Hematopathology Practice Questions

Q: The following RBC inclusion is composed of:

HbH disease. ***HbH disease*** - **HbH disease** is characterized by the presence of **beta-globin tetramers (β4)**, which are unstable and precipitate within red blood cells, forming characteristic inclusions. - These inclusions are typically visualized with **supravital stains** like brilliant cresyl blue and resemble a "golf ball" appearance [1]. *Hemoglobin barts* - **Hemoglobin Barts (γ4)** is primarily seen in **hydrops fetalis**, the most severe form of alpha-thalassemia, where all four alpha-globin genes are deleted. - While it is also an unstable hemoglobin, its presence is usually incompatible with life beyond the perinatal period and is not typically seen as an RBC inclusion in adult peripheral blood. *Pernicious anemia* - **Pernicious anemia** is a type of **megaloblastic anemia** caused by **vitamin B12 deficiency**, often due to lack of intrinsic factor. - RBC inclusions associated with pernicious anemia include **Howell-Jolly bodies** (nuclear remnants) and **Pappenheimer bodies** (iron granules), not unstable hemoglobin precipitates. *Malaria* - **Malaria** is caused by **Plasmodium parasites** that infect red blood cells. - RBC inclusions in malaria are the **parasites themselves** at various stages (ring forms, trophozoites, schizonts, gametocytes) and **malarial pigment (hemozoin)**, not precipitated hemoglobin. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 600-601.

Q: The following image shows presence of:

Leptocytes. ***Leptocytes*** - Leptocytes, also known as **target cells**, are red blood cells with a central area of hemoglobin surrounded by a pale ring, and then an outer ring of hemoglobin, resembling a **target**. - They are typically seen in conditions like **thalassemia**, **iron deficiency anemia**, and **liver disease**. *Tear drop cells* - Tear drop cells (dacryocytes) are red blood cells with a characteristic **teardrop or pear shape**. - They are commonly associated with **myelofibrosis** [1] and other conditions causing extramedullary hematopoiesis. *Ovalocytes* - Ovalocytes (elliptocytes) are **oval-shaped red blood cells**. - They are characteristic of **hereditary elliptocytosis** and can also be seen in megaloblastic anemia. *Acanthocytes* - Acanthocytes (spur cells) are red blood cells with **irregular, spiny projections** of varying length and width. - They are typically seen in severe **liver disease** (e.g., alcoholic cirrhosis) and **abetalipoproteinemia**. **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. 628-629.

Q: Which stain is preferred to diagnose these RBC inclusions seen in patients with elevated serum ferritin and serum iron?

Perl stain. ***Perl stain*** - The image suggests the presence of **siderocytes** (RBCs with non-heme iron granules) or **sideroblasts** (nucleated RBC precursors with iron granules), given the context of elevated serum ferritin and iron. - The **Perl stain**, also known as Prussian blue stain, is specifically used to detect and visualize **non-heme iron** deposits, which appear as blue granules within cells. *Rubeanic acid* - Rubeanic acid is primarily used to detect **copper** in tissues, not iron. - It forms a green-black precipitate with copper and is not relevant for identifying iron inclusions in RBCs. *Supravital stain* - **Supravital stains** (e.g., brilliant cresyl blue, new methylene blue) are used to visualize **reticulocytes** (RNA) and other RBC inclusions like **Heinz bodies** (denatured hemoglobin). - While useful for diagnosing certain anemias, it does not specifically stain or highlight iron granules. *Congo red* - **Congo red** is a special stain used to detect **amyloid deposits**, which appear apple-green birefringence under polarized light. - It has no role in visualizing iron inclusions within red blood cells. *PAS stain* - **Periodic Acid-Schiff (PAS)** stain is used to detect **glycogen** and mucopolysaccharides in cells. - In hematology, it can help identify abnormal cells in certain leukemias (e.g., erythroleukemia) but does not specifically stain iron granules in RBCs.

