1.

Which of the following findings is

consistent with a diagnosis of megaloblastic
anemia?
a. Hyposegmentation of neutrophils (Pelger
Huet)
b. Decreased serum lactate dehydrogenase
SEPTEMBER 6, 2021 level
HEMATOLOGY c. Absolute increase in reticulocytes
(reticulocytopenia)
ASSESSMENT d. Increased MCV (>100 fL)

Characteristic features • Megaloblastic anemias are caused by

conditions that impair synthesis of
• Macrocytes >8mm in diameter
DNA, such as Vitamin B12/ Folic acid
• Ova
deficiency or myelodysplasia (cells are
• Basophilic stippling abnormal or immature in bone marrow).
• Pappenheimer bodies
• Howell-Jolly
• Nuclear maturation lags behind
• Cabot rings
cytoplasmic development as a result
• Dacrocytes (Myelofibrosis)
• *hypersegmented neutrophils= >6 lobes
of the impaired DNA synthesis. (Cells
become bigger and bigger, but less supply of thymidine
• * SENILE NEUTROPHILS molecules needed for nuclear maturation)

• This asynchrony between nuclear and • A megaloblastic anemia is characterized by

cytoplasmic development results in larger
cells.
• All cells of the body are ultimately affected
by the defective production of DNA
• Pernicious anemia is one cause of vitamin
B12 deficiency, whereas malabsorption
secondary to IBD (Inflammatory bowel disease) is
one cause of folate deficiency.
oval macrocytes and hypersegmented
neutrophils (senile neutrophils) in the
peripheral blood and by megaloblasts or
large nucleated RBC precursors in the
bone marrow.
• The MCV in megaloblastic anemia can be
markedly increased (up to 150 fL), but
modest increases (105-115 fL) occur as
well.
2. A patient has a clinical picture of
megaloblastic anemia. The serum folate
level (IBD) is decreased, and the serum
vitamin B12 level is 600 pg/mL (reference
interval is 200–900 pg/mL). (Normal vit B12)
What is the expected value for the
methylmalonic acid assay?
a. Increased
b. Decreased
c. Within the reference interval
** Dec in B12 = Inc in MMA
• One is isomerization of methylmalonyl
coenzyme A (CoA) to succinyl CoA,
which requires vitamin B12 (in the
adenosylcobalamin form) as a cofactor
and is catalyzed by the enzyme
methylmalonyl CoA mutase.
• Folate is the general term used for
any form of the vitamin folic acid.
• Folic acid is the synthetic form in
supplements and fortified food.
• Folates consist of a pteridine ring
attached to para-aminobenzoate
with one or more glutamate
residues.
• Vit B12 (Cobalamin) is an
essential nutrient consisting of a
tetrapyrrole (corrin) ring containing
cobalt that is attached to 5,6-
dimethylbenzimidazolyl
ribonucleotide.
• Vitamin B12 is a coenzyme in two
biochemical reactions in humans.
• In the absence of vitamin B12,
the impaired activity of
methylmalonyl CoA mutase
leads to a Inc. level of serum
methylmalonic acid (MMA),
which is useful for the
diagnosis of vitamin B12
deficiency
• The function of folate is to transfer carbon
units in the form of methyl groups from
donors to receptors.
• In this capacity, folate plays an important
role in the metabolism of amino acids and
nucleotides.
• Deficiency of the vitamin leads to impaired
cell replication and other metabolic
alterations.
3. Which one of the following statements
characterizes the relationships among
macrocytic anemia, megaloblastic
anemia, and pernicious anemia?
a. Macrocytic anemias are megaloblastic.
(Macrocytic anemias can be non-megaloblastic anemia)
b. Macrocytic anemia is pernicious
anemia. (Folic acid def. anemia)
c. Megaloblastic anemia is macrocytic.
d. Megaloblastic anemia is pernicious
anemia (… and myelodysplasia)

