Hematology

Introduction to anaemia and data interpretation

1.What is the definition of anaemia? (1 mark)

Haemoglobin or haematocrit below the lower limit of normal for age and sex

2.What factors regulate erythropoesis? (2 marks)

erythropoetin, androgens, altitude, thyroxine

3.What is the difference between true and relative anaemia? (2 marks)

relative anaemia - increase in plasma volume with same amount of blood cells
true anaemia - decrease in blood cell mass

4.What do each of the following measure? Which type of anaemia show the results
below? (4 marks)
a)MCV raised
b)MCH and MCHC decreased

a)MCV - Mean cell volume. Measure of the size of a red blood cell. Increased in
megaloblastic anaemia
b)MCH and MCHC - Mean cell haemoglobin and mean cell haemoglobin concentration.
Measure of the haemoglobinisation of a red blood cell. Decreased in iron def anaemia
and thalassaemia.

5.Give two examples of a normocytic and normochromic anaemia? (4 marks)

Haemolysis, Acute blood loss, Marrow infiltration

Nutritional deficiency anaemia

1. What is needed for the transport of iron in the blood? What is needed for the
absorption of Vit B12? (2 marks)

transferrin ; intrinsic factor + transcobalamin II

2.What are the causes of iron deficiency anaemia? Name two. (2 marks)

blood loss, malabsorption, increased demand, poor dietary intake

3.What is the aetiology of megaloblastic anaemia? (4 marks)

Megaloblastic anaemia is as a result of defect in DNA synthesis due to a deficiency of

cobalamin (vit b12) and/or folate. Causes of folate deficiency include poor nutrition,
alcoholism, celiac disease/sprue and pregnancy. Causes of Vit B12 deficiency include
poor diet, impaired B12 absorption, achlorhydria and loss of pepsin secretion.

4.What is pernicious anaemia? What is the main morphological change seen?

Autoimmune disease directed against IF secreting gastric parietal cells. Atrophy of gastric
parietal cells.

5.What complication is seen in Vit B12 deficiency and not in folate deficiency? (2
marks)***

Neuropathy - demyelination of grey matter of cerebrum, spinal cord, peripheral nerves.

Blood, blood products & transfusion service

Question 1

a. What are the major blood groups?

A, B, O, AB, Rh

b. Match the following RBC Ags with the appropriate added sugars.
Antigen Sugar Added
O
A
B
AB

O=Fucose, A=N-acetyl galatosamine, B=Galactose, AB=N-acteyl

galatosamine+galactose

Question 2

What does Fresh Frozen Plasma contain? Give 3 conditions where FFP is used.

It contains all clotting factors. Replacement of coagulation factor deficiencies when a

specific factor concentrate is unavailable, immediate reversal of warfarin effect, DIC,
thrombotic thrombocytopenic purpura.

Question 3
Match the following to their appropriate uses.
Blood Product Uses
A. Whole Blood Liver failure, Vit K def, warfarin overdose (D)
B. Packed Cells Chronic anemia, thalassemia (B)
C. Cryoprecipitate von Willebrand disease (C)
D. Cryosupernatant Blood volume replacement, exchange transfusion
(A)

Question 4
a. What are donated blood tested for?(4)

HIV, HBsAg, Syphilis, HCV

b. How is ABO cell grouping done?

Recipient’s blood is mixed with the antibodies anti-A, -B, -AB. Presence of agglutination
indicates presence of matching antigen on recipient’s cells and vice versa.

c. How is ABO serum grouping done?

Recipient’s blood specimen is taken and the serum is isolated. Serum is mixed with blood
cells of known groupings(A, B, AB, O). Agglutination indicates that antibodies matching
the blood type is present in recipient’s serum and vice versa.

d. List 3 possible agents of transmission of infection by transfused blood.

Virus, bacteria, protozoa, prion

Hemostasis and Bleeding disorders

Question 1
a. Name the steps in hemostasis.

Vasoconstriction, platelet plug formation, coagulation, fibrinolysis

b. What are 2 main functions of thrombin?

Converts fibrinogen into fibrin and activates Factor XIII(fibrin stabilizing factor).

Question 2
Name the coagulation factors.

Coagulation factor Name

Factor I Fibrinogen
Factor II Prothrombin
Factor III Thromboplastin
Factor IV Calcium
Factor V Labile factor
Factor VII Stable factor/proconvertin
Factor VIII Anti-hemophiliac factor
Factor IX Christmas factor
Factor X Stuart-Prower factor
Factor XI Plasma thromboplastin anticedent (PTA)
Factor XII Hageman/Surface factor
Factor XIII Fibrin stabilizing factor

Question 3
a. What is Hemophilia A & B? Give a characteristic sign of hemophilia.
Hemophila A=deficiency in Factor VIII. Hemophilia B=deficiency in Factor IX.
Hemorrhage into joints, i.e. knees, elbows, ankles.

b. What is von Willebrand disease?

A hereditary bleeding disorder caused by decreased production and/or function of von

Willebrand factor.

Question 4

c. List 3 causes of thrombocytopenia.

BM failure (leukemia, aplastic anemia, myeloproliferative disease), DIC, immune
thrombocytopenic purpura.

d. Give 2 causes of Disseminated Intravascular Coagulation? What are the effects of

DIC?

Snake venom, widespread tissue damage, liver failure, burns, Gram-negative bacteremia,
malignancy. Widespread thrombosis followed by consumption coagulopathy->bleeding.

Question 5

a. List 2 screening tests for vascular & platelet disorders.

