Hematology Oncology II

Question 1

What is the initial step in management for a patient with suspected epidural spinal cord compression?

Answer 1

IV glucocorticoids

glucocorticoids should be administered before MRI

Question 2

What is the likely diagnosis in a chronic smoker that presents with dyspnea, weight loss, and face/arm swelling that is worst in the morning?

Answer 2

SVC syndrome

malignancy is the most common cause (often lung cancer and non-Hodgkin lymphoma); may also occur due to fibrosing mediastinitis or thrombosis from indwelling central venous catheters

Question 3

What is the likely diagnosis in a middle-aged patient with pancytopenia and splenomegaly without lymphadenopathy and the peripheral smear below?

Answer 3

Hairy cell leukemia

Question 4

What is the likely diagnosis in a patient that develops a fever, chills, and malaise two hours after starting RBC tranfusion? Coombs test is negative.

Answer 4

Febrile non-hemolytic transfusion reaction

due to cytokines released by residual leukocytes; the direct antiglobulin test is positive and plasma free hemoglobin is > 25 mg/dL in acute hemolytic reactions

Question 5

What is the likely diagnosis in a patient that develops fever/chills, flank pain, hemoglobinuria, and DIC 30 minutes after starting RBC tranfusion?

Answer 5

Acute hemolytic transfusion reaction

hemoglobinuria is a helpful clue that you’re dealing with an acute hemolytic transfusion rather than an allergic reaction

Question 6

What is the likely diagnosis in a patient that develops wheezing, respiratory distress, and hypotension minutes after reciving a pRBC transfusion?

Answer 6

Anaphylactic reaction

more common in individuals with IgA deficiency

Question 7

What is the likely diagnosis in a patient that presents 5 days post-CABG with large purple-black patches surrounded by erythema in the periumbilical area by sites of heparin injection?

Answer 7

Type 2 heparin-induced thrombocytopenia (HIT)

HIT should be suspected if there is a drop in platelets by > 50% or a new thrombus within 5-10 days of heparin initiation (may occur earlier in patients previously exposed to heparin)

Question 8

What is the likely diagnosis in a patient that received a bone marrow transplantation from a sibling that develops a maculopapular rash, bloody diarrhea, and elevated LFTs after two weeks?

Answer 8

Graft-versus-host disease (GVHD)

due to recognition of host HLA-antigens by donor T-cells; typically affects the skin, intestine, and liver

Question 9

What is the likely diagnosis in a patient with a facial rash that worsens with sun exposure and a history of DVT and 2 miscarriages?

Answer 9

Anti-phospholipid syndrome

more common in patients with SLE but can occur on its own; diagnosis requires clinical symptoms and presence of an antibody (e.g. antiphospholipid, anticardiolipin, or beta-2 glycoprotein-1 antibody)

Question 10

What is the likely diagnosis in a patient with a history of prostate cancer that presents with severe back pain, decreased lower extremity DTRs, and urinary retention?

Answer 10

Epidural spinal cord compression

Question 11

What is the likely diagnosis in a patient with a signficant smoking history that presents with daytime headaches, dizziness, and nausea? CBC reveals elevated hemoglobin levels. The patient works in a parking garage.

Answer 11

Carbon monoxide poisoning

chronic tissue hypoxia stimulates the kidney to produce more EPO, resulting in secondary polycythemia

Question 12

What is the likely diagnosis in a patient with abdominal pain, dark urine, and hepatic vein thrombosis with evidence of hemolytic anemia on laboratory exam?

Answer 12

Paroxysmal nocturnal hemoglobinuria

the combination of hemolytic anemia, cytopenias, and hypercoaguable state is suspicious for PNH

Question 13

What is the likely diagnosis in a patient with acute lymphoblastic leukemia that develops premature ventricular beats and acute kidney injury after initiating chemotherapy?

Answer 13

Tumor lysis syndrome

Question 14

What is the likely diagnosis in a patient with anemia, painful osteolytic lesions, hypercalcemia, and recurrent infections?