5. In the following description of a bone marrow smear, find the

4. Which of the following CBC findings is
most suggestive of a megaloblastic anemia?
a. MCV of 103 fL
b. Hypersegmentation of neutrophils
c. RDW of 16% (normal: 11.5% = 14.56)
(>14.5% : anisocytosis (different sizes)
(different in shape= poikolocytosis)
d. Hemoglobin concentration of 9.1 g/dL
(normal conc = 12-15 g/dL)
statement that is inconsistent with the expected picture in
megaloblastic anemia. “The marrow appears hypercellular with a
myeloid-to-erythroid ratio of 1:1 due to prominent erythroid
hyperplasia. Megakaryocytes appear normal in number and
appearance. The WBC elements appear larger than normal, with
especially large metamyelocytes, although they otherwise
appear morphologically normal. The RBC precursors also
appear large. There is nuclear-cytoplasmic asynchrony, with the
nucleus appearing more mature than expected for the color of
the cytoplasm.”
a. Erythroid nuclei that are more mature than cytoplasm
(cytoplasma is more mature than erythroid nuclei)
b. Larger than normal WBC elements
c. Larger than normal RBCs
d. Normal appearance of megakaryocytes
6. Which one of the following findings
would be inconsistent with elevated titers
of intrinsic factor blocking antibodies? (anti-
intrinsic factor= Pernicious anemia :
autoimmune hemolytic anemia : megaloblastic
anemia)
a. Hypersegmentation of neutrophils
b. Low levels of methylmalonic acid
c. Macrocytic RBCs
d. Low levels of vitamin B12
**Intrinsic factor: protein produced in the
stomach that binds Vit B12à move to the
intestinesà blood stream
• The vitamin B12-transcobalamin complex,
termed holotranscobalamin, is the
metabolically active form of vitamin B12.
• Holotranscobalamin binds to specific
receptors on the surfaces of many different
types of cells and enters the cells by
endocytosis, with subsequent release of
vitamin B12 from the carrier.
• The body maintains a substantial reserve of
absorbed vitamin B12 in hepatocytes.
(processing occurs in enterocytes)
8. Folate and vitamin B12
work together in the
production of:
a. Amino acids
b. RNA
c. Phospholipids
d. DNA
7. Which of the following is the most
metabolically active form of absorbed
vitamin B12? (whole= holo= active)
a. Transcobalamin
b. Intrinsic factor–vitamin B12 complex
c. Holotranscobalamin
d. Haptocorrin–vitamin B12 complex
• In the plasma, only 10% to
30% of the vitamin B12 is
bound to transcobalamin; the
remaining 75% is bound to
transcobalamin I and III,
referred to as the haptocorrins.
• Vitamin B12 and folate are needed for
the production of thymidine
nucleotides for DNA synthesis.
• Deficiencies of either vitamin impair
DNA replication, halt cell division, and
increase apoptosis (there is lysis),
which results in ineffective
hematopoiesis and megaloblastic
morphology of erythrocyte precursors.
• Lack of vitamin B12 leads to the
accumulation of MMA and
homocysteine.
• Folate deficiency, in particular,
leads to elevation of homocysteine
levels and possible risk of
coronary artery disease also
leading to ACS (acute coronary
syndrome).
9. The macrocytosis associated with megaloblastic
anemia results from:
a. Reduced numbers of cell divisions with normal
cytoplasmic development (cell division is reduced
due to nuclear lag)
b. Activation of a gene that is typically active only
in megakaryocytes
c. Reduced concentration of hemoglobin in the
cells so that larger cells are needed to provide the
same oxygen-carrying capacity
d. Increased production of reticulocytes in an
attempt to compensate for the anemia
10. Which one of the following
groups has the highest risk for
pernicious anemia?
a. Malnourished infants
b. Children during growth periods
c. Persons older than 60 years of
age
d. Pregnant women
• Folate deficiency may result from
inadequate intake, increased need with
growth or pregnancy, impaired absorption,
impaired use, or excessive loss.
• The action of folate can be impaired by
drugs such as those used to treat epilepsy
or cancer.
• Renal dialysis patients experience
significant folate loss to the dialysate.
• Slight macrocytosis often is the
earliest sign of megaloblastic anemia.
• Patients with uncomplicated
megaloblastic anemia are expected to
have decrease hemoglobin and
hematocrit values, pancytopenia,
thrombocytopenia & reticulocytopenia.
• Pernicious anemia is an autoimmune
disorder characterized by impaired
absorption of vitamin B12 due to a
lack of intrinsic factor.
• This condition is called pernicious
anemia because the disease was fatal
before its cause was discovered (fatal in
the past, before vitamin B12 treatments were available)
**Schilling Test: usual test for B12
• The incidence per year is
roughly 25 new cases per
100,000 persons older than 40
years of age.
• Pernicious anemia most often
manifests in the 6th decade or
later.
12. Idiopathic (means unknown
cause) acquired aplastic anemia
is due to a(n):
a. Drug reaction
b. Benzene exposure
c. Inherited mutation in stem
cells
d. Unknown cause
*Inherited (15% to 20% of
cases)
• Fanconi anemia
• Dyskeratosis congenita
• Shwachman Bodia Diamond
Syndrome
11. The clinical consequences of
pancytopenia (dec RBCs, dec
WBCs, dec platelets) include:
a. Pallor and thrombosis
b. Kidney failure and fever
c. Fatigue, infection, and bleeding
d. Weakness, hemolysis, and
infection
Etiologic Classification of Aplastic Anemia
Acquired (80% to 85% of cases)
*Idiopathic (70% of cases)
*Secondary (10% to 15% of cases)
-Dose dependent/predictable
• Cytotoxic drugs
• Benzene
• Radiation
- Idiosyncratic
•Drugs
•Chemicals
Insecticides
Cutting/lubricating oils
-Viruses
• Epstein-Barr virus
• Hepatitis virus (non-A, non-B, non-C, non-G)
• Human immunodeficiency virus
- Miscellaneous conditions
• Paroxysmal nocturnal hemoglobinuria
• Autoimmune diseases
• Pregnancy
13. The pathophysiologic mechanism in acquired
idiosyncratic aplastic anemia is:
• a. Replacement of bone marrow by abnormal
cells – (Myelophthisic anemia)
• b. Destruction of stem cells by autoimmune T
cells
• c. Defective production of hematopoietic growth
factors (inherited deficiency in Hematopeitic stem
cell growth factors à Myelophthisic)
• d. Inability of bone marrow stroma to support
stem cells – (Myelophthisic anemia)
• **Replacement of fibrous tissue= Myelofirbosis
• Bone marrow failure in
acquired aplastic anemia
occurs from destruction of
hematopoietic stem cells by
direct toxic effects of a drug,
autoimmune T-cell targeting of
stem cells, or other unknown
mechanisms.
14. The most consistent peripheral blood findings
in severe aplastic anemia are:
a. Hairy cells, monocytopenia, and neutropenia -
