Anaemia

Question 1

1. A 57 year old man present with signs of fatigue that are the result of anaemia. Workup reveals that his anaemia is the result of bleeding from a colon cancer located in the sigmoid colon. The lesion is resected and at the time of surgery no metastatic disease is found. Which of the following markers would be most useful for future follow-up of this patient for the evaluation of possible metastatic disease from his colon cancer?
   Select one:
   a. Chloroacetate esterase (CAE)
   b. Carcinoembryonic antigen (CEA)
   c. Prostate-specific antigen
   d. Human chorionic gonadotropin (hCG)
   e. α fetoprotein (AFP)

Answer 1

CEA

Question 2

2. A 54-year-old male complains of symptoms suggestive of mild depression. He has retrosternal burning discomfort after meals. His liver is palpable 2cm below the right costal margin. Hb 130g/L (130- 180) MCV 102f/L (78 -100) WBC 6.8 x 109/L (4 - 11) Differential Normal Platelets 380 x 109/L (150 - 400) _____
   Select one:
   a.
   Autoimmune haemolytic anaemia
   b.
   Chronic disease
   c.
   Iron deficiency
   d.
   Hereditary spherocytosis
   e.
   Myelofibrosis
   f.
   Chronic granulocytic leukaemia
   g.
   Lead poisoning
   h.
   Folic acid deficiency
   i.
   Thalassaemia
   j.
   Haemolytic anaemia
   k.
   Alcoholism
   l.
   Chronic lymphocytic leukaemia
   m.
   Acute leukaemia
   n.
   Vitamin B12 deficiency
   o.
   Aplastic anaemia

Answer 2

Alcoholism

Liver disease

Question 3

4. A 75 year old woman has increasing shortness of breath on exertion. Findings on physical examination are unremarkable. X-rays of the chest show no abnormalities of the heart or lungs. Pertinent laboratory findings include: Haemoglobin 90 g/L, MCV 70 fL What is the most likely explanation for these findings?
   Select one:
   a.
   Acquired haemolytic anaemia
   b.
   Pernicious anaemia
   c.
   Chronic blood loss
   d.
   Folic acid deficiency
   e.
   Thalassaemia minor

Answer 3

Chronic blood loss

Question 4

5. A 30-year-old female has splenomegaly and anaemia with spherocytosis. An inherited abnormality in which of the following best explains these findings:

Select one:
a.
Glucose-6-phosphate dehydrogenase
b.
A membrane cytoskeletal protein
c.
Haem
d.
Alpha globin chain
e.
Beta globin chain

Answer 4

Membrane cytoskeletal protein

Question 5

6. A 62-year-old woman complains of two months of increasing lower thoracic back pain. Two hard enlarged lymph nodes are detected in her left axilla.
   Select the most likely diagnosis.
   Hb 110 g/L (120 - 155)
   MCV 83 fL (80 - 98)
   WBC 6.2 x 109/L (4 - 11)
   Neutrophils 3.0 x 109/L (1.9 - 7.5)
   Lymphocytes 2.2 x 109/L (1.0-4.0)
   Platelets 130 x 109/L (150 - 400)
   Blood film - leukoerythroblastic.
   Select one:
   a.
   Glandular fever (acute EBV infection)
   b.
   Acute myeloid leukaemia
   c.
   Aplastic anaemia
   d.
   Chronic myeloid leukaemia
   e.
   Primary myelofibrosis
   f.
   Myelodysplastic syndrome
   g.
   Essential thrombocythaemia
   h.
   Polycythaemia vera
   i.
   Chronic lymphocytic leukaemia
   j.
   Mature B-cell neoplasm (non-Hodgkin lymphoma)
   k.
   Metastatic carcinoma to bone marrow
   l.
   Acute lymphoblastic leukaemia
   m.
   Hodgkin lymphoma

Answer 5

Metastatic carcinoma to bone marrow

Question 6

7. A 30-year-old pregnant woman complains to her physician of feeling very tired during her pregnancy. A blood count reveals a haemoglobin of 90 g/L, with hypersegmented neutrophils and large red cells. Deficiency of which of the following would be most likely to produce these findings?
   Select one:
   a.
   Iron
   b.
   Copper
   c.
   Cobalamin
   d.
   Folate
   E. Ascorbic acid