Q: The diagnosis for the given presentation is:

Howell Jolly bodies. ***Howell Jolly bodies*** - The presence of **Howell Jolly bodies** indicates impaired or absent splenic function, as the spleen normally removes these nuclear remnants from red blood cells [2]. - This finding is characteristic of **asplenia** or **hyposplenism**, which can be congenital or acquired (e.g., post-splenectomy) [1][2]. *Lead poisoning* - Lead poisoning is typically associated with **basophilic stippling** (coarse, dark blue granules) in red blood cells, not Howell Jolly bodies. - It also causes a **microcytic, hypochromic anemia** and can present with neurological or gastrointestinal symptoms. *Macrocytic anemia* - Macrocytic anemia is characterized by **enlarged red blood cells** (MCV > 100 fL), often due to **B12 or folate deficiency**. - While some macrocytic anemias can have associated red cell inclusions, Howell Jolly bodies are not a primary diagnostic feature of macrocytosis itself. *Heinz bodies* - **Heinz bodies** are denatured hemoglobin precipitates within red blood cells, typically seen in conditions like **G6PD deficiency** or **unstable hemoglobinopathies**. - They are visualized with **supravital stains** (e.g., crystal violet) and are distinct from nuclear remnants like Howell Jolly bodies. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 644-645. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 570-571.

Q: A 6-year-old child presents with lethargy and abdominal pain. Hemoglobin is 8 g/dL with increased serum ferritin. Peripheral smear is shown. Which is correct about the image?

Pappenheimer body. ***Pappenheimer body*** - The image shows **siderotic granules** (iron-containing inclusions) within red blood cells, which are characteristic of **Pappenheimer bodies**. - These bodies are seen in conditions like **sideroblastic anemia**, **hemolytic anemia**, and **splenectomy**, and are often associated with **iron overload** (consistent with increased serum ferritin). *Heinz body* - **Heinz bodies** are precipitates of denatured hemoglobin, typically seen in conditions like **G6PD deficiency** or unstable hemoglobinopathies [1]. - They are not visible with routine Romanowsky stains and require **supravital stains** (e.g., crystal violet) for visualization. *Lead poisoning* - While lead poisoning can cause **sideroblastic anemia** and **basophilic stippling**, the image specifically depicts iron inclusions (Pappenheimer bodies), not the diffuse ribosomal aggregates of basophilic stippling. - The clinical presentation of abdominal pain and anemia is consistent with lead poisoning, but the specific finding in the image points to Pappenheimer bodies. *Howell-Jolly body* - **Howell-Jolly bodies** are nuclear remnants (DNA fragments) within red blood cells, typically seen in conditions of **hyposplenism** or **asplenia** [2]. - They appear as single, round, dark blue inclusions and are distinct from the multiple, often irregular, iron-containing granules of Pappenheimer bodies. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 642-643. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 644-645.

Q: The following inclusions in multiple myeloma are called:

Russell body. ***Russell body*** - The image shows plasma cells with numerous, distinct, **intracellular inclusions** that appear as **acidophilic, hyaline, grape-like clusters**, which are characteristic of Russell bodies. - These inclusions are composed of **accumulated immunoglobulins** within the plasma cell's endoplasmic reticulum and are commonly found in conditions like multiple myeloma. *Dutcher body* - **Dutcher bodies** are intranuclear inclusions composed of immunoglobulins, not cytoplasmic like the ones seen in the image. - They are typically seen as **PAS-positive, eosinophilic inclusions** within the nucleus of plasma cells. *Mott cell* - A **Mott cell** is a plasma cell filled with multiple **Russell bodies**, giving it a characteristic "grape-like" or "mulberry" appearance. While the image depicts a Mott cell, the question specifically asks for the name of the *inclusions* themselves. - The term "Mott cell" describes the entire cell containing these inclusions, not the individual inclusions. *Flame cell* - **Flame cells** are a type of plasma cell that contains an abundance of **glycoprotein-rich secretory IgA**, which gives their cytoplasm a **distinct reddish or fiery hue** (hence "flame"). - The inclusions shown in the image are discrete, hyaline bodies, not a diffuse cytoplasmic blush, and are typically associated with IgG or IgM rather than IgA. *Auer rod* - **Auer rods** are **needle-like or rod-shaped cytoplasmic inclusions** composed of abnormal aggregates of azurophilic granules. - They are pathognomonic for **acute myeloid leukemia (AML)**, particularly in myeloblasts, and are not found in plasma cells or multiple myeloma.

Q: What is your diagnosis on the basis of image given below?

