MLPAO Hematology and Coagulation Case Studies 2 — Questions and Answers
Question 1: A patient has hemoglobin 70 g/L, MCV 110 fL, hypersegmented neutrophils, and elevated methylmalonic acid. What is the most likely diagnosis?
- Folate deficiency
- Vitamin B12 deficiency (Correct answer)
- Myelodysplastic syndrome
- Liver disease
Correct answer: Vitamin B12 deficiency
Macrocytic anemia with hypersegmented neutrophils indicates megaloblastic anemia. The elevated methylmalonic acid (MMA) specifically distinguishes vitamin B12 deficiency from folate deficiency, as MMA requires B12-dependent methylmalonyl-CoA mutase. MMA is normal in folate deficiency but elevated in B12 deficiency.
Question 2: A patient has WBC 150 × 10⁹/L with a differential showing a full spectrum of myeloid maturation from blasts to mature neutrophils, basophilia, and splenomegaly. What is the most likely diagnosis?
- Acute myeloid leukemia
- Chronic myeloid leukemia (Correct answer)
- Leukemoid reaction
- Myelofibrosis
Correct answer: Chronic myeloid leukemia
The hallmark of CML is an extremely elevated WBC with a complete spectrum of myeloid maturation ('pathological left shift'), basophilia, and massive splenomegaly. Unlike AML (blast predominance) or leukemoid reaction (no basophilia, positive LAP score), CML shows orderly maturation. Philadelphia chromosome/BCR-ABL1 testing confirms the diagnosis.
Question 3: A sample has a platelet count of 50 × 10⁹/L by impedance but the smear shows platelet clumps. What should the technologist do?
- Report the result as is
- Recollect in a sodium citrate tube to rule out EDTA-dependent pseudothrombocytopenia (Correct answer)
- Request a new EDTA sample only
- Report as critically low and notify physician immediately
Correct answer: Recollect in a sodium citrate tube to rule out EDTA-dependent pseudothrombocytopenia
Platelet clumping in EDTA is a well-known cause of pseudothrombocytopenia. EDTA can cause antibody-mediated platelet clumping in some patients. Recollection in sodium citrate (blue-top) often resolves the clumping. The platelet count from the citrate tube must be multiplied by 1.1 to correct for the dilution factor.
Question 4: A patient has pancytopenia with 25% blasts in the peripheral blood. What is the most likely category of disease?
- Aplastic anemia
- Acute leukemia (Correct answer)
- Chronic myeloproliferative neoplasm
- Vitamin B12 deficiency
Correct answer: Acute leukemia
The presence of ≥20% blasts in peripheral blood or bone marrow defines acute leukemia (by WHO classification). Pancytopenia results from marrow replacement by leukemic blasts, suppressing normal hematopoiesis. Flow cytometry and cytogenetics are needed to classify as AML or ALL and determine prognosis.
Question 5: A patient taking unfractionated heparin develops a platelet drop from 250 to 100 × 10⁹/L on day 7 with a new DVT. The 4T score is 7. What is the next step?
- Continue heparin and monitor
- Immediately stop all heparin, start alternative anticoagulant, and send HIT antibody testing (Correct answer)
- Switch to low-molecular-weight heparin
- Transfuse platelets
Correct answer: Immediately stop all heparin, start alternative anticoagulant, and send HIT antibody testing
A high 4T score (6-8) with >50% platelet drop, timing on day 7, and new thrombosis strongly suggests HIT type II. All heparin must be stopped immediately (including flushes), an alternative non-heparin anticoagulant started (argatroban or fondaparinux), and HIT antibody testing sent. LMWH cross-reacts with HIT antibodies and is contraindicated.
Question 6: A patient has hemoglobin 95 g/L, MCV 72 fL, HbA2 5.8%, and normal iron studies. What is the most likely diagnosis?
- Iron deficiency anemia
- Beta-thalassemia trait (Correct answer)
- Alpha-thalassemia trait
- Anemia of chronic disease
Correct answer: Beta-thalassemia trait
Microcytic anemia with elevated HbA2 (>3.5%) and normal iron studies is the classic pattern for beta-thalassemia trait. The reduced beta-globin chain production leads to a relative excess of delta-chains, increasing HbA2. Iron studies are normal because the anemia is not due to iron deficiency.
MLPAO Hematology and Coagulation Case Studies 2
A patient has hemoglobin 70 g/L, MCV 110 fL, hypersegmented neutrophils, and elevated methylmalonic acid.
What is the most likely diagnosis?