(Lymphoproliferative disease)
b. Macrocytosis, thrombocytopenia, and
neutropenia
c. Blasts, immature granulocytes, and
thrombocytopenia –(AML or Acute Promyelocytic
Leukemia =APL-> DIC)
d. Polychromasia, nucleated RBCs, and
hypersegmented neutrophils– (Megaloblastic
anemia with some DNA synthesis due to Vit B12
supp
• Aplastic anemia is classified as
nonsevere, severe, or very severe,
based on bone marrow
hypocellularity, absolute neutrophil
count, platelet count, hemoglobin
level, and reticulocyte count.
• The severity classification helps to
guide treatment decisions.
• The autoimmune reactions are
rare adverse events after
exposure to drugs, chemicals, or
viruses.
• They are idiosyncratic in that they
are unpredictable, and severity is
unrelated to the dose or duration
of exposure.
15. The treatment that has shown the best
success rate in young patients with severe
aplastic anemia is:
a. Immunosuppressive therapy
b. Long-term red blood cell and platelet
transfusions
c. Administration of hematopoietic growth
factors and androgens
d. Stem cell transplant with an HLA-identical
sibling
• Preferred treatment for severe and
very severe acquired aplastic anemia
is hematopoietic stem cell
transplant (HSCT) for younger
patients with an HLA-identical
sibling.
• For those without a matched sibling
donor and for those who are not HSCT
candidates, immunosuppressive
therapy with antithymocyte globulin
and cyclosphorine is recommended.
16. The test that is most useful in differentiating FA
from other causes of pancytopenia is:
a. Bone marrow biopsy (applicable to almost all
aplasia or aplastic anemia, so it cant differentiate)
b. Ham acidified serum test (screening test for
PNH or Paroxysmal Nocturnal Hemoglobinuria)
c. Diepoxybutane-induced chromosome breakage
d. Flow cytometric analysis of CD55 and CD59
cells (confirmatory for PNH)
**CD55: DAF (Decay Accelerating Factor)
**CD59: MIRL (Membrane Inhibitor of reactive
lysis)
**CD55 and CD59 are ”Protectins”
• A positive chromosome breakage study
with diepoxybutane is diagnostic.
• DKC can be auto. Dom, auto reces, & X-
linked, and mutations in 8 genes have
been identified.
• SBDS is auto rece. and is associated
with mutations in the SBDS gene.
• Telomerase complex defects play a
role in the pathophysiology of inherited
aplastic anemias and some acquired
aplastic anemias.
• The defects result in the inability of
telomerase to extend or elongate the
telomeres which leads to premature
hematopoietic stem cell senescence
and apoptosis.
• Fanconi anemia (FA), dyskeratosis
congenita (DKC), and Shwachman-
Bodian-Diamond syndrome (SBDS) are
inherited forms of aplastic anemia with
progressive bone marrow failure and
patients may present with characteristic
Physical malformations.
• FA is inherited in an autosomal recessive &
X-linked pattern, and mutations in __ genes
have been identified.
17. Mutations in genes that code for the
telomerase complex may induce bone marrow
failure by causing which one of the following?
a. Resistance of stem cells to normal apoptosis
b. Autoimmune reaction against telomeres in
stem cells
c. Decreased production of hematopoietic
growth factors
d. Premature death of hematopoietic stem cells
18. Diamond-Blackfan anemia
(Pure red cell aplasia) differs from
inherited aplastic anemia in that in
the former:
a. Reticulocyte count is increased
b. Fetal hemoglobin is decreased
c. Only erythropoiesis is affected
d. Congenital malformations are
absent
• Pure red cell aplasia is a disorder of
erythrocyte production.
• Acquired TEC (Transient
Erythroblastopenia in childhood and DBA
(Diamond-Blackfan anemia) are disparate
subtypes with distinct etiologies, clinical
features, and courses.
• Mutations in 9 different ribosomal protein
genes have been identified in DBA.
• The congenital dyserythropoietic
anemias (CDAs) are a heterogeneous
group of rare disorders characterized
by refractory anemia,
reticulocytopenia, hypercellular bone
marrow with markedly ineffective
erythropoiesis, and distinctive
dysplastic changes in bone marrow
erythroblasts.
Refractory Anemia
• A type low-risk MDS anemia
characterized by mono-lineage
dysplasia, anemia,
dyserythropoiesis, and low
percentage of blasts in bone
marrow and peripheral blood.
19. Which anemia should be suspected
in a patient with refractory anemia,
reticulocytopenia, hemosiderosis,
and binucleated erythrocyte
precursors in the bone marrow?
a. Fanconi anemia
b. Dyskeratosis congenita
c. Acquired aplastic anemia
d. Congenital dyserythropoietic anemia .
• Secondary hemosiderosis arises
from chronic intramedullary and
extramedullary hemolysis as well
as increased iron absorption
associated with ineffective
erythropoiesis.
• Iron overload develops even in the
absence of blood transfusions.
Fanconi’s anemia
Physical malformation
•
• Macrocytosis
• Elevated HbF
Anemia
•
• Neutropenia
• Thrombocytopenia
• Duplications and triplications of the long arm of
chromosome 1
• Gains of the portions of long arms of chromosome 3
• Monosomy 7
 Acquired Aplastic Anemia
• Hypocellular; blasts and abnormal cells
absent;
• Reticulin normal; RBC dyspoiesis may be
present;
• WBC and platelet dyspoiesis absent
• PNH cells* may be present;
• Chromosome abnormalities may be
present
• No splenomegaly
20. The primary pathophysiologic
mechanism of anemia associated with
chronic kidney disease is:
a. Inadequate production of
erythropoietin
b. Excessive hemolysis
c. Hematopoietic stem cell mutation
d. Toxic destruction of stem cells
Sperocytes
Elliptocytes
Acanthocytes
Burr cells
Schistocytes
Erythrophagocytosis
RBC agglutination
DKC (Dyskeratosis congenita)
• Moderate Pancytopenia
• Marked hypocellular marrow
(<10%)
• Reduced trilineage
hematopoiesis
• No evidence of malignancy
• Anemia is a common complication of chronic
kidney disease (CKD), with a positive correlation
between anemia and renal disease severity
• The primary cause of anemia in CKD is inadequate
production of erythropoietin.
• Without erythropoietin, the bone marrow lacks
adequate stimulation to produce RBCs.
• Another contributor to the anemia of CKD is uremia
(production of burr cells/ echinocytes; uremia is
associated with HUS -> EHEC) which inhibits
erythropoiesis and increases RBC fragility.
21. The term hemolytic disorder in general
refers to a disorder in which there is:
a. Increased destruction of RBCs after they
enter the bloodstream
b. Excessive loss of RBCs from the body
(hemorrhage)
c. Inadequate RBC production by the bone
marrow (aplasia)
d. Increased plasma volume with unchanged
red cell mass (hemodilution)
**hemodilution can be seen in voluminous
transfusions