Langerhans cell histiocytosis. ***Langerhans cell histiocytosis*** - The image likely depicts characteristic histological features such as **Birbeck granules** (tennis racket-shaped inclusions) or a proliferation of **Langerhans cells** with reniform nuclei, which are pathognomonic for Langerhans cell histiocytosis [1]. - This condition involves the clonal proliferation of Langerhans cells, often presenting with **lytic bone lesions**, skin rashes, or involvement of other organs [1]. *Plasmacytoma* - Plasmacytoma is a localized proliferation of **plasma cells**, which would show a different cellular morphology on histology, typically with eccentric nuclei and abundant cytoplasm [2]. - It is often associated with **monoclonal gammopathy** and can present as a solitary bone lesion or extramedullary mass [2]. *Viral encephalitis* - Viral encephalitis is an inflammation of the brain caused by a virus, and its histological findings would include **perivascular cuffing**, neuronal damage, and glial nodules, not a proliferation of histiocytic cells. - Clinical presentation would involve neurological symptoms like fever, headache, and altered mental status. *Leukemia* - Leukemia involves the proliferation of **immature white blood cells** in the bone marrow and peripheral blood, and its histological appearance would be characterized by blasts or immature myeloid/lymphoid cells. - It typically presents with pancytopenia, organomegaly, and systemic symptoms, which are distinct from the focal lesions seen in Langerhans cell histiocytosis. **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. [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. 606-607.

Q: Identify the RBC shown in the figure:

Echinocyte. ***Echinocyte*** - Echinocytes, also known as **burr cells**, have **evenly spaced, short, blunt projections** (10–30 in number) uniformly distributed around their surface. - They are commonly seen in conditions like **uremia**, pyruvate kinase deficiency, and can also be an artifact of slide preparation. *Acanthocyte* - Acanthocytes, or **spur cells**, have **irregularly spaced, spiny projections of varying lengths and sizes** (3–12 in number). - They are typically associated with severe liver disease (e.g., **cirrhosis**), abetalipoproteinemia, and McLeod syndrome. *Schistocyte* - Schistocytes are **fragmented red blood cells** resulting from mechanical damage within the circulation. - They are characteristic of microangiopathic hemolytic anemias (e.g., **DIC**, TTP, HUS) and mechanical heart valve hemolysis. *Spherocyte* - Spherocytes are **small, dense, spherical red blood cells** that lack central pallor. - They are seen in conditions like **hereditary spherocytosis**, autoimmune hemolytic anemia, and ABO incompatibility. *Codocyte* - Codocytes, or **target cells**, appear as RBCs with a **central dense area surrounded by a pale ring and an outer dense rim**, resembling a target or bull's-eye. - They are associated with **thalassemia**, hemoglobin C disease, liver disease, iron deficiency anemia, and post-splenectomy states. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 640-641.

Q: All are true about the slide shown except:

ABVD chemotherapy. ***ABVD chemotherapy*** - ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) is the standard chemotherapy regimen for **Hodgkin lymphoma**, not Burkitt lymphoma. - Burkitt lymphoma is typically treated with intensive, short-course chemotherapy regimens, often including high-dose methotrexate, cyclophosphamide, and cytarabine [3]. *Occurs due to c-Myc gene activation* - **Burkitt lymphoma** is characterized by translocations involving the **c-Myc oncogene**, most commonly t(8;14) [1]. - This translocation leads to the overexpression of the c-Myc protein, promoting uncontrolled cell proliferation [1]. *Non-Hodgkin's lymphoma* - Burkitt lymphoma is a highly aggressive type of **B-cell non-Hodgkin lymphoma (NHL)** [3]. - It is one of the fastest-growing human tumors. *Burkitt lymphoma* - The "starry sky" appearance on a biopsy, with numerous tingible body macrophages amidst a monotonous population of small, non-cleaved lymphocytes, is a classic histological feature of **Burkitt lymphoma** [2]. - This appearance is due to the rapid proliferation of lymphoma cells and the presence of macrophages phagocytosing apoptotic tumor cells [2]. **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, p. 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, pp. 605-606.