Answer 14

Multiple myeloma

manifestations of MM may be remembered with the mnemonic CRAB: hyperCalcemia, Renal complications, Anemia, Bone lytic lesions

Question 15

What is the likely diagnosis in a patient with brownish skin pigmentation, elevated fasting glucose, and elevated LFTs?

Answer 15

Hereditary hemochromatosis

other common manifestations include hypogonadism, arthralgias, and hepatomegaly

Question 16

What is the likely diagnosis in a patient with epistaxis, red blanchable papules on the lips, digital clubbing and isolated polycythemia on laboratory exam?

Answer 16

Hereditary telangiectasia (Osler-Weber-Rendu syndrome)

associated with widespread AV malformations; AVMs in the lung can result in right-to-left shunting with chronic hypoxemia (clubbing), reactive polycythemia, and hemoptysis

Question 17

What is the likely diagnosis in a patient with hemolytic anemia with an increased MCHC and negative Coombs test?

Answer 17

Hereditary spherocytosis

increased MCHC is classic for hereditary spherocytosis

Question 18

What is the likely diagnosis in a patient with night sweats, weight loss, and splenomegaly? Laboratory exam reveals leukocytosis with increased levels of basophils and myelocytes.

Answer 18

Chronic myeloid leukemia

high myelocyte count and basophilia favors diagnosis of CML > leukemoid reaction (normal basophil levels and higher metamyelocyte count)

Question 19

What is the likely diagnosis in a patient with pruritus, especially after bathing, splenomegaly, headaches, and pancytosis on laboratory exam?

Answer 19

Polycythemia vera

almost always caused by a JAK2 mutation

Question 20

What is the likely diagnosis in a patient with recurrent hemarthrosis after mild trauma and a family history significant for a maternal uncle with a similar issue?

Answer 20

Hemophilia A or B

i.e. factor VIII or IX deficiency, respectively

Question 21

What is the likely diagnosis in a young adult female with prolonged bleeding and ecchymoses and isolated thrombocytopenia on laboratory exam?

Answer 21

Idiopathic thrombocytopenic purpura (ITP)

diagnosis of exclusion; due to production of IgG autoantibodies against platelet membrane glycoproteins

Question 22

What is the likely diagnosis in a young adult with worsening knee pain refractory to NSAID therapy and an expansile lytic area in the epiphysis of the distal femur identified on X-ray?

Answer 22

Giant cell tumor of bone (osteoclastoma)

X-ray demonstrates classic “soap-bubble” appearance

Question 23

What is the likely diagnosis in a young male that presents with irritability, aggressive behavior, and gynecomastia with isolated polycythemia on laboratory exam?

Answer 23

Androgen abuse

mechanism underlying polycythemia is not well understood

Question 24

What is the likely diagnosis in an adult African-American patient that presents with splenomegaly and scleral icterus two weeks after having a URI treated with amoxicillin? Peripheral blood smear reveals spherocytosis.

Answer 24

Autoimmune hemolytic anemia

sickle cell disease is less likely given the splenomegaly and spherocytes; AIHA may be precipitated by viral infections and penicillins

Question 25

What is the likely diagnosis in an African-American male that develops dark urine, fatigue, and jaundice after being treated with TMP-SMX? Peripheral smear reveals bite cells, but a G6PD activity assay is normal.

Answer 25

G6PD deficiency

most erythrocytes with severe G6PD deficiency are hemolyzed early during the acute episodes, thus the G6PD assay may initially be abnormally normal; it is best to wait 3 months after the episode before re-testing

Question 26

What is the likely diagnosis in an African-American male that presents with fever, jaundice, dark urine and the peripheral smear below?

Answer 26

Glucose-6-phosphate dehydrogenase (G6PD) deficiency

Question 27

What is the likely diagnosis in an African-American patient that presents with polyuria and nocturia? Serum Na+ levels and urinalysis are normal.