Answer 6

Folate

Question 7

A two month old baby develops a life-threatening anaemia. Blood tests show a normal serum ferritin. Haemoglobin electrophoresis reveals increased haemoglobin A2 and increased Haemoglobin F. This baby’s anaemia is likely to be secondary to:
Select one:
a.
Lead poisoning
b.
The presence of Haemoglobin M
c.
A deficiency of folate
d.
An inability to manufacture haem
e.
Failure of beta chain production
f.
Bone marrow failure
g.
The presence of Haemoglobin S
h.
Failure of alpha chain production
i.
A deficiency of iron
j.
A deficiency of B12

Answer 7

Failure of beta chain production

Question 8

A 50-year-old man has experienced chronic fatigue and weight loss for the past three months. There are no remarkable findings on physical examination. Laboratory studies show haemoglobin 112 g/L; MCV 83 fL; platelet count 240 x 10(9)/L; neutrophil count 5.6 x 10(9)/L; serum ferritin, 565 µg/L. The ANA test result is positive. Which of the following is the most likely diagnosis?
Select one:
a.
Anaemia of inflammation
b.
Thalassaemia minor
c.
Microangiopathic haemolytic anaemia
d.
Megaloblastic anaemia
e.
Iron deficiency anaemia
f.
Aplastic anaemia

Answer 8

Anaemia of inflammation

Question 9

A 60 year old man is receiving steroid and anti-inflammatory drug treatment for rheumatoid arthritis. He complains of continuing joint pain and stiffness and tiredness.
Hb 102 g/L (130 - 180)
MCV 79 fL (80 -98)
Neutrophils 7.0 x 10(9)/L (1.9 - 7.5)
Platelets 421 x 10(9)/L (150 - 400)
No abnormal cells seen on blood film.
Of the following choices, which is the most likely diagnosis:
Select one:
a.
Primary myelofibrosis
b.
Hereditary spherocytosis
c.
Acute leukaemia
d.
Anaemia of inflammation
e.
Thalassaemia
f.
Autoimmune haemolytic anaemia
g.
Alcoholism
h.
Haemolytic anaemia
i.
Chronic lymphocytic leukaemia
j.
Aplastic anaemia
k.
Lead poisoning
l.
Chronic myeloid leukaemia
m.
Vitamin B12 deficiency
n.
Folic acid deficiency

Answer 9

Anaemia of inflammation

Question 10

A 50-year-old man has had headache, dizziness, and fatigue for the past three months. His friends have been commenting about his increasingly ruddy complexion. He also has experienced generalized and severe pruritus, particularly when showering. He notes that his stools are dark. On physical examination, he is afebrile, and his blood pressure is 165/90 mm Hg. There is no hepatosplenomegaly or lymphadenopathy. The blood cont shows haemoglobin 223 g/L; haematocrit 67.1%; MCV 81 fL; platelet count, 453 x 10(9)/L; and neutrophil count 9.4 x 10(9)/L. The serum erythropoietin level is low. What is the most likely diagnosis?
Select one:
a.
Megaloblastic anaemia
b.
Primary myelofibrosis
c.
Polycythaemia vera
d.
Chronic myeloid leukaemia
e.
Iron deficiency anaemia
f.
Essential thrombocythaemia

Answer 10

Polycythaemia vera

Bone marrow cancer

Question 11

A 29-year-old woman has had malaise and a low-grade fever for the past week. On physical examination, she appears very pale. She has a history of chronic anaemia, and spherocytes are observed on a peripheral blood smear. Her haematocrit, which normally ranges from 105 g/L to 114 g/L, is now 84 g/L, and the reticulocyte count is very low. The serum bilirubin level is 15 umol/L. Which of the following events is most likely to have occurred in this patient?
Select one:
a.
Development of anti-RBC antibodies
b.
Reduced erythropoiesis from parvovirus infection
c.
Disseminated intravascular coagulation
d.
Accelerated hemolysis in the spleen
e.
Superimposed iron deficiency