Q: A 45-year-old female has complaints of painless cervical lymphadenopathy with fever and weight loss. A lymph node biopsy was performed. All of the following statements are true regarding this condition except:

CD15+, CD20+ and CD30+. ***CD15+, CD20+ and CD30+*** - Hodgkin's lymphoma Reed-Sternberg cells are typically **CD15+ and CD30+**, but **CD20−** (negative). - The claim that RS cells are CD20+ is **incorrect** — CD20 positivity would instead suggest a B-cell non-Hodgkin lymphoma. - This makes the statement FALSE, confirming it as the correct exception. *5-year survival rate is high* - Hodgkin's lymphoma generally has a **high 5-year survival rate** (>85% in early stages) due to its excellent responsiveness to chemotherapy (ABVD) and radiation therapy. - This statement is **TRUE**, so it is not the exception. *Reed-Sternberg cells are pathognomonic for Hodgkin's lymphoma* - Classic **Reed-Sternberg cells** (large binucleated giant cells with prominent "owl-eye" nucleoli) are the hallmark finding of Hodgkin's lymphoma and are considered **pathognomonic** in the appropriate clinical context. - This statement is **TRUE**, so it is not the exception. *LP must be done to rule out meningeal involvement* - **Lumbar puncture (LP)** is NOT routinely performed in Hodgkin's lymphoma; it is reserved for aggressive non-Hodgkin lymphomas (e.g., diffuse large B-cell lymphoma) or when neurological symptoms are present. - While this statement is also false, **Option A (CD20+) is more definitively incorrect** and is the standard teaching point. *EBV association is seen in some cases* - **Epstein-Barr Virus (EBV)** is associated with approximately **30–40% of classical Hodgkin's lymphoma cases**, particularly the mixed cellularity subtype. - EBV-encoded RNA (EBER) can be detected in Reed-Sternberg cells in these cases. - This statement is **TRUE**, so it is not the exception. **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. 614–618. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. pp. 559–560.

Question 1

The following RBC inclusion is composed of:

Accepted Answer

HbH disease

Answer

Hemoglobin barts

Answer

Pernicious anemia

Answer

Malaria

Answer

G6PD deficiency

Question 2

The following image shows presence of:

Accepted Answer

Leptocytes

Answer

Tear drop cells

Answer

Ovalocytes

Answer

Acanthocytes

Answer

Spherocytes

Question 3

Which stain is preferred to diagnose these RBC inclusions seen in patients with elevated serum ferritin and serum iron?

Accepted Answer

Perl stain

Answer

Rubeanic acid

Answer

Supravital stain

Answer

Congo red

Answer

PAS stain

Question 4

The diagnosis for the given presentation is:

Accepted Answer

Howell Jolly bodies

Answer

Lead poisoning

Answer

Macrocytic anemia

Answer

Heinz bodies

Answer

Pappenheimer bodies

Question 5

A 6-year-old child presents with lethargy and abdominal pain. Hemoglobin is 8 g/dL with increased serum ferritin. Peripheral smear is shown. Which is correct about the image?

Accepted Answer

Pappenheimer body

Answer

Heinz body

Answer

Basophilic stippling

Answer

Howell-Jolly body

Answer

Cabot rings

Question 6

The following inclusions in multiple myeloma are called:

Accepted Answer

Russell body

Answer

Dutcher body

Answer

Mott cell

Answer

Flame cell

Answer

Auer rod

Question 7

What is your diagnosis on the basis of image given below?

Accepted Answer

Langerhans cell histiocytosis

Answer

Plasmacytoma

Answer

Viral encephalitis

Answer

Leukemia

Answer

Gaucher disease

Question 8

Identify the RBC shown in the figure:

Accepted Answer

Echinocyte

Answer

Acanthocyte

Answer

Schistocyte

Answer

Spherocyte

Answer

Codocyte

Question 9

All are true about the slide shown except:

Accepted Answer

ABVD chemotherapy

Answer

Occurs due to c-Myc gene activation

Answer

Non-Hodgkin's lymphoma

Answer

Burkitt lymphoma

Answer

High proliferation index (Ki-67 near 100%)

Question 10

A 45-year-old female has complaints of painless cervical lymphadenopathy with fever and weight loss. A lymph node biopsy was performed. All of the following statements are true regarding this condition except:

Accepted Answer

CD15+, CD20+ and CD30+

Answer

5-year survival rate is high

Answer

Reed-Sternberg cells are pathognomonic for Hodgkin's lymphoma

Answer

LP must be done to rule out meningeal involvement

Answer

EBV association is seen in some cases

Hematopathology — MCQs

Hematopathology — MCQs

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