A 26-year-old man had his spleen removed after a road traffic accident in Pune. His smear six weeks later shows small, round, dark purple inclusions in many red cells. What are these inclusions?

Precipitated denatured haemoglobin

An 18-year-old man in Hyderabad had acute hepatitis two months ago; tests for hepatitis A, B, C and E were negative and his liver enzymes have now settled. He presents with petechiae and fatigue: Hb 7.0 g/dL, WBC 1,400/µL, platelets 9,000/µL, reticulocytes 0.1%. What is the most likely diagnosis?

Hepatitis-associated aplastic anaemia

Megaloblastic anaemia from malnutrition

Anaemias: smear, indices and diagnosis

33 NEET-PG practice questions on Anaemias: smear, indices and diagnosis, part of Pathology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 22-year-old primigravida at 12 weeks is seen in a district hospital antenatal clinic: Hb 10.4 g/dL, MCV 64 fL, MCH 20 pg, RBC count 5.9 million/µL, RDW 13% (reference 11.5-14.5%), serum ferritin 88 ng/mL; the smear shows microcytes and target cells. Consider four statements: 1. The Mentzer index favours beta-thalassaemia trait. 2. A full course of therapeutic oral iron will correct her anaemia. 3. HPLC showing HbA2 above 3.5% would confirm the likely diagnosis. 4. Her husband should be screened for carrier status. Which statements are correct?
1. A1 and 3 only
2. B1, 2, 3 and 4
3. C1, 2 and 3 only
4. D1, 3 and 4 only
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Answer: D · 1, 3 and 4 only
Statements 1, 3 and 4 are correct. Microcytosis with a high red cell count, normal RDW and normal ferritin points to beta-thalassaemia trait; the Mentzer index (MCV/RBC = 64/5.9, about 10.8) is below 13, whereas iron deficiency usually gives an index above 13 and a raised RDW. HPLC (or Hb electrophoresis) showing HbA2 above 3.5% confirms the trait, and the husband is screened because if both are carriers the couple needs counselling about prenatal diagnosis. Statement 2 is false: her iron stores are normal, so therapeutic iron cannot correct a genetic defect of globin synthesis and can cause iron overload over time.
- A: Omits husband screening, the key next step for a carrier in pregnancy.
- B: Includes therapeutic iron, which is wrong when ferritin is normal.
- C: Includes therapeutic iron, which does not correct thalassaemia trait, and omits husband screening.
Question 2 · Medium
A 24-year-old woman with menorrhagia has Hb 8.0 g/dL and MCV 66 fL. Consider these statements about the iron studies expected in her: 1. Serum ferritin is low. 2. Total iron binding capacity is raised. 3. Transferrin saturation is low. 4. Soluble transferrin receptor level is low. Which statements are correct?
1. A1, 2 and 3 only
2. B2 and 3 only
3. C3 and 4 only
4. D1 and 4 only
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Answer: A · 1, 2 and 3 only
In iron deficiency, storage iron (ferritin) is low, the liver makes more transferrin so TIBC rises, and serum iron falls, so transferrin saturation is low, often below 15%. Soluble transferrin receptor is raised, not low, because iron-starved erythroid precursors express more transferrin receptors. Raised soluble transferrin receptor helps separate iron deficiency from anaemia of inflammation, where it is normal. Statements 1, 2 and 3 are therefore correct.
- B: Leaves out the low ferritin, the most specific marker of iron deficiency.
- C: Includes a low soluble transferrin receptor; it is raised in iron deficiency.
- D: Includes a low soluble transferrin receptor and leaves out the raised TIBC and low saturation.
Question 3 · Easy
A 26-year-old man had his spleen removed after a road traffic accident in Pune. His smear six weeks later shows small, round, dark purple inclusions in many red cells. What are these inclusions?
1. ANuclear remnants of DNA
2. BPrecipitated denatured haemoglobin
3. CIron-containing mitochondria
4. DAggregated ribosomal RNA
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Answer: A · Nuclear remnants of DNA
These are Howell-Jolly bodies, small round fragments of nuclear DNA that are normally removed from red cells by the spleen. After splenectomy or with functional hyposplenism, as in sickle cell disease or coeliac disease, they persist in circulating cells. Their presence on the smear is a useful marker of absent splenic function. Such patients need vaccines against encapsulated bacteria and advice about urgent care for fever.
