r). SUPPLEMENTARY/SECOND OPPORTUNITY EXAMINATION PAPER nnmlbih UNIVERSITY Sophia Blaauw INSTRUCTIONS FACULTY OF HEALTH AND APPLIED SCIENCES

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1 r). nnmlbih UNIVERSITY OF SCIEFICE nnd TECHNOLOGY FACULTY OF HEALTH AND APPLIED SCIENCES DEPARTMENT OF HEALTH SCIENCES QUALIFICATION: BACHELOR OF MEDICAL LABORATORY SCIENCES QUALIFICATION CODE: 08BMLS LEVEL: 6 COURSE CODE: HAM621$ COURSE NAME: HAEMATOLOGY 23 SESSION: JANUARY 2018 PAPER: THEORY DURATION: 3 HOURS MARKS: 110 SUPPLEMENTARY/SECOND OPPORTUNITY EXAMINATION PAPER EXAMINER Sophia Blaauw MODERATOR: Martin Gonzo INSTRUCTIONS 1. Answer ALL the questions. 2. Write clearly and neatly. 3. Number the answers clearly. PERMISSIBLE MATERIALS 1. Non-Programmable Calculator THIS QUESTION PAPER CONSISTS OFfl PAGES (Including this front page)

2 ' HAEM HAM ZB: SUPPLEMENTARY/Znd OPPORTUNITY EXAMINATION- JANUARY 2018 SECTION A [31] QUESTION 1 [6] 1.0 Which technical terms would describe the following phrases the best? 1.1 These granules begin to occur in the myelocytes and increase as the cell matures. [1] 1.2 The co-enzyme that Protein C requires to function as an inhibitor. [1] 1.3 Extremely high leukocyte counts seen in a non- leukaemic state and may be [1] lymphoid or granulocytic in nature. 1.4 The process of dissolving a clot at the end of the clotting cascade. [1] 1.5 The commonest malaria species in the hotter parts of the world and responsible [1] for much sickness and even death. 1.6 The Anopheles infected with Plasmodium bites a person to suck his blood and at [1] the same time, it releases... in the blood of this person. QUESTION 2 [25] 2.0 Answer ALL the questions. Write ONLY the question number and the letter of the CORRECT answer. Each correct answer is worth ONE mark. 2.1 Select a group of two cases where it is most likely to find that the patient has [1] neutropenia: a) Leukaemoid reaction and autoimmune disease b) Chemotherapy and infectious mononucleosis c) Chemotherapy and autoimmune disease d) Chemotherapy and anaemia e) Leukaemia and leukaemoid reaction 2.2 Identify a reason for the selection in 1.1: [1] a) The bone marrow just does not produce enough neutrophils therefore antibodies are not present b) The bone marrow's ability to produce neutrophils is impaired and antibodies that destroy neutrophils are present c) Antibodies that destroy neutrophils and white cell proliferation are present d) A severe infection in the patient plus antibodies that destroy neutrophils are present e) The condition is inherited 2.3 Select the most accurate version of cells with a high nuclear cytoplasmic ratio: [1] a) A small nucleus and large amounts of cytoplasm b) An atypical nucleus with basophilic cytoplasm c) Very little cytoplasm with a large nucleus cl) These cells are usually lymphocytes e) An unusual large nucleus with clumped chromatin Page 1 of 10

3 HAM621$ ZB: SUPPLEMENTARY/2nd OPPORTUNITY EXAMINATION JANUARY Which choice out of the following statements best defines May-Hegglin [1] anomaly? a) b) C) d) e) Bi-lobed neutrophils are found in the peripheral blood Giant granules in the neutrophils Mild thrombocytopenia with giant platelets Increased white cell count and platelet count Patients usually die in childhood 2.5 During an infection the following may happen: (Chose I, II or III) [1] a) b) C) d) e) Bone marrow becomes involved and releases mature cells Neutrophils in circulation go to the tissue Stem cells commit to produce further granulocytes Maturation is increased Extra cell divisions will also occur to get more cells f) Release of immature neutrophils but never blasts l. Only b), c) and e) ll. Only a), c), e) and f) II. All of the above 2.6 A 25-year-old healthy female experiences trauma to the abdomen in a motor [1] vehicle accident. A splenectomy was performed on this patient. Following her splenectomy, which of the following peripheral blood morphologic findings is most likely to be present? a) b) C) d) e) Tear drop cells Elliptocytes Macro-ovalocytes Microcytes Red blood cell inclusion bodies 2.7 Choose the reason for your choice in Q [1] a) b) C) d) e) Splenectomy increases the formation of poikilocytosis of the red blood cells A functioning spleen would normally remove any poikilocytosis of the red blood cells Splenectomy increases the formation of red blood cell inclusion bodies A functioning spleen would normally bodies All of the above remove red blood cell inclusion 2.8 The WHO classification for myeloproliferative disorders includes which one of [1] the following disorders? a) b) C) d) e) 5q- syndrome Multiple myeloma Myelofibrosis Refractory anaemia with excess blasts Acute lymphocytic leukaemia Page 2 of 10