Tourniquet test, bleeding time, blood film inspection, platelet count

b. List 3 screening tests for coagulation disorders.

Thrombin time, prothrombin time, partial thromboplastin time.

c. What is Prothrombin time? What deficiencies can it detect?

It measures the extrinsic and common pathway. It detects deficiencies in Factors I, II, V,
VII, X.

d. What is partial thromboplastin time? What deficiencies can it detect?

It measures the intrinsic and common pathway. It detects deficiencies in Factors I, II, V,
VIII, IX, X, XI, XII.

e. What is thrombin time?

It measures the conversion of fibrinogen to fibrin.

Hematinics

1. Name 4 substances that chelate with iron. (2m)

Antibiotics – tetracycline and penicillamine, cipro /nor /a-FLOXACIN (anti-TB drugs)

Anti-hypertensives – Methyl/cari/levo-DOPA

2. State 4 ways iron can be lost from the body. (4m)

Desquamated skin.
Shedded gut cells.
Menstruation.
Pregnancy.

3. How is iron poisoning treated? (2m)

Administer desferrioxamine, followed by forced emesis or gastric lavage.

4. Fill in the blanks about vitamin B12. (4m)

Absorbed complexed with… Intrinsic factor

Location of absorption Distal ileum
Bound in plasma with… Transcobalamin II
Deficiency in… Vegetarians and the poor
Thalassemia

1. ß – thalassemia is caused by mutations in the genes of the affected individuals. Name

one type of gene mutation that can lead to ß – thalassemia.

Promoter region mutations

Chain terminator mutations
Splicing mutations

2. Regarding ß – thalassemia;
a) explain why the red blood cells are hypochromatic.

In ß – thalassemia, there are inadequate ß chains.

Therefore, fewer Hb A are formed within the RBCs.
Decreased Hb concentrations (MCHC) in the cells make them hypochromatic.

b) explain why the red blood cells have a shortened life span

The _ chains in the RBCs have no ß chains to bind to.

The excess of _ chains form unstable intracellular aggregates.
The inclusions formed by _ chain aggregates are plucked out by splenic
macrophages, impairing the RBC membrane. This leads to premature RBC death.

3. State three clinical features ß – thalassemia. Explain why iron overload may occur in ß
– thalassemic patients.

Severe anaemia.
Failure to thrive/anorexia/diarrhoea/recurrent fever (all resulting from hypoxia and
leukopenia)
Hepatosplenomegaly.
Mongoloid (chipmunk) facies – marrow expansion in malar bones.
Skull x-ray shows hair on end appearance – due to erythroid hyperplasia.
Septicemia (due to susceptibility to severe infections).

Iron overload may occur as a result of repeated blood transfusions or increased

absorption of dietary iron. (haemosiderosis and secondary haemochromatosis)

4. Give two investigations and their expected findings for patients with ß – thalassemia.

Peripheral blood smear : severe microcytic hypochromic anaemia/ tear drop cells/
target cells
 Granular cytoplasmic inclusion bodies – aggregates of _
chains
WBC count raised
MCV, MCH, MCHC : Reduced
Serum bilirubin raised. Serum haptoglobin reduced. (Note : haptoglobin binds free Hb)
Skull X-ray – ‘hair on end appearance’ due to erythroid hyperplasia
Bone marrow biopsy – erythroid hyperplasia
Hb electrophoresis – Predominant Hb is HbF. (HbA small to moderate amounts)

5. State two common forms of treatment for ß – thalassemia.

Blood transfusion
Iron chelating agents – desferrioxamine (to reduce iron overload)
Splenectomy
Bone marrow transplant

6. Deletions of the _ globin gene loci result in _-thalassemia.

State the number of _ globin genes deleted in the following conditions:

silent carrier state : 1

_-thalassemia trait : 2
HbH : 3 or 4
HbBart : 3 or 4

7. Explain how foetal death due to hydrops foetalis occurs.

Hydrops foetalis is the most severe form of _-thalassemia.

Deletion of all four _ globin genes result in an excess of _4 tetramers.
As these have a high oxygen affinity, severe tissue anoxia develops.
Intrauterine death occurs.
Chronic Fatigue Syndrome

1. True/ False:-

a) Patients with CFS suffer severe fatigue that can be reduced with sufficient rest.

b) Disturbed sleep, muscle pain & impaired memory are among the diagnostic criteria for
CFS.

c) Anti-depressant & anxiolytic agents are among the medication treatment for CFS.

d) Cognitive behavioural therapy can be used to cure patients with CFS.

e) A doctor can facilitae the treatment outcome of CFS by being empathetic to the patient
and educate them about his condition.

Ans: FTTFT
Aplastic Anaemia

1. Describe the morphology of the bone marrow in a patient with aplastic anaemia. (2
marks)

- devoid of haemopoietic elements.

- mostly fat cells.

2. Give 3 possible causes of aplastic anaemia. (3 marks)

- Fanconi’s anaemia, Diamond-Blackfan syndrome, Epstein-Barr virus, HIV, Hepatitis

virus, radiation, toxic chemicals (benzene), drugs (chloramphenicol), Paroxysmal
nocturnal haemoglobinuria, pregnancy.

3. Give 2 medical treatments for aplastic anaemia. (2 marks)

- Bone marrow transplant, blood transfusion, treatment of infections, immunosuppressive

therapy.