Answer 11

Reduced erythropoiesis from parvovirus infection

Question 12

Blood film shows spherocytosis. A 19 year old woman is anaemic (Hb 90 g/L; normal 115-150) and has a mildly enlarged spleen. Which of the following statements is correct?
Select one:
a.
The direct antiglobulin test (DAT) will be diagnostically useful
b.
The red cell half-life will be normal
c.
Hereditary spherocytosis is seen only in males
d.
The serum haptoglobin level will be elevated
e.
The features are consistent with bone marrow failure

Answer 12

DAT

Question 13

A 24-year-old man has a one month history of slowly increasing tiredness. Over this period he has noted increased bruising on his legs. For this patient with anaemia select the most likely diagnosis:
Hb 64 g/L (130 - 175)
MCV 95 fL (80 - 99)
0.4 x 109/L (1.9 - 7.5)

Neutrophils
Platelets 21 x 109/L (150 - 400)
No abnormal cells seen on blood film

Select one or more:
a.
Chronic myeloid leukaemia
b.
Chronic disease
c.
Alcoholism
d.
Iron deficiency
e.
Thalassaemia
f.
Folic acid deficiency
g.
Lead poisoning
h.
Chronic lymphocytic leukaemia
i.
Acute leukaemia
j.
Primary myelofibrosis
k.
Aplastic anaemia
l.
Haemolytic anaemia
m.
Vitamin B12 deficiency
n.
Hereditary spherocytosis
o.
Autoimmune haemolytic anaemia
p.
Chronic disease

Answer 13

Acute leukaemia

Question 14

A 30-year-old woman has a five year history of systemic lupus erythematosis. For several weeks she has noted increasing fatigue and breathlessness on exertion. On examination there is mild jaundice and the spleen is palpable at the left costal margin. Hb 79 g/L (120 - 155) MCV 100 fL (80 - 98) WBC 8.2 x 10(9)/L (4 - 11) differential normal. Platelets 330 x 10(9)/L (150 - 400) . Haptoglobin <0.05 g/L (0.34 - 2.0 g/L) Direct antigobulin test positive.

The most likely diagnosis is:
Select one:
a.
Autoimmune haemolytic anaemia
b.
Chronic myeloid leukaemia
c.
Vitamin B12 deficiency
d.
Chronic disease
e.
Hereditary spherocytosis
f.
Folic acid deficiency
g.
Lead poisoning
h.
Iron deficiency
i.
Primary myelofibrosis
j.
Haemolytic anaemia
k.
Aplastic anaemia
l.
Alcoholism
m.
Chronic lymphocytic leukaemia
n.
Acute leukaemia
o.
Thalassaemia

Answer 14

Autoimmune haemolytic anaemia

Question 15

A 60-year-old man with known alcoholism has the following blood film. Hb 110 g/L (130 - 180) MCV 111 fL (80 - 98), neutrophils 2.5 x 10(9)/L, platelets 140 x 10(9)/L (150 - 400). Blood film: oval macrocytes and hypersegmented neutrophils present.

The most likely diagnosis is:
Select one:
a.
Acute leukaemia
b.
Hereditary spherocytosis
c.
Alcoholism
d.
Chronic lymphocytic leukaemia
e.
Chronic disease
f.
Haemolytic anaemia
g.
Primary myelofibrosis
h.
Vitamin B12 deficiency
i.
Autoimmune haemolytic anaemia
j.
Thalassaemia
k.
Lead poisoning
l.
Folic acid deficiency
m.
Iron deficiency
n.
Chronic myeloid leukaemia
o.
Aplastic anaemia

Answer 15

Folic acid deficiency

Question 16

A 12-year-old boy has a history of episodes of severe abdominal and back pain since early childhood. On physical examination, he is afebrile, and there is no organomegaly. Laboratory studies show haemoglobin of 112 g/L, platelet count of 194 x 10(9)/L, and WBC count of 9.0x 10(9)/L. The peripheral blood smear shows occasional sickled cells, nucleated RBCs, and Howell-Jolly bodies. Haemoglobin electrophoresis shows 1% haemoglobin A2, 6% haemoglobin F, and 93% haemoglobin S. Hydroxyurea therapy is found to be beneficial in this patient. Which of the following is the most likely basis for its therapeutic efficacy?
Select one:
a.
Stimulation of erythrocyte production
b.
Increase in production of haemoglobin A
c.
Increase in oxygen affinity of haemoglobin
d.
Increase in production of haemoglobin F
e.
Decrease in overall globin synthesis