22. RBC destruction that occurs
when macrophages ingest and
destroy RBCs is termed:
a. Extracellular
b. Macrophage-mediated
c. Intra-organ
d. Extrahematopoietic
23. A sign of hemolysis that is
typically associated with both
fragmentation and macrophage-
mediated hemolysis is:
a. Hemoglobinuria (IVH)
b. Hemosiderinuria (IVH)
c. Hemoglobinemia (IVH)
d. Elevated urinary urobilinogen level
• When only the unconjugated
(indirect) B1 fraction of the total
serum bilirubin is elevated,
hemolytic jaundice is confirmed.
• An elevated urinary urobilinogen
level strengthens the conclusion.
Differential Diagnosis for hemolytic anemias
1
2
3
4
5
6
7
8
9
10
1.
2.
hemolysis, acute, fragmentation (IVH)
H, A, MM, (EVH)
3. H, Chronic, Fragmentation type (IVH)
4.
5.
H, C, MM, (EVH)
Hemorrhage or Hemodilution
6. Hemorrhage or Hemodilution
7. Recovery from hemorrhage
8. Treated anemia (with iron, vitB12, Folic acid)
9. Hemorrhage into a body cavity
10. Ineffective erythropoiesis (Megalobastic anemia and drugs)
• A rapid decrease in hemoglobin
concentration (e.g., 1 g/dL per week)
from levels previously within the
reference interval can signal
hemolysis when hemorrhage and
hemodilution have been ruled out.
• Jaundice and reticulocytosis provide
additional confirmation of a hemolytic
cause for an anemia of at least several
days duration.
• The rapid decrease in hemoglobin
during an acute hemolytic episode,
however, usually is apparent before
reticulocytosis and bilirubinemia
develop.
• For acute hemolysis, hemoglobinemia
and hemoglobinuria are expected with
fragmentation causes; therefore, their
absence suggests a macrophage-
mediated cause.