4. What occurs during myelodysplastic syndromes, & what medical condition can it
predispose to? (3 marks)

- Bone marrow partly or wholly displaced by the clonal progeny of a mutant multipotent
stem cell – ineffective & disorderly.
- Pancytopaenia in peripheral blood.
- Increased risk of transformation into acute myeloid leukaemia.
Haemoglobinopathies

1.State the pathogenesis of sickle cell anemia. Include the changes that happen to the
haemoglobin and blood flow in response to low oxygen levels. (6 marks)

RBCs contain large amount of HbS that sickle at an O2 tension of 50 – 60 mmHg, which
occurs at the microcirculation. This occurs due to lack of oxygen. The HbS molecules
undergo aggregation and polymerisation. This change converts cell cytosol from a freely
flowing liquid to a viscous gel, leading ultimately to formation of HbS fibres and
resultant distortation of the red cells, which acquire a sickle or holly leaf shape. Sickling
of red cells is initially a reversible phenomenon if the rate of bloodflow is rapid, the cells
are swept away and with oxygenation, HbS returns to the depolymerised state. However,
with repeated episodes of sickling and unsickling, this leads to permanent membrane
damge. Thus, cells become irreversibly sickled. The precipitation of HbS fibres also has
deleterious effects on the red cell membrane.

2. State 3 factors that affect RBC sickling. (3marks)

? Amount of HbS and its interaction with other haemoglobin chains in the cell. Eg. In
heterozygotes, there is little tendency to sickle, except in severe hypoxia. Hence, no
haemolysis of red cells and no anemia. Whereas in homozygotes, sickle cell anemia
results.
?Physical properties of Hb other than HbS. Eg. Hb other than normal HbA (especially
HbF) influences the crystallization of HbS and the severity of sickle cell anaemia. HbF
inhibits the polymerisation of HbS. HbC has a greater tendency to aggregate with HbS.
?reduced oxygen affinity in homozygous trait and MCHC.
dehydration: increases the MCHC that greatly facilitates sickling and vascular occlusion.
?Fall in pH: Acidosis reduces the oxygen affinity of haemoglobin and thus increases
sickling because it enhances the amount of deoxygenated HbS.

3. What are the main consequences of HbS? (2 marks)

The main consequences are Hemolytic anemia and vaso-occlusive complications.

4. What is 3 main characteristic of Sickle cell anemia? (3 marks)

The main characteristics are severe anemia due to increased destruction of the sickled red
blood cells, chronic hyperbilirubinemia due to increased release of haemoglobin and
formation of bilirubin, vaso-occlusive complications due to capillary stasis and
thrombosis leading to tissue ischaemia and painful crises.
5. Is x-ray important in the diagnosis of sickle cell anaemia? Why? (3 marks)

Yes. Crew hair cut in the skull. This is due to erythroid hyperplasia and expansion of the
marrow that may lead to resorption of bone with secondary new bone formation.

6. State 3 morphologies of organs found in sickle cell anemia. (3 marks)***

Enlarged spleen up to 500 gms in children with congestion of red pulp, conjuctival
icterus, enlarged and tender liver.

7. State 5 clinical signs and symptoms in sickle cell anemia. (5 marks)

i. Increased susceptibility to infectios by pneumococci, meningococci, H.influenza,

E.coli. these infection occurs secondary to impaired splenic function, splenic fibrosis the
limits the function and defects in alternative complement pathway,
ii. trombotic episodes with acute pain that seen in pulmonary blood vessels.
iii. microvascular occlusion and infarction in bone, brain, spleen, kidney and retina.
iv. pigment stones
v. vascular stagnation in subcutaneous tissue that will lead to chronic leg ulcers in adults
vi. Hyperbilirubinemia in acute hemolysis.

8. Explain why is there autosplenectomy. (3 marks)

Marked congestion of the red pulps due to trapping of the sickled red blood cells in the
splenic sinusoids and cords. Erythrostasis may lead to thrombosis and infarction or
marked tissue hypoxia. This causes continuous scarring which results in progressive
shrinking of spleen. Hence, small fibrotic spleen.

9. What are the complications in Sickle cell anemia? Name four. (4 marks)

a) Acute chest syndrome: fever, cough, chest pain and pulmonary infiltrates
b) aplastic crises: temporary cessation of the bone marrow activity (parvovirus infection).
c) Sequestration crisis: In children with splenomegaly. Massive splenic enlargement,
hypovolemia and shock will result.
d) hypoxia: May produce seizure or stroke. Chronic hypoxia causes generalized
impairment of growth and development as well as organ damage.

10. State 6 investigations that can be carried out other than RBC smear. Include positive
and negative findings. (6 marks)
a) sickle cell test: RBC take on sickle shape when mixed with reducing agent like sodium
metasulphite. It depends on the decreased solubility of HbS at low oxygen tension.
b) Hb solubility test: sickle cells are insoluble in phosphate buffer wih reducig agent. The
crystals that form refract light and cause solution to be turbid.
c) Neutrophil leukocytosis
d) platlet count which is usually normal
e) hyperbilirubinemia
f) ESR – low, prevention of rouleaux formation by sickle cells.
g) MCV and MCH normal.

11. Why homozygous sickle cell trait is more dangerous than the heterozygous cell trait?
(2 marks)

In heterozygotes, the red cells do not contain sufficient HbS to undergo sickling at the
reduced oxygen tension.

12. Apart from the patient experiencing tiredness and breathlessness due to anemia, what
other clinically important signs and symptoms that can be picked up? Give 5 examples.
(5 marks)

Vaso-occlusion crisis – painful (bones, lungs, liver,spleen,brain and penis), infection,

dehydration, acidosis, hand-foot-syndrome due to dactylitis of bones of the hands and
feet or both.