Answer 16

Increase in production of haemoglobin F

Question 17

In an epidemiologic study of anaemias, the findings show that there is an increased prevalence of anaemia in individuals of West African ancestry. By haemoglobin electrophoresis, a subset of individuals of this ancestry are found to have increased haemoglobin S levels. The distribution of infectious illnesses is correlated with the prevalence of haemoglobin S in this population. Which of the following infectious agents is most likely to account for these observations?
Select one:
a.
Cryptococcus neoformans
b.
Borrelia burgdorferi
c.
Schistosoma haematobium
d.
Trypanosoma gambiense
e.
Treponema pallidum
f.
Clostridium perfringens
g.
Plasmodium falciparum

Answer 17

Plasmodium falciparum

Question 18

A 30-year-old woman has had a constant feeling of lethargy since childhood. On physical examination, she is afebrile and has a pulse of 80/min, respirations of 15/min, and blood pressure of 110/70 mm Hg. The spleen tip is palpable, but there is no abdominal pain or tenderness. Laboratory studies show haemoglobin of 117 g/L, platelet count of 159 x 10(9)/L, and WBC count of 5.4 x 10(9)/L. The peripheral blood smear shows spherocytosis. An inherited abnormality in which of the following RBC components best accounts for these findings?
Select one:
a.
α-Globin chain
b.
β-Globin chain
c.
Glucose-6-phosphate dehydrogenase
d.
Carbonic anhydrase
e.
Haem
f.
Membrane cytoskeletal protein

Answer 18

Membrane cytoskeletal protein

Question 19

A 22-year-old vegetarian woman complains of tiredness. She has two children aged 1 and 3 years. No abnormality is found on physical examination. Hb 92 g/L (120 - 155) MCV 69 fL (80 - 98) WBC 8.4 x 10(9)/L (4 - 11) differential normal. Platelets 490 x 10(9)/L (150 - 400).

The most likely diagnosis is:
Select one:
a.
Haemolytic anaemia
b.
Iron deficiency
c.
Alcoholism
d.
Autoimmune haemolytic anaemia
e.
Chronic myeloid leukaemia
f.
Acute leukaemia
g.
Aplastic anaemia
h.
Hereditary spherocytosis
i.
Folic acid deficiency
j.
Chronic disease
k.
Lead poisoning
l.
Vitamin B12 deficiency
m.
Thalassaemia
n.
Chronic lymphocytic leukaemia
o.
Primary myelofibrosis

Answer 19

Iron deficiency

Question 20

A 60-year-old man with osteoarthritis and on NSAIDs is becoming increasingly tired and listless. He occasionally passes dark stools. A full blood count indicates the following:
Haemoglobin 97 g/L
69.7 fL
MCV
White cell count 5.5

The most probable explanation is:
Select one:
a.
Autoimmune haemolytic anaemia
b.
Beta thalassaemia major
c.
Chronic alcoholism
d.
Iron deficiency
e.
Vitamin B12 deficiency

Answer 20

Iron deficiency

Question 21

Megaloblastic anaemia has two most likely causes, deficiency of folate and deficiency of cobalamin. In patients with cobalamin deficiency, treatment with folate improves the haematologic features but not in the neurologic symptoms. What is the most likely explanation for this?
Select one:
a.
Folate in high concentrations can serve as cofactor for the conversion of homocysteine to methionine
b.
Excess folate blunts the trapping of folate as N5-methyltetrahydrofolate
c.
Cobalamin deficiencies are not serious
d.
Excess folate directly inhibits the destruction of red blood cells
e.
Excess folate stimulates erythropoietic tissues to synthesize cobalamin in situ