- B: Denatured haemoglobin forms Heinz bodies, seen with supravital stains in G6PD deficiency.
- C: Iron-laden granules are Pappenheimer bodies, seen in sideroblastic anaemia.
- D: Aggregated ribosomal RNA gives basophilic stippling.
Question 4 · Easy
A 19-year-old college student in Jaipur has fatigue, and her haemoglobin is still 12.4 g/dL with a normal MCV. She has had heavy periods for a year. Which laboratory value falls first as she develops iron deficiency?
1. AHaemoglobin
2. BSerum ferritin
3. CSerum iron
4. DMean corpuscular volume
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Answer: B · Serum ferritin
Iron deficiency develops in stages: storage iron is used up first, then transport iron falls, and only then is red cell production affected. Serum ferritin reflects storage iron, so it is the first value to fall, while haemoglobin and MCV are still normal. A low ferritin is diagnostic of iron deficiency, but ferritin is an acute-phase reactant and can be falsely normal in inflammation. This is why ferritin is the single most useful test for iron deficiency in an otherwise well patient.
- A: Haemoglobin falls last, after stores and transport iron are exhausted.
- C: Serum iron falls after stores are gone and varies widely through the day.
- D: Microcytosis appears only once iron-deficient erythropoiesis is established.
Question 5 · Medium
An 18-year-old man in Hyderabad had acute hepatitis two months ago; tests for hepatitis A, B, C and E were negative and his liver enzymes have now settled. He presents with petechiae and fatigue: Hb 7.0 g/dL, WBC 1,400/µL, platelets 9,000/µL, reticulocytes 0.1%. What is the most likely diagnosis?
1. AMegaloblastic anaemia from malnutrition
2. BAcute lymphoblastic leukaemia
3. CHypersplenism from cirrhosis
4. DHepatitis-associated aplastic anaemia
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Answer: D · Hepatitis-associated aplastic anaemia
Aplastic anaemia can follow an acute seronegative hepatitis, usually in young males, appearing weeks to months after the hepatitis has resolved. The mechanism is thought to be immune: T cells activated by the hepatitis attack haematopoietic stem cells. It is often severe, and the marrow is markedly hypocellular. It is treated like other severe aplastic anaemia, with transplantation or immunosuppression.
- A: Megaloblastic anaemia gives macrocytes and hypersegmented neutrophils, not a reticulocyte count of 0.1% with severe pancytopenia after hepatitis.
- B: ALL usually shows blasts, lymphadenopathy or organomegaly.
- C: Hypersplenism needs portal hypertension and splenomegaly, and gives milder cytopenias.
Question 6 · Easy
A 9-year-old boy from Gujarat develops dark urine and jaundice two days after eating fava beans at a wedding. Hb has fallen from 12.8 to 8.6 g/dL. Which finding is expected on his routine Leishman-stained smear?
1. ATarget cells
2. BBite cells
3. CSpur cells
4. DTear-drop cells
Answer and explanation in LearnFree account
Question 7 · Hard
A 28-year-old woman in Bengaluru has haemolytic anaemia. Her haematocrit is 30% and her reticulocyte count is 9%. Using a normal haematocrit of 45% and a maturation (shift) correction of 2 days for this haematocrit, what is her reticulocyte production index?
1. A3.0
2. B4.5
3. C9.0
4. D6.0
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Question 8 · Easy
A 5-year-old tribal child from Wayanad has had repeated painful swelling of the hands and feet since infancy. A sickling test is positive and HPLC shows mostly HbS with no HbA. Which change in the beta-globin chain causes his disease?
1. AValine replaced by glutamic acid at position 6
2. BGlutamic acid replaced by lysine at position 6
3. CGlutamic acid replaced by valine at position 6
4. DDeletion of both beta-globin genes
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Question 9 · Medium
A 32-year-old man has passed dark urine in the mornings for several months and now has abdominal pain and ascites from hepatic vein thrombosis. Hb 8.4 g/dL, reticulocytes 6%, LDH high, haptoglobin low, DAT negative, platelets 92,000/µL. Which investigation confirms the likely diagnosis?
1. AFlow cytometry for CD55 and CD59
2. BSerum ADAMTS13 activity
3. COsmotic fragility test
4. DDirect antiglobulin test with anti-C3
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Question 10 · Medium