13. Why does the sickle cell trait protect against malaria? (2 marks)

This is because in low oxygen tension, RBC undergoes hemolysis and malaria could not
finish it's life cycle in RBC. Hence, this reduces the chances affected by malaria.

14. Name one virus that causes aplastic crisis in sickle cell anemia. (1 mark)

Parvovirus
Haemopoiesis II

1. Name 3 chemicals that influence platlet production and elaborate on how each
chemical affects platlet production. (6 marks)***

Thrombopoietin(TPO), IL-6, IL-3 and MK-CSF (megakaryocyte-colony stimulating

factor).
a) TPO controls platlet production at various stages of megakaryocyte and platlet
formation.
b) IL-6 has thrombopoietin like activity that acts at various stages of megakaryocyte
and platlet formation.
IL-3 and MK-CSF exhibit megakaryocyte stimulating activity

2. Explain the development steps of granulocyte cells. (5 marks)

haemopoietic stem cell_myeloid stem cell_GM-precursor

cell_myeloblast_promyelocyte_myelocyte_metamyelocyte_band cell_mature
WBC_neutrophils, eosinophil, basophil, mast cell.

3. What are the differences between granulocytes and agranulocytes? (4 marks)

Granulocytes: lobed nucleus, special membrane bound granules in cytoplasm (granule

contents are function specific), generally phagocytes (neutrophils, basophils, mast
cells, eosunophils).
Agranulocytes: lack obvious granules in cytoplasm, B and T lymphocytes, monocyte,
macrophage, NK cell, distinct and unrelated functions.

4. Name two chemicals that control the development of granulocytes. (2 marks)

GM-CSF (granulocyte-monocyte) and G-CSF (granulocyte)

5. In which form do monocytes appear in bone marrow and in the periphery? (4

marks)

Bone marrow: haemopoietic stem cells, myeloid stem cells, monoblasts.

Promonocytes
Periphery: monocytes ,tissue macrophage (depending on tissues the monocytes
migrate to eg: liver: kuppfer cells, brain: microglial cells)

6. In which form are seen neutrophil granulocytes in the bone marrow and in
peripheral blood? (4 marks)
 bone marrow: haemopoietic stem cells, myeloid stem cells, myeloblasts,
promyelocytes, myelocytes, metamyelocytes
peripheral: band cells and mature granulocytes (neutrophil, eosinophil and basophil)

Platlet biology and Hemostasis

1. Name the 3 major steps of hemostasis.

Vasoconstriction, formation of platelet plug, coagulation of blood

2. Name the three functions of platelets.

?
Hemostasis,
Blood coagulation,
Clot retraction,

3. Name 2 substance that is release from the endothelial cells that inhibit aggregation.

Prostacyclin and NO

4. Name 1 stimulatory substance for each of the following processes ***

Vasoconstriction – serotonin, thromboxane A2, ADP

Platelet aggregation – thromboxane A2, ADP
Blood coagulation – platelet phospholipid

5. Describe the roles of thromboxane A2 and Prostacyclin in the process of platelet

aggregation.

Thromboxane A2 will increase calcium and reduce cAMP resulting in platelet

aggregation.
Prostacyclin will reduce calcium and increase cAMP resulting in inhibition of
platelet aggregation

6. Name 2 clotting factors for each of the following 3 categories.***

Contact factors – XII, XI, HMWK

Vit K Dependant factors – II, VII, IX, X
 Fibrinogen factors – fibrinogen, V, VIII, XIII

7. What are the factors that will trigger the following pathway?

Intrinsic pathway – exposed collagen surface, surface of activated surface, glass

surface
Extrinsic pathway – traumatized endothelial cells

8. Give an example of a prothrombin activator.

Platelet phospholipids/ calcium/ factor V

9. Name an anti-clotting system and briefly describe its process.

Tissue factor pathway inhibitor – TFPI is secreted by endothelial cells and it binds
to the Tissue
Factor-Factor VIIa complex, thereby inhibiting
generation of Xa.
Endothelium receptor – activates protein C that will inactivate inhibitors
of tissue
plasminogen activator and inactivate factors Va
and VIIa
Antithrombin Mechanism – heparin bound to antithrombin III will prevent the
clot from
spreading

10. Name a fibrinolytic system and briefly describe its process.

Plasminogen activators – intrinsic is caused by Kallikrien and Factor 12a while

extrinsic is caused by t-PA and u-PA
Streptokinase – activates plasminogen to change to plasmin.
Fibrin is broken down to Fibrin Degradation Products by
plasmin.
Abnormalities of Haemostasis

1. Write down the effects of Hemophilia A and Von Williebrand Factor deficiency.

Hemophilia A Von Williebrand factor

Deficiency
Bleeding time Normal Prolonged
Platelet count Normal Normal
Clotting time Prolonged Prolonged
APTT Prolonged Prolonged
Prothrombin time Normal Normal

2. What are the 2 functions of the von Williebrand factor?

Platelet adhesion and agglutination

Stabilizes factor VIII

3. Define the following terms.

i. Bleeding time – Time interval from oozing of blood after a cut or injury
till the arrest of
bleeding.

ii. Clotting time – Time interval from oozing of blood after a cut or injury
till the formation
of a solid clot.

iii. Platelet count – Number of platelets per cu mm of blood.

iv. Prothrombin time – Time taken by plasma to clot after Tissue Factor and Ca2+
are added.

v. Thrombin time – Time taken for plasma to coagulate after Thrombin and
Ca2+ are added to
the citrated plasma.
?
vi. Activated Partial – Time taken by plasma, previously incubated with Kaolin
or other
Contact Factors to clot in the presence of Ca2+ and
Platelet Phospholipids.
Haemolytic Anaemias
(Source: Haemolytic Anaemias lecture, Radha: 12/04/2005; RBC Physiology &
Haemoglobin lecture, CWL: 05/04/05)