•RBC morphology and
haptoglobin levels can
assist in differentiating
fragmentation from a
macrophage-mediated
cause.
25. Which of the following tests
provides a good indication of
accelerated erythropoiesis?
a. Urine urobilinogen level
b. Hemosiderin level
c. Reticulocyte count
d. Glycated hemoglobin level
** high RPI (Reticulocyte
production index)= compensation
24. An elderly white woman is evaluated for worsening
anemia, with a decrease of approximately 0.5 mg/dL of
hemoglobin each week. The patient is pale, and her
skin and eyes are slightly yellow. She complains of
extreme fatigue and is unable to complete the tasks of
daily living without napping in midmorning and
midafternoon. She also tires with exertion, finding it
difficult to climb even five stairs. Which of the features
of this description points to a hemolytic cause (inc in
B1 bilirubin) for her anemia?
a. Pallor
b. Yellow skin and eyes (Ictericia & jaundice)
c. Need for naps
d. Tiredness on exertion
Laboratory Evaluation of Hemolysis
*Hematologic Intravascular Extravascular
(fragmentation) (Macrophage-Mediated)
Blood film Reticulocytosis Polychromasia
Reticulocyte Inc Inc
Bone marrow Erythroid Erythroid
hyperplasia hyperplasia
*Serum or Plasma Inc Bi
Bilirubin
Inc Bi
Haptoglobin Dec to absent Normal to Dec to
Absent
Plasma free Inc Inc Normal to Inc
hemoglobin
26. A 5-year-old girl was seen by her physician
several days prior to this visit and was diagnosed
with pneumonia. Her mother has brought her to the
physician again because the girl’s urine began to
darken after the first visit and now is alarmingly dark.
The girl has no history of anemia, and there is no
family history (Acquired) of any hematologic
disorder. The CBC shows a mild anemia,
polychromasia, and a few schistocytes. This anemia
could be categorized as: (IVH=fragmentation)
a. Acquired, fragmentation
b. Acquired, macrophage-mediated
c. Hereditary, fragmentation
d. Hereditary, macrophage-mediated
27. A patient has a personal and family history of a mild
hemolytic anemia. The patient has consistently elevated
levels of total and indirect serum bilirubin and urinary
urobilinogen. The serum haptoglobin level is consistently
decreased, whereas the reticulocyte count is elevated. The
latter can be seen as polychromasia on the patient’s blood
film, along with spherocytes. Which of the findings reported
for this patient is inconsistent with a classical diagnosis of
fragmentation hemolysis? a. Elevated total and indirect
serum bilirubin
• b. Elevated urinary urobilinogen
• c. Decreased haptoglobin
• d. Spherocytes on the peripheral film
• **(fragmentation= shistocytes)
• **(MM= spherocytes)
28. Select the statement that is true about bilirubin
metabolism.
a. Indirect bilirubin Direct Bilirubin is formed in the
liver by the addition of two sugar molecules to
direct bilirubin.
b. Macrophages of the spleen liberate bilirubin
during hemoglobin catabolism.
c. Urobilinogen is not water soluble and is not
excreted in the urine.
d. Normally, the major fraction of bilirubin in the
blood is the direct (conjugated) Indirect
(unconjugated) form released from macrophages.

29. A patient has anemia that has been worsening over the last 30. Which of the following sets of test results
several months. The hemoglobin level has been declining slowly,
with a drop of 1.5 g/dL of hemoglobin over about 6 weeks. is typically expected with chronic
Polychromasia and anisocytosis are seen on the blood film,
consistent with the elevated reticulocyte count and RBC fragmentation hemolysis?
distribution width (RDW). Serum levels of total bilirubin and
indirect fractions are normal. Urinary urobilinogen level also is (Fragmentation: shcistocytes, IVH)
normal. When these findings are evaluated, the conclusion is
drawn that the anemia does not have a hemolytic component. • Serum Haptoglobin (Dec)
Based on the data given here, why was hemolysis ruled out as
the cause of the anemia? (if Hemolytic: Inc B1, Inc • Urine Hemoglobin (+)
Phtoporphyrin metabolism, yellow)
a. The decline in hemoglobin is too gradual to be associated with • Urine Sediment Prussian Blue Stain (+)
hemolysis.
b. The elevation of the reticulocyte count suggests a malignant
a. Increased Positive Positive
cause. b. Decreased Negative Negative
c. Evidence of increased protoporphyrin catabolism is lacking.
d. Elevated RDW points to an anemia of decreased production. c. Decreased Positive Positive
d. Increased Positive Negative

31. In HS (hereditary • Hereditary spherocytosis arises

Spherocytosis) (spherocytes) a
from defects in proteins that
characteristic abnormality in the
CBC results is: (Not macrocytic) provide vertical support for the
membrane.
• a. Increased MCV
• Hereditary elliptocytosis is due
• b. Increased MCHC
to defects in cytoskeletal proteins
• c. Decreased MCH (Inc MCH)
that provide horizontal support for
• d. Decreased platelet and WBC
the membrane.
counts (normal)