A 62-year-old woman with hypothyroidism has fatigue and a smooth, sore tongue. Hb 8.6 g/dL, MCV 116 fL and serum vitamin B12 is low. She is not vegetarian. Which test is most specific for the likely underlying cause?
1. ASerum gastrin level
2. BSerum homocysteine level
3. CAnti-intrinsic factor antibody
4. DAnti-gastric parietal cell antibody
Answer and explanation in LearnFree account
Question 11 · Medium
A 2-year-old boy in Lucknow is pale and irritable. He drinks about a litre of cow's milk a day and eats little else. Hb 7.6 g/dL, MCV 58 fL, MCH 17 pg, RBC count 3.9 million/µL and RDW 19% (reference 11.5-14.5%). Which result most strongly favours iron deficiency over beta-thalassaemia trait?
1. ARaised RDW
2. BLow MCH
3. CLow haemoglobin
4. DLow MCV
Answer and explanation in LearnFree account
Question 12 · Hard
A 30-year-old woman from Bihar who eats little meat or dairy has fatigue. Hb 7.6 g/dL, MCV 84 fL, RDW 24% (reference 11.5-14.5%). The smear shows two populations of red cells, small hypochromic cells and large oval macrocytes, with hypersegmented neutrophils. Stool shows hookworm ova. What is the most likely explanation of her blood picture?
1. ACombined iron and vitamin B12 deficiency
2. BAnaemia of chronic inflammation
3. CMyelodysplastic syndrome with ring sideroblasts
4. DRecent transfusion of normal red cells
Answer and explanation in LearnFree account
Question 13 · Medium
A 40-year-old man in Nagpur has been on isoniazid, rifampicin, pyrazinamide and ethambutol for 4 months without pyridoxine. Hb 8.2 g/dL, MCV 70 fL, serum ferritin 420 ng/mL; Prussian blue stain of the marrow shows ringed sideroblasts. What is the mechanism of his anaemia?
1. AFolate antagonism by isoniazid
2. BIron malabsorption caused by rifampicin
3. CHaemolysis induced by pyrazinamide
4. DPyridoxine deficiency impairing ALA synthase
Answer and explanation in LearnFree account
Question 14 · Hard
A 6-year-old boy from Bhopal developed dark urine and jaundice three days after being given a drug for fever. On admission: Hb 7.0 g/dL, reticulocytes 12%, bite cells on smear. A quantitative G6PD assay done on the second day of the illness is reported as normal. What should be done next?
1. AStart oral prednisolone for haemolysis
2. BAccept the normal result and look for another cause of haemolysis
3. CSend the sample for haemoglobin HPLC
4. DRepeat the G6PD assay about 3 months after recovery
Answer and explanation in LearnFree account
Question 15 · Hard
A 25-year-old woman at 10 weeks of pregnancy in Mumbai has Hb 9.2 g/dL, MCV 63 fL, RBC count 5.1 million/µL and serum ferritin 5 ng/mL. HPLC shows HbA2 3.2% (trait cut-off 3.5%). Her husband has beta-thalassaemia trait with HbA2 5.6%. What is the most appropriate next step?
1. AProceed directly to chorionic villus sampling now
2. BReport her as not a carrier and reassure the couple
3. CStart regular red cell transfusion
4. DGive oral iron and repeat HPLC after iron repletion
Answer and explanation in LearnFree account
Question 16 · Medium
A 12-year-old boy with sickle cell anaemia from Chhattisgarh has fever, pain and swelling over the lower tibia. X-ray shows periosteal reaction and the bone aspirate grows a Gram-negative bacillus. Which organism is classically more frequent as a cause of osteomyelitis in sickle cell disease?
1. ASalmonella species
2. BPseudomonas aeruginosa
3. CHaemophilus influenzae
4. DKlebsiella pneumoniae
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Question 17 · Medium
A 30-year-old woman in a PHC in Odisha has Hb 8.2 g/dL with microcytic hypochromic cells and serum ferritin 6 ng/mL. She is started on oral ferrous sulphate and asked to return. Which result is the earliest evidence that she is responding?
1. ANormal serum ferritin within 2 weeks
2. BRise in reticulocyte count within 7-10 days
3. CNormal MCV within 2 weeks
4. DNormal haemoglobin within 3 weeks
Answer and explanation in LearnFree account
Question 18 · Easy
A 38-year-old man who has worked for 10 years at a battery recycling unit in Meerut has colicky abdominal pain, constipation and a blue-grey line on his gums. Hb is 9.6 g/dL with microcytic cells. Which feature is expected on his peripheral smear?
1. ACoarse basophilic stippling
2. BHowell-Jolly bodies
3. CHypersegmented neutrophils
4. DSchistocytes (fragmented cells)
Answer and explanation in LearnFree account
Question 19 · Medium
A 48-year-old man with chronic heavy alcohol use and a poor diet has Hb 9.4 g/dL and MCV 112 fL with hypersegmented neutrophils. He has no neurological signs. Serum homocysteine is raised and serum methylmalonic acid is normal. Which deficiency is most likely?