QUESTION 1 (10m):

A young boy, aged 6, was admitted into the hospital for lethargy. The doctor who
examined him found the patient to be slightly jaundiced and pale (pallor). Splenomegaly
was also present.
Investigations were carried out. The following are a few of the test results:

- Peripheral blood smear: Microcytic, hyperchromic RBCs. Presence of spherocytes

- Reticulocyte count: Increased
- Plasma bilirubin: Increased
- Mean cell haemoglobin concentration (MCHC): Increased

On further questioning, the doctor discovered that the boy’s uncle and two other cousins
also had the same condition. The doctor later concluded that the boy has hereditary
spherocytosis.

a) Name another important test which is used to diagnose this pathology. What
would the results be if the person has such condition, and why do you say so?
(2m)

Ans: - Osmotic fragility test

- Result: increased osmotic fragility
- Spherocytes are particularly vulnerable to osmotic lysis

b) The following statements make up the pathogenesis of hereditary

spherocytosis. Arrange them in the proper chronological order. (2m)
I – The cells assume the smallest possible diameter for a given volume. They
become spheres.
II – Mutations in the ankyrin molecule cause a secondary deficiency of
spectrin, which results in reduced membrane stability of the red blood
cells (RBCs).
III – The affected cells consequently lose membrane fragments as they are
exposed to the sheer stresses in the blood circulation.
IV – The spherocytes are later sequestered in the spleen and phagocytosed
by splenic macrophages. Haemolytic anaemia occurs.

Ans: II  III  I  IV
 c) “Splenomegaly was also present…”
How did this happen? (3m)

Ans: - Spherocytes are less deformable than normal RBCs

- They are therefore eventually prevented from passing through the
Cords of Biliroth to the splenic sinusoids in the spleen (splenic
sequestration). Extensive erythrophagocytosis by splenic
macrophages occur.
- Splenomegaly results when there is marked congestion of the cords
of Biliroth.

d) In terms of treatment for hereditary spherocytosis, splenectomy is done when

there is a markedly enlarged spleen, severe anaemia or complications such as
gall stone formation. Then why is such treatment usually delayed in patients
below 5 years old? (1m)

Ans: - Splenectomy in children under 5 years old is associated with an

increased risk of fatal infections, particularly by encapsulated
bacteria.
[NOTE: In cases of patients below 5 years old, splenectomy is usually delayed until they
are 5-10 years old]

e) Give 2 features seen on peripheral blood smears in hereditary spherocytosis.

(2m)

Ans: Microcytic, hyperchromic picture/ presence of spheroidal RBCs/

Affected RBCs lack the central zone of pallor/ Increased
reticulocytes
(Source: Haemolyic Anaemias lecture, Radha: 24/04/2005)

QUESTION 2 (10m):

a) Match the answers given to the following statements. The answers provided
can be used more than once or none at all. (3m)

No. Statement Answer

i. Only form of haemolytic anaemia that results from an acquired D
membrane defect secondary to a mutation involving the
phosphatidyl inositol glycan A (PIG-A) gene which affects
myeloid stem cells
ii. Asymptomatic unless RBCs are subjected to oxidant injury by A
exposure to certain drugs, toxins or infections
iii. Schistocytes (made up of Burr cells, Helmet cells, triangle F
cells, microspherocytes) seen on peripheral blood smears
iv. Heinz bodies and “bite” cells A
v. Only disease associated with increased mean cell haemoglobin C
concentration (MCHC)
vi. Destruction of RBCs within cells of mononuclear phagocyte B
system (MPS)

G6PD deficiency –A Extravascular haemolysis –B

Hereditary spherocytosis – C Paroxysmal nocturnal haemoglobinuria – D
Intravascular haemolysis – E Microangiopathic haemolytic anaemia – F

[NOTE: MPS is also known as reticuloendothelial (RE) system]

An 18-year old man of Mediterranean origin went to a general practitioner, complaining

of ‘yellow eyes’. He also looked very tired and pale. On further questioning, the doctor
discovered that he has G6PD deficiency, and he had eaten some fava beans a couple of
days before.

b) Both intravascular and extravascular haemolysis occur in G6PD deficiency.

List 2 differences between intravascular haemolysis and extravascular
haemolysis. (2m)

Ans: (Choose any two differences)

Intravascular Haemolysis Extravascular Haemolysis

Occurs when RBCs are subjected to
mechanical trauma/ damaged by a variety
of biochemical or physical agents [ takes
place within the vascular system]
There is haemoglobinaemia and
Occurs when there is destruction of RBCs
within the cells of mononuclear phagocyte
system (MPS) aka RE system [destruction
takes place largely within phagocytic cells
in the spleen and liver]
There is no haemoglobinaemia and
haemoglobinuria haemoglobinuria
Not so common More common mode of cell destruction

c) Why are the serum haptoglobin levels characteristically low in haemolytic

anaemias? (2m)

Ans: - Increased destruction of RBCs results in increased release of

free haemoglobin (Hb) into the circulation
- Haptoglobin (an apoprotein) binds to free Hb, and consequently
its levels in the plasma decreased

d) Why would glucose 6-phosphate dehydrogenase (G6PD) deficiency lead to

haemolytic anaemia? (3m)

