **MPO stain** is used to identify **myeloid lineage cells** and differentiate **acute myeloid leukemia** from other hematologic malignancies. - Not useful for detecting **bone marrow fibrosis** or **reticulin fiber deposition** in myelofibrotic disorders. *Verhoeff-Van Gieson (VVG)* - **VVG stain** demonstrates **elastic fibers** and is primarily used in **cardiovascular pathology** and **connective tissue disorders**. - Does not specifically highlight **reticulin fibers** needed for diagnosing **bone marrow fibrosis**. *Prussian blue stain (for iron)* - **Prussian blue stain** detects **iron deposits** in tissues and is useful for diagnosing **iron overload** or **sideroblastic anemia**. - Cannot demonstrate **reticulin fibrosis** or help confirm **myelofibrosis** in bone marrow specimens.

Q: A 46-year-old lady presents with pallor. You suspect iron deficiency anemia. Which of the following blood investigation results is NOT consistent with this provisional diagnosis?

Decreased level of red cell protoporphyrin. In Iron Deficiency Anemia (IDA), the body lacks sufficient iron to complete the final step of heme synthesis. Under normal conditions, the enzyme **ferrochelatase** inserts ferrous iron into a precursor molecule called **protoporphyrin IX** to form heme. **Why Option D is the Correct Answer:** When iron is deficient, protoporphyrin has no iron to bind with. Consequently, it accumulates within the red blood cells. Therefore, in IDA, we see an **increased** level of **Free Erythrocyte Protoporphyrin (FEP)**, not a decreased level. This makes Option D inconsistent with the diagnosis. **Analysis of Incorrect Options:** * **A. Low plasma ferritin:** Ferritin is the storage form of iron [1]. A low serum ferritin is the **most specific** initial laboratory finding in IDA, reflecting depleted body stores [2]. * **B. Decreased saturation of transferrin:** As serum iron drops and Total Iron Binding Capacity (TIBC) increases, the percentage of transferrin saturated with iron falls (typically <16% in IDA) [2]. * **C. Decreased hemoglobin:** This is the hallmark of anemia [1]. In IDA, hemoglobin synthesis is impaired, leading to microcytic hypochromic anemia [2]. **NEET-PG High-Yield Pearls:** * **Earliest sign of IDA:** Decreased serum ferritin (depletion of stores) [2]. * **Earliest functional sign:** Increase in Red Cell Distribution Width (RDW) [2]. * **Gold Standard Investigation:** Bone marrow aspiration (Prussian blue staining) showing absent haemosiderin (though rarely done clinically) [2]. * **Mentzer Index:** (MCV/RBC count) 13 suggests IDA.

Q: In lymphoplasmacytoid lymphoma, which of the following monoclonal immunoglobulins is most commonly seen?

IgM. **Explanation:** **Lymphoplasmacytoid Lymphoma (LPL)** is a mature B-cell neoplasm characterized by a proliferation of small B-lymphocytes, plasmacytoid lymphocytes, and plasma cells. 1. **Why IgM is Correct:** The defining clinical feature of LPL is the secretion of a monoclonal protein. In the vast majority of cases (approximately 90-95%), this protein is **IgM** [1]. When LPL involves the bone marrow and is associated with a monoclonal IgM gammopathy of any size, it is clinically termed **Waldenström Macroglobulinemia (WM)** [1]. The large size of the IgM pentamer leads to the classic clinical presentation of hyperviscosity syndrome [1]. 2. **Why Other Options are Incorrect:** * **IgG and IgA:** While rare variants of LPL can secrete IgG or IgA, these are much more commonly associated with **Multiple Myeloma** or Monoclonal Gammopathy of Undetermined Significance (MGUS) [1]. * **IgD:** This is extremely rare and is typically associated with a specific, aggressive subtype of Multiple Myeloma, not LPL. **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Marker:** Over 90% of LPL/WM cases harbor the **MYD88 L265P mutation**, which is a key diagnostic marker. * **Clinical Triad:** Look for anemia, hepatosplenomegaly/lymphadenopathy, and hyperviscosity (visual disturbances, mucosal bleeding, neurological symptoms) [1]. * **Morphology:** Bone marrow biopsy shows a "lymphoplasmacytoid" infiltrate and increased mast cells [1]. * **Differentiator:** Unlike Multiple Myeloma, LPL/WM typically does **not** cause lytic bone lesions or hypercalcemia (No "CRAB" features).

Question 1

A 30-year-old female with anemia, unresponsive to iron, folic acid, and B12 supplementation, underwent further evaluation. Her CBC profile showed Hb-4.7 g/dL, total WBC count-4,000/mm3, and platelet count-70,000/mm3. Peripheral smear findings are provided. Her bone marrow aspirate revealed a dry tap, and a bone marrow biopsy confirmed the diagnosis. Which of the following stains would have been useful in confirming the bone marrow biopsy findings?

Accepted Answer

Reticulin stain

Answer

Myeloperoxidase (MPO)

Answer

Verhoeff-Van Gieson (VVG)

Answer

Prussian blue stain (for iron)

Question 2

An elderly male presents with headache, recurrent infections, and multiple punched-out lytic lesions on X-ray skull. Which of the following investigations will best help in establishing the diagnosis?

Accepted Answer

Protein electrophoresis

Answer

Serum calcium

Answer

Acid phosphatase levels

Answer

Alkaline phosphatase levels

Question 3

All the following MALT lymphomas are related to a specific organism except:

Accepted Answer

MALT lymphomas of skin - Bartonella henselae

Answer

MALT lymphomas of stomach - Helicobacter pylori

Answer

MALT lymphomas of eye - Chlamydophila psittaci

Answer

MALT lymphomas of small intestine - Campylobacter jejuni

Question 4

Pawn ball megakaryocytes are characteristic of which condition?

Accepted Answer

Myelodysplastic syndrome

Answer

Idiopathic thrombocytopenic purpura

Answer

Thrombotic thrombocytopenic purpura

Answer

Chloramphenicol toxicity

Question 5

Which of the following surface glycoproteins is most often expressed in human hematopoietic stem cells?

Accepted Answer

CD 34

Answer

CD 22

Answer

CD 40

Answer

CD 15

Question 6

CD59 defect is a marker of which disease?

Accepted Answer

Paroxysmal Nocturnal Hemoglobinuria

Answer

PTEN

Answer

Hereditary spherocytosis

Answer

Cowden syndrome

Question 7

Burkitt's lymphoma is associated with which of the following gene anomalies?

Accepted Answer

t(8:14)

Answer

t(9:22)

Answer

del. 5q

Answer

t(17:15)

Question 8

A 46-year-old lady presents with pallor. You suspect iron deficiency anemia. Which of the following blood investigation results is NOT consistent with this provisional diagnosis?

Accepted Answer

Decreased level of red cell protoporphyrin

Answer

Low levels of plasma ferritin

Answer

Decreased saturation of transferrin

Answer

Decreased level of hemoglobin

Question 9

A triad of leukoerythroblastosis, tear drop erythrocytes, and large platelets is seen in which of the following conditions?

Accepted Answer

Primary myelofibrosis

Answer

Essential thrombocytosis

Answer

Myelodysplastic syndrome

Answer

Langerhans cell histiocytosis

Question 10

In lymphoplasmacytoid lymphoma, which of the following monoclonal immunoglobulins is most commonly seen?

Accepted Answer

IgM

Answer

IgA

Answer

IgD

Answer

IgG

Hematopathology — MCQs

Hematopathology — MCQs

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