4 HAM621S ZB: SUPPLEMENTARY/2nd OPPORTUNITY EXAMINATION JANUARY Complete this sentence: Acute lymphoblastic leukaemia... [1] 3) often has a relatively good prognosis b) seldom occurs in children c) is classified only according to morphologic appearance d) is only diagnosed when 30% or more of the nucleated cells are lymphoblasts e) has positive CD13 and CD33 markers 2.10 While screening a stained blood smear, you notice a blast with Auer rods in it. [1] This patient most likely has: a) A bacterial infection b) A myeloproliferative disease c) An acute myeloid leukaemia d) An acute lymphoblastic leukaemia e) Chronic myeloid leukaemia 2.11 A differential report notes the presence of more than 20% blasts. This number [1] confirms the diagnosis of: a) Chronic lymphoid leukaemia b) Chronic myeloid leukaemia c) Polycythemia d) Hairy cell leukaemia e) Acute myeloid leukaemia 2.12 In Idiopathic thrombocytopenic purpura the bone marrow aspiration and biopsy [1] will reveal the following: (choose I, II, III or IV) a) Increased platelet production b) Decreased platelet production c) Increased megakaryocytes d) Decreased megakaryocytes e) Mild erythroid hyperplasia if bleeding has taken place I- bl. d). e) II. a), c), e) III. a), C) IV. all of above 2.13 What condition is not characteristically associated with reactive thrombocytosis? [1] a) Acute haemorrhage b) Aplastic anaemia c) Chronic inflammatory disorders d) Iron deficiency anaemia e) History of splenectomy Page 3 of 10

5 HAM621$ ZB: SUPPLEMENTARY/2nd OPPORTUNITY EXAMINATION- JANUARY Auer rods have been determined to be: [1] a) Composed of histamine b) Diagnostic for acute lymphoblastic leukaemia c) Positive for proteolytic esterases d) Present in high numbers in adolescent acute myeloid leukaemia e) Diagnostic for acute myeloid leukaemia 2.15 Large platelets with a deficiency of GPlb is a feature of: [1] a) Von Willebrand s disease b) Bernard Soulier Syndrome c) Thrombasthenia cl) Idiopathic thrombocytopenia purpura e) MayHegglin anomaly 2.16 Which of the following disorders is NOT associated with an isolated, prolonged [1] partial thromboplastin time (PTT)? a) Factor VII deficiency b) Heparin therapy c) Lupus anticoagulant d) Factor XI deficiency e) Severe von Willebrand's disease 2.17 Heparin is used as an anticoagulant. The following is true about Heparin EXCEPT: [1] a) it is an inhibitor of blood coagulation b) It combines with Antithrombin III to inhibit thrombin c) Heparin impairs platelet function d) Heparin is not absorbed from the gastrointestinal tract e) It crosses the placenta and is therefore preferred for pregnant patients 2.18 International normalized ratio is used to monitor warfarin therapy. The therapeutic [1] range of choice would be: a) b) c) d) e) Identify the features most likely to find in patients with a diagnosed multiple [1] myeloma. a) ESR: 4 mm/hour b) Peripheral smear with severe auto agglutination of the red cells c) Peripheral d) Toxic granulation e) Large platelets smear with severe Rouleaux formation of the red cells Page 4 of 10