Answer 21

Excess folate blunts the trapping of folate as N5-methyltetrahydrofolate

Question 22

A newborn baby is suspected to be suffering from neonatal sepsis. Which of the following abnormality in the peripheral blood picture is most helpful in reaching the diagnosis?
Select one:
a.
Hypochromia
b.
High percentage of band cells
c.
Microcytosis
d.
Thrombocytosis
e.
Reticulocytosis

Answer 22

High percentage of band cells

Question 23

A 20-year-old female is found to have the following blood report taken as part of a routine assessment. Hb 114 g/L (120 - 155) MCV 68 fL (80 - 98) WBC 7.2 x 10(9)/L (4 - 11) differential normal. Platelets 320 x 10(9)/L (150 - 400). No abnormal cells seen on blood film.

From the options provided, which is the most likely diagnosis:
Select one:
a.
Lead poisoning
b.
Hereditary spherocytosis - no
c.
Vitamin B12 deficiency
d.
Chronic myeloid leukaemia
e.
Chronic lymphocytic leukaemia
f.
Thalassaemia
g.
Autoimmune haemolytic anaemia
h.
Aplastic anaemia
i.
Chronic disease
j.
Acute leukaemia
k.
Alcoholism
l.
Haemolytic anaemia
m.
Folic acid deficiency

Answer 23

Thalassaemia

Question 24

A 25-year-old woman has a three year history of arthralgias. Physical examination shows no joint deformity, but she appears pale. Laboratory studies show haemoglobin of 125 g/L, platelet count of 217 x 10(9)/L, and WBC count of 5.9 x 10(9)/L. The peripheral blood smear shows hypochromic RBCs. Iron and ferritin levels are normal. Haemoglobin electrophoresis shows an elevated haemoglobin A2 level of 5.8%. What is the most likely diagnosis?
Select one:
a.
β-Thalassemia minor
b.
Autoimmune haemolytic anaemia
c.
Vitamin B12 deficiency
d.
Infection with Plasmodium vivax
e.
Alpha thalassaemia trait
f.
Iron deficiency anaemia
g.
Folate deficiency
h.
Anaemia of chronic disease

Answer 24

β-Thalassemia minor

Question 25

A 25 year old Mediterranean female with thalassemia major presents with jaundice. The colour of her stool and the colour of her urine are normal. Upon laboratory tests she is found to have an unconjugated hyperbilirubinaemia. Her peripheral blood smear shows a microcytic anaemia as well as target cells. What is the likely cause of her jaundice?
Select one:
a.
Hepatocellular jaundice
b.
Extrahepatic obstructive jaundice
c.
Intrahepatic obstructive jaundice
d.
Haemolytic jaundice
E.Obstructive jaundice consisting of both intrahepatic and extrahepatic obstruction

Answer 25

Haemolytic jaundice

Question 26

A 62-year-old woman complains of slowly progressive tiredness. There is a past history of hypothyroidism. She eats an adequate diet and has no gastrointestinal tract symptoms. Hb 72 g/L (120 - 155) MCV 110 fL (80 - 98) Neutrophils 2.1 x 10(9)/L (1.9 - 7.5) Platelets 135 x 10(9)/L (150 - 400) Blood film shows occasional hypersegmented neutrophils.

The most likely diagnosis is:
Select one:
a.
Vitamin B12 deficiency
b.
Chronic lymphocytic leukaemia
c.
Aplastic anaemia
d.
Acute leukaemia
e.
Thalassaemia
f.
Chronic myeloid leukaemia
g.
Autoimmune haemolytic anaemia
h.
Chronic disease
i.
Haemolytic anaemia
j.
Lead poisoning
k.
Folic acid deficiency
l.
Iron deficiency
m.
Alcoholism
n.
Primary myelofibrosis
o.
Hereditary spherocytosis

Answer 26

Vitamin B12 deficiency

Question 27

A 62-year-old woman complains of slowly progressive tiredness. There is a past history of hypothyroidism. She eats an adequate diet and has no gastrointestinal tract symptoms For this patient with anaemia select the most likely diagnosis:
Hb 72 g/L (120 - 155)
MCV 110 fL (80 - 98)
WBC 5.2 x 109/L (4 - 11)
Neutrophils 2.1 x 109/L (2 - 7.5)
Platelets 135 x 109/L (150 - 400)
Blood film shows occasional hypersegmented neutrophil.