•Blood smear shows
Spherocytes and
polychromosia (reticulocytosis)
•Hemoglobin electrophoresis is
normal.
•MCHC usually >36 g/dL.
•Inc. retics, Inc. osmotic fragility.
32. The altered shape of the spherocyte in HS is
due to:
a. An abnormal RBC membrane protein affecting
vertical protein interactions
b. Defective RNA synthesis (lymohoytes:
agammaglobulinemia; ”Bruton’s”) (drugs,
chemicals, sensitizers)
c. An extrinsic factor in the plasma (Multiple
myeloma)
d. Abnormality in the globin composition of the
hemoglobin molecule (hemoglobinopathies)
34. The RBCs in HE are abnormally shaped and
have unstable cell membranes as a result of:
a. Abnormal shear stresses in the circulation
(MAHA- Macro/micro-angipatic hereditary anemia;
Heriditary stomatocytosis)
b. Defects in horizontal membrane protein
interactions
c. Mutations in ankyrin (Heriditary sterocytosis)
d. Lack of all Rh antigens in the RBC membrane
(Heriditary stomatocytosis)
• Diagnostic of Hereditary spherocytosis:
Osmotic Fragility Test (OFT)
• Blood is added to serial dilutions of NaCl &
incubated.
• Amount of hemolysis determined by reading
absorbance of supernatant from each tube.
• ↑ in HS
• ↓ with TIST: Target cells, IDA, SCA,
Thalassemia.
• **Target cells: Liver disease
• **Leptocytes: Codocytes
33. Which of the following results are consistent
with HS?
a. Increased osmotic fragility, negative DAT result
b. Decreased osmotic fragility, positive DAT result
c. Increased osmotic fragility, positive DAT result
d. Decreased osmotic fragility, negative DAT result
**Herditary S: INC Osmotic fragility
** Acquired: DEC Osmotic Fragility
**HS is non-immune
**HIV infection: SIADH -> Lunh problemà P.
carnii/ P. jiroveci
35. The peripheral blood film for patients with
mild HE (Hereditary Elliptocytosis) is
characterized by:
a. Elliptical RBCs
b. Oval RBCs with one or two transverse
ridges
c. Overhydrated RBCs with oval central pallor
d. Densely stained RBCs with a few irregular
projections
 South East Asian Ovalocytosis
•Defect in band 3 causing
increased membrane rigidity.
•Only exists in heterozygous
State 30% oval cells with
one or two transverse
ridges.
Overhydrated Hereditary Stomatocytosis
• Increased membrane permeability to
sodium and potassium;
• increased intracellular sodium causing
influx of water, increase in cell volume,
and decreased cytoplasmic viscosity
• Stomatocytes (5%–50%),
• macrocytes
36. Laboratory test results for patients with
HPP (microspherocytes) include all of the
following except:
a. RBCs that show marked thermal
sensitivity at 41° C to 45° C
b. Marked poikilocytosis with elliptocytes,
RBC fragments, and microspherocytes
c. Low fluorescence when incubated with
eosin-5’-maleimide
d. Increased MCV and normal RDW (Dec
MCV and Inc RDW
Hereditary Pyropoikilocytosis
commonly associated with burn patients and electrocution
• Severe defect in spectrin that disrupts
horizontal linkages in protein
cytoskeleton;
• Severe RBC fragmentation
• Elliptocytes,
• Schistocytes,
• Microspherocytes
Dehydrated Hereditary Stomatocytosis
• Increased membrane permeability
to potassium;
• decreased intracellular potassium,
resulting in loss of water from cell,
• decrease in cell volume,
• increased cytoplasmic viscosity
• **PIEZO TYPE MECHANOSENSITIVE
37. Acanthocytes are found in association
with:
a. Abetalipoproteinemia
b. G6PD deficiency (Bite cells, Heinz
bodies)
c. Rh deficiency syndrome (stomatocytes)
d. Vitamin B12 deficiency
(Diphyllobothiasis)
Basophilic
stippling
Howell Jolly
bodies
Cabot rings
Pappenheimer
bodes
38. The most common manifestation of
G6PD deficiency is:
a. Chronic hemolytic anemia caused by cell
shape change
b. Acute hemolytic anemia caused by drug
exposure or infections
c. Mild compensated hemolysis caused by
ATP deficiency– blood parasites
d. Chronic hemolytic anemia caused by
intravascular RBC lysis– IgM related AIHA
• Oxidation converts hemoglobin to
methemoglobin and forms
sulfhydryl groups and disulfide
bridges in hemoglobin
polypeptides.
• This leads to decreased
hemoglobin solubility and
precipitation as heinz bodies
Sideotic
granules
Retics
(Brilliant Cresyl
Blue BCB)
Heinz bodies
• G6PD-deficient RBCs cannot generate
sufficient NADPH to reduce
Glutathione and thus cannot
effectively detoxify the hydrogen
peroxide produced upon exposure to
oxidative stress.
• Oxidative damage to cellular proteins
and lipids occurs, particularly affecting
hemoglobin and the cell membrane.
39. A patient experiences an episode of acute
intravascular hemolysis after taking primaquine for
the first time. The physician suspects that the
patient may have G6PD deficiency and orders an
RBC G6PD assay 2 days after the hemolytic
episode begins. How will this affect the test result?
a. No effect
b. False increase due to reticulocytosis
c. False decrease due to hemoglobinemia
d. Absence of enzyme activity
** Falsely Inc/ Normal results in G6PD is due to
reticulocytosis, leukocytosis, thrombocytosis.
• Reticulocytosis typically occurs as a response
to an acute hemolytic episode and will falsely
increase the patient’s G6PD activity over
baseline values.
• Patients who are not G6PD deficient are
expected to have high G6PD activity during
hemolytic episodes.
• When a patient with reticulocytosis has an
unexpectedly normal G6PD activity result,
G6PD deficiency should be suspected.
• G6PD= N = Inc
• G6PD= Dec = N
• To avoid falsely elevated or falsely
normal results, biochemical assays for
G6PD activity should not be performed
during acute hemolysis.
• The testing should be performed after
the reticulocyte and total RBC counts
have returned to baseline, which may
take 2 weeks to 2 months after the
hemolytic episode

40. The most common defect or

•G6PD is the most common
deficiency in the anaerobic glycolytic
pathway that causes chronic HNSHA RBC enzymopathy, but the
(non-spherocytic) is: vast majority of patients are
a. Pyruvate kinase deficiency. asymptomatic.
b. Lactate dehydrogenase deficiency
c. Glucose-6-phosphate
dehydrogenase deficiency
d. Methemoglobin reductase deficiency