6 HAM621S ZB: SUPPLEMENTARY/2nd OPPORTUNITY EXAMINATION- JANUARY Inhibitors are mechanisms or substances at each step of coagulation to prevent too [1] much clotting. Identify such a mechanism or substances out of the following: a) Platelets b) Anti-thrombinlll c) Hagemanfactor d) Calcium e) Plasminogen 2.21 A 35 year old female with anaemia, bleeding tendency and with 20% blasts in the [l] peripheral smear was diagnosed to have disseminated intravascular coagulation. Most likely aetiology in this case is? a) Lymphoblastic leukaemia b) Chronic lymphocytic leukaemia c) Monocyticleukaemia d) Promyelocytic leukaemia e) Acute myelocytic leukaemia year old man complains of weakness, weight loss, and bone pain. Physical exam [1] is significant for hepatosplenomegaly and lymphadenopathy. Serum protein electrophoresis reveals an M-protein spike, with an elevated serum lgg level. Bone marrow aspiration shows plasmacytoid lymphocytes. Which of the following most likely diagnosis? a) Heavy chain disease b) Monoclonal gammopathy of undetermined significance c) Multiple Myeloma d) Plasmacytoma e) Waldenstrom s Macroglobulinemia is the 2.23 Which description is NOT consistent with the reactive changes in a neutrophil? [1] a) Have azurophilic granules b) Dohle body formation c) Cytoplasmic vacuoles d) May see ingested microorganisms as well e) Cell is pushed in by red blood cells to make ballerina cells 2.24 A patient with chronic myeloid leukaemia (CML) would most probably go through [1] different phases during the course of this disease. In the accelerated phase, the following is true: a) >20% myeloblasts in the blood b) Cytogenetic evolution with new abnormalities in addition to Philadelphia chromosome c) During this phase, patients are usually asymptomatic d) In this phase, CML is a slowly progressing disease e) Infections, bleeding and anaemia are unusual in this phase Page 5 of 10

7 'HAM621S ZB: SUPPLEMENTARY/2ml OPPORTUNITY EXAMINATION JANUARY The following were observed when the full blood count and the stained smear [1] were done on a patient with acute Promyelocytic Leukaemia (M3): that would be the most consistent with this diagnosis. a) Anaemia and atypical lymphocytes b) Anaemia and toxic granulation c) Anaemia and thrombocytosis d) Anaemia and thrombocytopenia e) Anaemia and eosinophilia choose a result SECTION B [52] QUESTION 3 [9] 3.1 Explain the development of neutropenia. [6] 3.2 What are the clinical features of a patient with neutropenia? [1] 3.3 Which way is the best to diagnose neutropenia? [2] QUESTION 4 [11] 4.0 Eosinophils are a type of disease-fighting white blood cell. 4.1 List the features of the eosinophil regarding the proliferation sequence, granules, [3] nucleus and the reference range in adults. 4.2 Describe the key causes of eosinophilia. [8] QUESTION 5 [14] 5.0 A patient with chronic myeloid leukaemia (CML) would most probably go through different phases during the course Of this disease. How would you explain these different phases? QUESTION 6 [18] 6.0 Differentiate between the following: 6.1 Leukaemia and lymphoma [4] 6.2 FAB and WHO classification of leukaemia [4] 6.3 The 2 types Of heparininduced thrombocytopenia (HIT) [4] 6.4 Describe the reactive changes a neutrophil can undergo. [3] 6.5 Myelofibrosis can be secondary to many disorders. Name three such disorders. [3] Page 6 of 10

8 HAM ZB: SUPPLEMENTARY/2nd OPPORTUNITY EXAMINATION- JANUARY 2018 SECTION c [27] QUESTION 7 [3] 7.0 A 1 year old boy was seen in casualty with a recent onset of easy bruising, bleeding gums, and persistent epistaxis. His mother said he was "never sick before in his entire life." He has numerous petechiae and purpura. No organomegaly. Patient results Units White cell count 5.3 X109/L Haemoglobin 13.4 g/dl Mean cell volume 84 fleet RDW 14 % Platelets 10 X109/L PT Normal results PTT Normal results A bone marrow aspirate on this boy revealed that the erythrocyte and granulocyte maturation were within normal limits. Megakaryocytes appear normal in number and morphology. 7.1 What would the most likely diagnosis be? [1] 7.2 This patient presents with petechiae. How are these formed and what is the [2] significance of petechiae? QUESTION 8 [7] 8.0 Study the following full blood count results as well as the images patient: from the same Patient results Units White cell count 56.0 X109/L Haemoglobin 6.4 g/dl Platelets 76 X109/L Page 7 of 10