Select one or more:
a.
Chronic disease
b.
Acute leukaemia
c.
Chronic lymphocytic leukaemia
d.
Lead poisoning
e.
Hereditary spherocytosis
f.
Thalassaemia
g.
Aplastic anaemia
h.
Primary myelofibrosis
i.
Iron deficiency
j.
Haemolytic anaemia
k.
Vitamin B12 deficiency
l.
Chronic disease
m.
Chronic myeloid leukaemia
n.
Alcoholism
o.
Folic acid deficiency
p.
Autoimmune haemolytic anaemia

Answer 27

Vitamin B12 deficiency

Question 28

A 73-year-old man has been healthy all his life. He takes no medications and has had no major illnesses or surgeries. For the past year, he has become increasingly tired and listless, and he appears pale. Physical examination shows no hepatosplenomegaly and no deformities. CBC shows haemoglobin 97 g/L; MCV 70 fL; platelet count, 331 x 10(9)/L and WBC count, 5.5 x 10(9)/L. Which of the following is the most likely underlying condition causing this patient’s findings?
Select one:
a.
Chronic alcoholism
b.
Autoimmune haemolytic anaemia
c.
β-Thalassemia major
d.
Haemophilia A
e.
Vitamin B 12 deficiency
f.
Occult malignancy

Answer 28

Occult malignancy

Question 29

A 65-year-old man diagnosed with follicular lymphoma is treated with chemotherapy. He develops fever and cough. On examination, there are bilateral pulmonary rales. A chest radiograph shows diffuse interstitial infiltrates. A shell vial assay of sputum is positive for cytomegalovirus. He develops scleral icterus. Laboratory studies show haemoglobin, 103 g/L; MCV 101 fL; neutrophil count 5.6 x 10(9)/L; and platelet count, 205 x 10(9)/L. His serum total bilirubin is 60 µmol/L, direct bilirubin is 8 µmol/L and haptoglobin is < 0.05 g/L. The direct antiglobulin test is positive. Which of the following is the most likely mechanism for his anaemia?
Select one:
a.
Binding of IgM to red blood cells
b.
Cytomegalovirus hepatitis
c.
Dietary folate deficiency
d.
Chemotherapeutic bone marrow toxicity
e.
Metastases to colon

Answer 29

Binding of IgM to red blood cells

Question 30

A 30-year-old woman reports becoming increasingly tired for the past five months. On physical examination, she is afebrile and has mild splenomegaly. Laboratory studies show a haemoglobin concentration of 118 g/L. The peripheral blood smear shows spherocytes and rare nucleated RBCs. The DAT is positive for IgG but negative for C3d. Which of the following underlying diseases is most likely to be diagnosed in this patient?
Select one:
a.
Systemic lupus erythematosus
b.
Mycoplasma pneumonia infection
c.
Escherichia coli septicaemia
d.
Hereditary spherocytosis
e.
Acute EBV infection

Answer 30

Systemic lupus erythematosus

Question 31

A 22-year-old woman has experienced malaise and a sore throat for two weeks. Her fingers turn white on exposure to cold. On physical examination, she has a temperature of 37.8°C, and the pharynx is erythematous. Laboratory findings include EBV-VCA-IgM. Direct and indirect antiglobulin test results are positive at 4°C, although not at 37°C. Which of the following substances on the surfaces of the RBCs most likely accounts for these findings?
Select one:
a.
IgG
b.
IgE
c.
Histamine
d.
Fibronectin
e.
Complement C3

Answer 31

Complement C3

Question 32

A 64 year old woman has a moderate macrocytic anaemia. Which of the following statements is correct?
Select one:
a.
The features are consistent with iron deficiency
b.
The features are diagnostic of the anaemia of chronic disease
c.
The features are diagnostic of Vitamin B12 deficiency
d.
The features are diagnostic of folic acid deficiency
e.
Vitamin B12 and folic acid levels should be measured

Answer 32

Vitamin B12 and folic acid levels should be measured