Ans: - G6PD induces generation of NADPH

- NADPH is used by the enzyme gluthatione reductase to convert the
oxidized form of gluthatione (GSSH) to its reduced form (GSH)
- The reduced form of gluthatione is an antioxidant that protects
RBC’s cell membrane from free radicals.
- GSSH cannot be converted to GSH when there is G6PD deficiency
 RBC cell membrane is damaged and haemolytic anaemia
occurs
Plasma Cell Dyscrasias
(Source: Plasma Cell Dyscrasias lecture, TP: 15/04/05)

QUESTION 10 (10m):

A 45-year old man went to a hospital yesterday after he fell down in the park while
taking his dog out for a walk. When examined, his right leg was a little swollen and
quite tender.
The patient also noted that he gets tired easily in the last 3 months. He can no longer
play badminton continuously with his friends, nor swim 40 laps like he used to. He
also tends to bruise easily, and suffers from ‘excruciating’ bone pains.
A number of investigations were carried out:

X-ray of the right leg : Numerous bone lesions noted

Urine test : Presence of Bence-Jones proteins
Serum electrophoresis : “M” spike absent
Calcium levels in serum: Elevated
Peripheral blood smear : Normocytic, normochromic anaemia. There is rouleux
formation
Bone marrow aspiration : Increased numbers of plasma cells.

a) What is your probable diagnosis? (1m)

Ans: Multiple myeloma

b) What is Bence-Jones protein? (1m)

Ans: Free monoclonal light chains produced by plasma cells

c) Why is the “M spike” not present in this case? (2m)

Ans: - The “M proteins” produced by the plasma cells in this case are light
chains, and these chains pass through the glomerular filter easily
(these light chains are excreted in the urine and are referred to as
Bence-Jones proteins)
- Therefore, the serum level of “M proteins” is usually low, and hence
cannot be detected by electrophoresis (that is why the “M spike” is
not present)

d) Give 3 complications of this medical condition. (3m)

Ans: (Choose any 3)

- Anaemia; secondary myelodysplasia and acute leukaemia;
cryoglobulinaemia; hyperviscosity; renal failure; infections; plasma

cell leukaemia (rare)

 e) Match the following with the most appropriate answers. (3m)

No. Statement Answer

i. This is used to stage multiple myeloma and determine prognosis B
ii. Presence of M proteins in serum of asymptomatic, healthy people C
iii. Precipitation of macroglobulins at low temperatures, producing A
Reynaud’s phenomenon and cold urticaria
iv. X-rays show characteristic soap-bubble/ pepper-pot appearance D
v. Found in the upper respiratory tract in 80% of cases E
vi. Mott cells and Russell bodies present D

Cryoglobulinaemia –A
Durie-Salmon Staging System –B
Monoclonal gammopathy of uncertain significance (MGUS) –C
Multiple myeloma –D
Extramedullary plasmacytoma –E
Rai’s Staging System –F
Waldenström Macroglobulinaemia –G
Leukocyte abnormalities and their benign disorders

1. Where is the highest concentration of bone marrow found?

a. Pelvic bones

2. What is the peripheral blood leukocyte count is influenced by?

a. Size of the myeloid and lymphoid precursor and storage cell pools
b. Rate of release of cells from the storage pool into the circulation
c. The proportion of cells that are marginating at any one time
d. The rate of extravasation of cells from the peripheral blood into tissues

3. What is the contrasting feature of a leukaemoid reaction compared with chronic

myeloid leukaemia?

a. High neutrophil alkaline score (low in CML)

4. Name 5 drugs that induce neutropenia

a. Amidopyrine, noramidopyrine, phenylbutazone

b. Indomethacin
c. Chlorpromazine
d. Carbamazepine
e. Carbimazole
f. Septrin, methicillin, dapsone
g. Thiazides, captopril

5. What are 2 mechanisms that lead to neutropenia?

a. Marrow failure, as in aplastic anaemia or infiltration due to leukaemias

b. Accelerated removal or destruction of neutrophils due to immune
meditated injury to neutrophils – idiopathic or due to drugs or
overwhelming infection
Acute and Chronic Leukemia

1. Regarding chronic leukemias:

A. The indolent and low grade quality of most chronic leukemias allow time to achieve
cures with appropriate therapy.
B. Many cases exhibit specific chromosome abnormalities.
C. Chronic myelogenous leukemia almost always progresses to an acute leukemia.
D. Chronic lymphocytic leukemia is generally a neoplasm of B lymphocytes
E. Chronic leukemias are proliferations or accumulations of mature or differentiated cells.

Answers: F T T T T
Although chronic leukemias of both lymphoid and myeloid types may follow an indolent
course, likelihood of a “cure” is thought to be remote. This may reflect a relatively low
percentage of neoplastic precursor cells in active replication in chronic leukemias, which
are thus sensitive to cell cycle therapeutic agents.

2. Regarding leukemias:
A. the Philadelphia chromosome can be observed in CML and ALL
B. The poorest prognosis for patients with CLL is associated with anemia and
thrombocytopenia.
C. In hairy cell leukemia, there will be pancytopenia, splenomegaly and clonal
proliferation of B lymphoid cells.
D. There will be positive tartrate resistance and phosphate test in AML.
E. Serum vitamin B12 level measurement can be used to differentiate AML and ALL.

Answers: T T T F F
The TRAP test is positive in hairy cell leukemia.
Lymphoma

a) State 2 macroscopic appearances of the affected lymph nodes in Hodgkin disease.

Ans: Enlarged, discrete, mobiule, rubbery in consistency, cut surface – homogenous

white

b) What is specific name for the true neoplastic cell seen in Hodgkin disease? Describe
how it looks like.