• Patients with classes II and III G6PD

variants may develop acute hemolytic
anemia after infections or after
ingestion of certain drugs or fava
beans
• A small percentage of patients have
class I G6PD variant and chronic
hereditary nonspherocytic hemolytic
anemia (HNSHA).
• Most patients with PK pyruvate
kinase deficiency have symptoms
of hemolysis.
• Burr cells cells are commonly
observed on the peripheral blood
film.
• PK deficiency is the most common
cause of HNSHA.
41. Which of the following laboratory tests would be
best to confirm PNH?
a. Acidified serum test (Ham test) (screening of DNH- less
sensitive)
b. Osmotic fragility test (screening of DNH- less sensitive)
c. Flow cytometry for detection of eosin-59-
maleimide binding on erythrocytes (Heriditary
spherocytosis: decreased )
d. Flow cytometry for detection of CD55, CD59, and
FLAER binding on neutrophils and monocytes –
Fluorescein-labeled proaerolysin
**phosphatidylinositol glycan–class A (PIG-A) mutations
42. Which one of the following is a feature found in
all microangiopathic hemolytic anemias?
a. Pancytopenia
b. Thrombocytosis
c. Intravascular RBC fragmentation
d. Prolonged prothrombin time and partial
thromboplastin time
COMMON FACTOR DEFICINECIES:
(X, V, II- thrombin, I- fibrinogen)

•Microangiopathic hemolytic • The RBC fragmentation occurs

anemias (MAHAs) are a intravascularly by the mechanical
group of potentially life- shearing of RBC membranes as
the cells rapidly pass through
threatening disorders turbulent areas of small blood
characterized by RBC vessels that are partially blocked
Fragmentation and by microthrombi or damaged
Thrombocytopenia. endothelium

• Upon shearing, RBC membranes 43. Typical laboratory findings in TTP

quickly reseal with minimal escape of and HUS include:
hemoglobin, but the resulting a. Schistocytosis and thrombocytopenia
fragments (called schistocytes) are b. Anemia and reticulocytopenia
distorted and become rigid. c. Reduced levels of lactate
• The spleen clears the rigid RBC dehydrogenase and aspartate
fragments from the circulation through aminotransferase
the extravascular hemolytic process d. Increased levels of free plasma
hemoglobin and serum haptoglobin