Answer 27

Hyposthenuria (secondary to sickle cell trait)

i.e. inability of the kidney to concentrate urine due to RBC sickling in the vasa rectae of the inner medulla, which impairs countercurrent exchange and free water absorption (also occurs with sickle cell disease); normal serum Na+ levels helps differentiate from diabetes insipidus (high Na+) and primary polydipsia (low Na+)

Question 28

What is the likely diagnosis in an alcoholic patient that begins bleeding from an IV site on post-operative day 7 after having an emergency surgery? Laboratory exam reveals anemia with elevated PT/PTT and normal platelet counts.

Answer 28

Vitamin K deficiency

acutely ill patients with underlying liver disease can become vitamin K deficient in 7 - 10 days

Question 29

What is the likely diagnosis in an alcoholic vegan patient being treated with thiamine and folate for anemia that develops recurrent falls and increasing forgetfulness?

Answer 29

Vitamin B12 deficiency/subacute combined degeneration

folic acid supplementation for patients with vitamin B12 deficiency leads to rapid progression of neurologic complications

There is a risk that if folic acid is given to people who have undiagnosed deficiency of vitamin B12 it may lead to neurological damage. Vitamin B12 deficiency produces both an anaemia identical to that of folate deficiency but also causes irreversible damage to the central and peripheral nervous systems. Folic acid will correct the anaemia of vitamin B12 deficiency and so delay diagnosis but will not prevent progression to neurological damage. For this reason trials of folic acid supplements may involve simultaneous administration of vitamin B12.

Question 30

What is the likely diagnosis in an asymptomatic Italian male that is found to have microcytic anemia with an abnormally high HbA2 on routine laboratory testing?

Answer 30

Beta-thalassemia minor

common in those of Mediterranean descent; think about thalassemia if a microcytic, hypochromic anemia doesn’t respond to iron therapy

Question 32

What is the likely diagnosis in an elderly patient that presents with headaches, blurry vision, hepatosplenomegaly? Serum protein electrophoresis reveals a sharp M-spike of IgM.

Answer 32

Waldenstrom macroglobulinemia

typically presents with symptoms of hyperviscosity, neuropathy, and cryoglobulinemia

Question 33

What is the likely diagnosis in an elderly patient with recurrent infections and with hepatosplenomegaly, lymphadenopathy, and marked lymphocytosis on physical/laboratory exam?

Answer 33

Chronic lymphocytic leukemia (CLL)

recurrent infection due to hypogammaglobulinemia from monoclonality

Question 34

What is the likely diagnosis in an elderly patient with significant smoking history that presents with a hard, non-tender submandibular lymph node and occasional ear pain? Physical exam is otherwise unremarkable.

Answer 34

Squamous cell carcinoma

non-tender, solitary nodes in the head and neck in a patient with a significant smoking history are most likely to be SCC

Question 35

What is the likely underlying cause of anemia in a patient with a history of gastrectomy that presents with a shiny tongue, pale palmar creases, and laboratory evidence of hemolysis?

Answer 35

Vitamin B12 deficiency (impaired DNA synthesis)

deficiency due to loss of intrinsic factor; high numbers of immature megaloblasts in the bone marrow results in increased intramedullary hemolysis, thus causing indirect hyperbilirubinemia and elevated LDH

Question 36

What is the likely underlying cause of microcytic anemia in a patient with chronic kidney disease that recently began erythropoietin therapy?

Answer 36

Iron deficiency

the erythropoietin-induced surge in RBC production can precipitate iron deficiency

Question 37

What is the likely underlying cause of vitamin B12 deficiency in a Caucasian male with fatigue, atrophic glossitis, vitiligo, and a vegan diet x5 months?

Answer 37

Pernicious anemia

pernicious anemia is the most common cause of vitamin B12 deficiency; it would take 4 - 5 years of a vegan diet before B12 deficiency develops

Question 38

What is the likely underlying etiology of anemia in an elderly patient with fatigue, lymphadenopathy, and splenomegaly?

Answer 38

Bone marrow infiltration (e.g. lymphoma, leukemia)