Ans: Reed-Sternberg cell. Quite large, binucleate/bilobed, with the two halves often
appearing as mirror image of each other. Nucleus is enclosed with an abundant amophilic
cytoplasm, and contains large inclusion-like, owl eyed nucleoli, surrounded by a clear
halo.

c) Name the two types of Burkitt Lymphoma and give 2 differences between them.

Ans:

Burkitt Non-Burkitt
Involves children Involves adults
Seen in Africa Seen in America
Involves bones of the jaw Does not involve bones of the jaw, instead
involves abdomen and peripheral lymph
nodes

d) i) How does Non-Hodgkins lymphoma spread?***(incoherent question, u cannot ask

questions
regarding chaos and disorder u could answer "anyhow it likes" and its still correct)

Ans: In a disorderly fashion.

ii) Give 2 clinical features of Non-Hodgkins lymphoma.

Ans: GI bleeding, abdominal pain, vomiting, weight loss, hepatosplenomegaly,

autoimmune diseases

iii) Between hodgkins and non-hodgkins lymphoma, in which is staging a useful guide
to therapy?

Ans: Hodgkin disease, as staging accurately shows the progress and extent of the disease
as it speads in
 an orderly fashion

e) State two viruses that can be an etiological agent in lymphoma.

Ans: EBV, HTLV-1, HIV

Myeloproliferative Disorders

a) i) Define myeloproliferative disorders.

Ans: Proliferative transformation of a multipotent progenitor cell, capable of giving rise

to mature erythrocytes, platelets, granulocyte and monocytes. There is marrow
hypercellularity accompanied by elevated peripheral blood counts.

ii) What characterizes the spent phase?

Ans: Marrow fibrosis and peripheral blood cytopenias.

b) i) In polycythemia vera, what characteristic of its progenitor cells may be a possible

explanation for the increased production and proliferation?

Ans: Its progenitor cells require extremely small amounts of erythropoietin and other
haemopoietic growth factors for proliferation and survival.

ii) Polycythemia vera can transform to a type of leukemia. Which type is it?

Ans: AML

c) State 2 clinical features of polycythemia vera.

Ans: Plethoric cyanotic patients, hypertension, headache, dizziness, GI symptoms,

intense pruritus, hyperuricemia.

d) Insert the appropriate alphabet. Alphabets may be used more than once.

Marked increase in marrow reticulin fibres

Marked splenomegaly
Normochromic normocytic anaemia
Increased tendency towards peptic ulcers
Minimal reticulin fibrils
Trephine biopsy to establish the diagnosis
Alkaline phophatase levels are above normal
Tear drop cells

A – Polysythemia Vera
B – Essential thrombocytosis
C – Myelofibrosis

Ans: ACCABCAC
Principles of anticoagulant therapy

1.Vitamin K is an important co-factor in the formation of clotting factors II, VII, IX, and
X. Warfarin is an anticoagulant which is very similar in structure to vitamin K. Explain
how warfarin functions as an anticoagulant.

Factors 2, 7, 9 and 10 are glycoproteins with attached gamma carboxylglutamic acid

residues. The gamma carboxylation requires vitamin K as a co-factor. Warfarin binds to
the carboxylases and prevents the carboxylation process from taking place.

2. heparin is a commonly used parenteral anticoagulant. Describe how it functions.

Antithrombin is synthesized in the liver and inhibits clotting factor proteases (7a, 9a,
10a…) by binding to them, very slowly. Heparin increases the binding process 100 fold
by binding to the antithrombin, changing its configuration, and exposes its active site for
more rapid interaction with the proteases.

3. Give 2 examples of antiplatelet agents and briefly describe their function.

Aspirin, dipyridamole, ticlopidine, clopidogel, abciximab. They inhibit platelet

aggregation by deactivating the enzymes (COX) that synthesize thromboxane A2, which
induces platelet aggregation.

4. What are the 3 major categories of drugs used to prevent hemostasis?

Anticoagulants, antiplatelet agents, fibrinolytic agents.

5. Briefly describe the workings of the fibrinolytic system

Plasminogen is converted into plasmin, which digests fibrin clots and other plasma
proteins.
Tissue plasminogen activator is released from endothelial cells, which binds to fibrin and
converts plasminogen to plasmin. TPA does not function well in the absence of fibrin.
Malaria

1. Name 2 stages of the malaria parasite’s life cycle in the mosquito.

Gametocyte, ookinete, oocyst, sporozoite.

2. Hypnozoites are dormant malaria parasites in the liver. Name one species of malaria
parasite which may result in hypnozoite production.

Plasmodium vivax, Plasmodium ovale

3. Give 2 clinical signs/symptoms of malaria.

Fever preceded by chills and rigors, headache, myalgia, malaise, splenomegaly, possible
hepatomegaly, anemia.

4. List 3 complications of malaria.

Cerebral malaria (in P. falciparum infection), severe anemia, renal failure, pulmonary
edema, hypoglycemia, circulatory collapse, spontaneous bleeding, acidosis,
hyperpyrexia, jaundice.

5. malaria parasites may be eradicated with drugs during certain stages in their life cycles.
Name 2 drugs used to treat malaria.

Quinine, mefloquine, primaquine, tetracycline, artemisinin, tafenoquine.