• The major microangiopathic hemolytic
anemias include
• Thrombotic thrombocytopenia purpura
(TTP),
• Hemolytic uremic syndrome (HUS),
• HELLP (Hemolysis, Elevated Liver
enzymes, Low PH) syndrome
• Dessimenated intravascular coagulation
(DIC)
• TTP can be idiopathic, secondary, or
inherited.
• Idiopathic TTP has no known
precipitating event.
• In idiopathic TTP, autoantibodies to
ADAMTS-13 inhibit its activity, causing
a severe deficiency.
• These autoantibodies are usually of
the IgG class but can be IgM or IgA.
• Secondary TTP is very
heterogeneous, and the
mechanisms that trigger the
TTP pathophysiology are not
completely clear.
44. The pathophysiology of idiopathic TTP involves:
a. Shiga toxin (assoc with ETEC) damage to endothelial
cells (assoc with HUS) and obstruction of small blood
vessels in glomeruli
b. Formation of platelet-VWF thrombi due to autoantibody
inhibition of ADAMTS-13
c. Overactivation of the complement system and
endothelial cell damage due to loss of regulatory function
à HUS
d. Activation of the coagulation and fibrinolytic systems with
fibrin clots throughout the microvasculature à DIC & HUS
• Secondary TTP can be triggered by infections,
pregnancy, surgery, trauma, inflammation, and
disseminated malignancy, possibly by depressing
the synthesis of ADAMTS-13.
• Other conditions may induce an inhibitory
reaction to ADAMTS-13, including (HAHQTT),
HSCT (Hemotopoietic stem cell transplantation),
Autoimmune disease, HIV, Trimethroprim,
Ticlopidine
45. Which one of the following laboratory
results may be seen in BOTH traumatic
cardiac hemolytic anemia and exercise-
induced hemoglobinuria?
a. Schistocytes on the peripheral blood
film
b. Thrombocytopenia
c. Decreased serum haptoglobin
d. Hemosiderinuria
46. Which of the following species of
Plasmodium produce hypnozoites that
can remain dormant in the liver and
cause a relapse months or years later?
a. P. falciparum
b. P. vivax or P. ovale
c. P. knowlesi
d. P. malariae
48. Which Plasmodium species is
widespread in Malaysia, has RBCs with
multiple ring forms, has band-shaped early
trophozoites, shows a 24-hour erythrocytic
cycle, and can cause severe disease and
high parasitemia?
• a. P. falciparum
• b. P. vivax
• c. P. knowlesi
• d. P. malariae
50. What RBC morphology is characteristically
found within the first 24 hours following extensive
burn injury?
a. Macrocytosis and polychromasia (compensated
anemia)
b. Burr cells and crenated cells (uremia)
c. Howell-Jolly bodies and bite cells (splenectomy
& G6PD)
d. Schistocytes and microspherocytes
47. Which one of the following is not a mechanism causing
anemia in P. falciparum infections?
a. Inhibition of erythropoiesis
b. Lysis of infected RBCs during schizogony
c. Competition for vitamin B12 in the erythrocyte --
Diphyllobothriasis
d. Immune destruction of noninfected RBCs in the spleen
Blind Loops:
- also associated with competition of vit B12
- Ocurs in stenotic (narrowed) intestines --> inflammation
and surgery à bacteria may lurk in this area and
competes for vit B12
49. One week after returning from a vacation in Rhode
Island, a 60-year-old man experienced fever, chills,
nausea, muscle aches, and fatigue of 2 days’ duration. A
complete blood count (CBC) showed a WBC count of 4.5 x
109/L, hemoglobin level of 10.5 g/dL, a platelet count of
134 x 109/L, and a reticulocyte count of 2.7%. The medical
laboratory scientist noticed tiny ameboid ring forms in some
of the RBCs and some tetrad forms in others. These
findings suggest:
a. Bartonellosis
b. Malaria
c. Babesiosis
d. Clostridial sepsis
51. Which of the following tests yields
results that are abnormal in DIC but are
usually within the reference interval or just
slightly abnormal in TTP and HUS?
a. Indirect serum bilirubin and serum
haptoglobin
b. Prothrombin time and partial
thromboplastin time
c. Lactate dehydrogenase and aspartate
aminotransferase
d. Serum creatinine and serum total protein
52. Immune hemolytic anemia is due to a(n):
a. Structural defect in the RBC membrane
b. Allo- or autoantibody against an RBC
antigen
c. T cell immune response against an RBC
antigen
d. Obstruction of blood flow by intravascular
thrombi
54. In hemolysis mediated by IgG
antibodies, which abnormal RBC
morphology is typically observed on the
peripheral blood film?
a. Spherocytes
b. Nucleated RBCs (severe anemia)
c. RBC agglutination
d. Macrocytes
• IgG antibodies are not efficient in
activating complement, and
intravascular hemolysis by full
activation of complement from C1
to C9 is rare (except with anti-P1
in paroxysmal cold
hemoglobinuria)
53. The pathophysiology of immune
hemolysis with IgM antibodies
always involves:
• a. Complement
• b. Autoantibodies
• c. Abnormal hemoglobin
molecules
• d. Alloantibodies
• Hemolysis mediated by IgG antibodies
occurs with or without complement
and predominantly by extravascular
mechanisms.
• RBCs sensitized with IgG are removed
from circulation by macrophages in the
spleen, which have receptors for the
Fc component of IgG1 and IgG3
• Often, IgG-sensitized RBCs are
only partially phagocytized by
macrophages, which results in the
removal of some membrane.
• Sperocytes are the result of this
process, and they are the
characteristic cell of IgG-mediated
hemolysis
55. The most important finding in the diagnostic
investigation of a suspected autoimmune
hemolytic anemia is:
a. Detection of a low hemoglobin and hematocrit
b. Observation of hemoglobinemia in a specimen
c. Recognition of a low reticulocyte count
d. Demonstration of IgG and/or C3d on the RBC
surface
• The types of genetic mutations
that occur in the
hemoglobinopathies include point
mutations, deletions, insertions,
and fusions involving one or more
of the adult globin genes alpha,
beta, gamma, delta
57. The substitution of valine for glutamic
acid at position 6 of the B chain of
hemoglobin results in hemoglobin that: a2b2
6 gluval = Hgb S
a. Is unstable and precipitates as Heinz
bodies *congenital Heinz bodies anemia
b. Polymerizes to form tactoid crystals
c. Crystallizes in a hexagonal shape *a2b2 6
glulys = Hbg C
d. Contains iron in the ferric (Fe31) state
56. A qualitative abnormality in hemoglobin may
involve all of the following except:
a. Replacement of one or more amino acids in a
globin chain *hemoglobinopathies
b. Addition of one or more amino acids in a globin
chain *hemoglobinopathies
c. Deletion of one or more amino acids in a globin
chain *hemoglobinopathies
d. Decreased production of a globin chain
*thalassemia
• Deletions involve the removal of one or
more nucleotides, whereas insertions result
in the addition of one or more nucleotides.
• Usually deletions and insertions are not
divisible by three and disrupt the reading
frame, which leads to the nullification of
synthesis of the corresponding globin
chain.
• This is the case for the quantitative
thalassemias.
Hb SC-Harlem (Hb C-Georgetown)
 58. Patients with SCD usually do not
exhibit symptoms until 6 months of age
because:
a. The mother’s blood has a protective
effect
b. Hemoglobin levels are higher in
infants at birth
c. Higher levels of Hb F are present
d. The immune system is not fully
developed

• Individuals affected with SCD are Positive result in hemoglobin solubility

characteristically symptom free until the
second half of the first year of life because
of the protective effect of Hb F.
• Toward the end of the first 6 months of life,
mutated beta chains begin to be produced
and gradually replace normal gamma
chains, which causes Hb S levels to
increase and Hb F levels to decrease.
test: Turbidity and precipitation
• Erythrocytes containing Hb S
become susceptible to hemolysis,
and a progressive hemolytic
anemia and splenomegaly may
become evident.

59. Which of the following is the most

definitive test for Hb S?
• a. Hemoglobin solubility test
• b. Hemoglobin electrophoresis at alkaline
pH
• c. Osmotic fragility test
• d. Hemoglobin electrophoresis at acid pH
• *confirmatory test
60. Which of the following is the principle for WBC
measurement in Abbott CELL-DYN Sapphire?

a. Impedance volume and conductivity and five-

angle light scatter measurement *Beckman Coulter
b. Fluorescent staining; forward light scatter and
side fluorescent light detection *Sysmex XN
c. Light scatter and impedance
d. Light scatter and absorption *Siemens ADVIA