9 HAM621S 2B: SUPPLEMENTARY/2nd OPPORTUNITY EXAMINATION-JANUARY 2018 Below are images of the stained thin blood smear of this patient: 8.1 Evaluate the full blood count results and the image. Decide if this is more likely [1] to be a chronic leukaemia OR an acute leukaemia. 8.2 What specifics did you use to make your choice in 8.1? [2] 8.3 Can you identify other features to distinguish between a chronic leukaemia and [4] an acute leukaemia? QUESTION 9 [8] 9.0 A 20-year-old male, presented to the physician with a long medical history of a bleeding tendency. He has had several instances of severe bruising following minor trauma. Laboratory findings were as follows: Platelet count 319 x log/l PT 10 seconds PTT 97 seconds Haematocrit and white blood cell count were both normal 9.1 What is the most likely diagnosis for this patient? [1] 9.2 PTT is the abbreviations for... [1] 9.3 PT is the abbreviations for... [1] 9.4 The PTT is monitoring the effectiveness of which pathway? [1] 9.5 Name at least 3 more cases where a prolonged/elevated PTT can be found. [3] 9.6 Which anticoagulant would you recommend to collect blood for coagulation? [1] Page 8 of 10

10 HHAM621S - ZB: SUPPLEMENTARY/2" l OPPORTUNITY EXAMINATION- JANUARY 2018 QUESTION 10 [9] 10.0 Acute lymphoblastic leukaemia is diagnosed in a child of 8 years. The thin smear was stained with the Romanowsky stain. performed and 69% lymphocytic blasts were counted. The differential count was 10.1 Which of the following peripheral smears, Image or Image , [1] would most likely be consistent with this diagnosis? Image Image The following results were observed when the full blood count of this child was [1] performed: choose a result that would be the most consistent with this diagnosis. a) High white cell count, normochromic normocytic anaemia and atypical lymphocytes b) High white cell count, toxic granulation and thrombocytosis c) High white cell count, normochromic normocytic anaemia and thrombocytopenia d) High white cell count and thrombocytosis e) High white cell count, severe rouleaux formation and thrombocytosis 10.3 Which of the following phrases would NOT be consistent with this diagnosis? [1] a) Patient can have enlarged lymph nodes b) Easy bleeding and bruising c) Growth delay present d) Patient can have enlarged liver and spleen e) Anaemia present 10.4 Select the panel of lmmunophenotyping results that is MOST UNLIKELY for this [1] child s acute leukaemia: a) Positive for CD3, CD10, CD 4 b) Positive for CD41, CD 33, CD61 c) Positive for CD4, CD10, CD19 d) Negative for CD4, CD10, CD19 e) Positive for CD3, CD7, CD 20 Page 9 of 10

11 l L ~ HAEM HAM621$ - ZB: SUPPLEMENTARY/2nd OPPORTUNITY EXAMINATION- JANUARY The WHO classification of acute lymphoblastic leukaemia is primarily based on: l1] a) Cytogenetic and morphology abnormalities b) Morphology and cytochemistry of blasts c) Immunophenotyping of blasts and genetic analysis d) Molecular genetic abnormalities and cytochemistry of blasts e) Cytogenetic abnormalities 10.6 The FAB classification of acute lymphoblastic leukaemia is primarily based on: l1] a) Cytogenetic and morphology abnormalities b) Morphology and cytochemistry of blasts c) ImmunophenOtyping of blasts and genetic analysis d) Molecular genetic abnormalities and cytochemistry e) Cytogenetic abnormalities of blasts 10.7 Which of the following findings in acute lymphoblastic leukaemia can help differentiate it from acute myeloid leukaemia? [1] a) Presence of Auer rods b) Positivity for myeloperoxidase c) Positivity for CD19 and CD22 d) >20% Blasts present e) Presence of immature granulocytes 10.8 Why is it necessary to immunophenotype the lymphoblasts in acute lymphoblastic leukaemia if they have been identified as lymphoblasts morphologically? [1] 10.9 Read the following statement and state whether it is TRUE or FALSE. l1] If FALSE motivate your answer (correct the false statement to make them true). Smear or smudge cells will be observed on the stained thin smear of this patient. TOTAL 110 Page 10 of 10