Babesiosis and Trypanosomiasis

a. Give a causative agent of babesiosis? (1mark)

Babesia macroti/ Babesia divergens

b. Give 2 morphological differences between the causative agents of babesiosis and

malaria. (2marks)***

Babesia spp. parasites contain no pigments whereas the Plasmodium spp.

parasites do.
Babesia spp. parasites have no sexual stage in the mammalian host whereas the
Plasmodium spp. parasites do.

c. Which parasite is transmitted by the tick, Ixodes scapularis? (1mark)

Babesia macroti

d. Which parasite usually causes babesiosis in asplenic patients? (1mark)

Babesia divergens

e. What is the infective stage of the causative organism of African trypanosomiasis?

(1mark)

Metacyclic trypanosomes

f. Give an investigative technique used in the diagnosis of African trypanosomiasis.

(1mark)

Detection of trypanosomes in chancre, blood, lymph node aspirate or CSF/

Xenodiagnosis (for Trypanosoma brucei rhodesiense)/
In-vitro culture of blood, CSF or lymph fluid/
Card indirect agglutination test for trypanosomiasis (CIATT) for Ag detection
(test is 99% specific)/
Branched DNA (bDNA) assay (100% sensitive and specific)
Card agglutination test (CATT) for Ab.

g. What is the vector for American trypanosomiasis? (1mark)

 Reduviid bug

h. State a complication of Chagas’ disease. (1mark)

Cardiomyopathy/
Chagasic myocarditis/
Ventricular dilatation with cardiac arrhythmias (cardiac aneurysm may develop)/
Megasyndrome (megaoesphagus and megacolon)

i. What is the treatment for Chagas disease? (1mark)

Nifurtimox/ Benznidazole
Viral Hemorrhagic Diseases

a. Explain the pathophysiology of shock in dengue fever. (3marks)

Antibody-mediated destruction of platelets (thrombocytopaenia) and antibody-

mediated damage to blood vessels lead to seepage of blood and plasma into tissues.
This can result in massive hemorrhage and “dengue shock”.

b. Describe the problem with developing a vaccine for dengue hemorrhagic fever.
(2marks)

There are 4 distinct but closely related viruses that can cause DHF. Two or more
sequential challenges by different serotypes can lead to the hemorrhagic form of
dengue. Furthermore, there is the risk of hemorrhagic fever developing as a result
of an allergic reaction on administration of a vaccine.

c. Give one preventive measure that can be taken against dengue hemorrhagic fever
directed against the vector and disrupting its life cycle. (1mark)

Proper disposal of discarded man-made containers that can hold stagnant water/
Prevent access by egg laying females by covering water containers/
Keeping small mosquito eating fish in ponds/
Aerosol insecticides (swing fogging) to kill adult mosquitoes (limited value)
Larvicide and “abate salts” to kill larvae.

d. What is the vector for the sylvatic (jungle) yellow fever? (1mark)

Haemogogus mosquitoes

e. State one mode of transmission of the causative agent of Rift Valley Fever. (1mark)

Bite of infected mosquitoes (Aedes, Culex and a variety of other species)/

Contact with blood, body fluids or organs of infected animals during slaughtering
of infected animals/
Drinking of raw milk/
Through inoculation 9wound from contaminated knife)/
Inhalation of aerosol.

f. Give the reservoir and mode of transmission for Lassa fever. (2marks)

Reservoir: field rodents and rats.

Mode of Transmission: Aerosol or direct contact with excreta of rodents
deposited on floor or food.
Filariasis

a. List 2 parasites that cause lymphatic filariasis. (2marks)

W. Bancrofti, B. Malayi, B. Timori

b. Give a brief explanation on the life cycle of a lymphatic filariasis parasite.

(3marks)

Microfilaria taken up by mosquito from circulation of infected person.

Microfilaria develop in thoracic muscles into L1, L2 and L3. L3 migrate to
proboscis and are deposited on skin surface during probing of skin before blood
meal. L3 moults twice and develops into L4 and adult. Microfilaria produced
enter the circulation.

c. Give 2 drugs that are used to treat lymphatic filariasis. (2marks)

DEC, albendazole, ivermectin, doxycycline.

d. What is the main vector for onchocerciasis. (1mark)

Simulum Damnosum

e. If a patient is suspected of having onchocerciasis, what would be the clinical

presentations that you would expect to find in this patient? Give three. (3marks)

Onchocercomas, skin itchiness, skin depigmentation, lymphadenitis, visual

impairment, elephantiasis of genitals.

f. List a method of control of oncocerciasis. (1mark)

Control of vector, mass chemotherapy (ivermectin), reduction of human – vector

contact.
 Epidemiology of zoonoses and vector – borne diseases.

a. Match the following features of disease to the correct causative disease. The
diseases given can be used once, more than once or not at all. (6marks)

Japanese Encephalitis
Trypanosomiasis
Malaria
Scrub Typhus
Leishmaniasis
Filariasis
Plague
Yellow Fever

Features of disease Disease

Acute inflammatory viral disease of the brain, Japanese Encephalitis
spinal cord & meninges.
Also known as the “sleeping sickeness”. Trypanosomiasis
The anopheles mosquito is a vector. Malaria
Vector is the tromboculid mite. Scrub Typhus
Vector is the Tsettse fly Scrub Typhus
Transmitted through the bite of sandflies. Leishmaniasis
Causes disfiguration and ulceration of the
human host.

b. Give simple explanations on what the following terms mean. (4marks)

1. disease vector – an arthropod which carries the infecting agent from one host to
another. The agent might or might not undergo changes while in / on the vector.
2. Animal reservoir – an animal in which the infective agent lives and multiplies and
which it depends primarily for survival.
3. Disease carrier – person / animal that harbours an infective agent without
discernable clinical disease. Serves as a potential source of infection.
Zoonosis – infectious disease transmissible under natural conditions between vertebrate
animals and man.