1. APyridoxine deficiency
2. BVitamin B12 deficiency
3. CCopper deficiency
4. DFolate deficiency
Answer and explanation in LearnFree account
Question 20 · Hard
A 19-year-old man in Kolkata has severe aplastic anaemia: ANC 300/µL, platelets 11,000/µL, absolute reticulocyte count 12,000/µL and a marrow cellularity of 10% with no abnormal cells or cytogenetic abnormality. His 22-year-old brother is a full HLA match. What is the best definitive treatment?
1. AOral danazol with growth factor support
2. BAntithymocyte globulin with ciclosporin
3. CAllogeneic stem cell transplant from his brother
4. DRegular transfusions of irradiated red cells and platelets
Answer and explanation in LearnFree account
Question 21 · Medium
A 55-year-old man with fatigue has macrocytic anaemia and is suspected to have vitamin B12 deficiency. Consider these features: 1. Hypersegmented neutrophils. 2. Raised MCV. 3. Raised reticulocyte count. 4. Raised serum LDH. Which are expected in his blood?
1. A1, 2 and 4 only
2. B2 and 3 only
3. C1 and 4 only
4. D1, 2, 3 and 4
Answer and explanation in LearnFree account
Question 22 · Medium
A 58-year-old man in a medical ward in Chennai has Hb 7.8 g/dL, MCV 120 fL, hypersegmented neutrophils and tingling in both feet with reduced vibration sense. His serum B12 and folate reports will take 3 days. The intern wants to start folic acid alone today. What is the best course?
1. ATransfuse two units of packed red cells
2. BStart folic acid alone and add B12 if low
3. CWait for the reports before any treatment
4. DStart parenteral vitamin B12 along with folic acid
Answer and explanation in LearnFree account
Question 23 · Medium
In a Kochi surgical OPD, a teenager booked for cholecystectomy for pigment stones gives a history of yellow eyes off and on since early childhood; his father lost his spleen at 20. Blood: Hb 10.2 g/dL, MCHC 37 g/dL (32-36), reticulocytes 8%, spherocytes, DAT negative. Which test best confirms the likely diagnosis?
1. ADirect antiglobulin test repeated with anti-C3
2. BRed cell G6PD enzyme assay
3. CEosin-5-maleimide binding test by flow cytometry
4. DHaemoglobin HPLC
Answer and explanation in LearnFree account
Question 24 · Medium
A 34-year-old vegan woman has Hb 7.2 g/dL, MCV 114 fL, reticulocytes 0.6%, serum LDH 2,100 U/L (reference up to 250) and raised unconjugated bilirubin. Her bone marrow is hypercellular with megaloblasts. What best explains the raised LDH and bilirubin?
1. AAutoimmune destruction of red cells within the spleen
2. BIneffective erythropoiesis with intramedullary death
3. CIntravascular haemolysis of mature red cells
4. DLeakage of LDH from damaged hepatocytes
Answer and explanation in LearnFree account
Question 25 · Medium
A 22-year-old hostel student in Manipal recovering from atypical pneumonia has jaundice and fatigue. Hb 8.8 g/dL; the EDTA sample shows visible clumping at room temperature that disperses on warming. The DAT is positive with anti-C3 and negative with anti-IgG. Which antibody is most likely responsible?
1. AIgG warm autoantibody
2. BIgM anti-I cold agglutinin
3. CIgG Donath-Landsteiner antibody
4. DIgM anti-A isohaemagglutinin
Answer and explanation in LearnFree account

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Anaemias: smear, indices and diagnosis

A 26-year-old man had his spleen removed after a road traffic accident in Pune. His smear six weeks later shows small, round, dark purple inclusions in many red cells. What are these inclusions?

A 19-year-old college student in Jaipur has fatigue, and her haemoglobin is still 12.4 g/dL with a normal MCV. She has had heavy periods for a year. Which laboratory value falls first as she develops iron deficiency?

An 18-year-old man in Hyderabad had acute hepatitis two months ago; tests for hepatitis A, B, C and E were negative and his liver enzymes have now settled. He presents with petechiae and fatigue: Hb 7.0 g/dL, WBC 1,400/µL, platelets 9,000/µL, reticulocytes 0.1%. What is the most likely diagnosis?

A 9-year-old boy from Gujarat develops dark urine and jaundice two days after eating fava beans at a wedding. Hb has fallen from 12.8 to 8.6 g/dL. Which finding is expected on his routine Leishman-stained smear?

A 28-year-old woman in Bengaluru has haemolytic anaemia. Her haematocrit is 30% and her reticulocyte count is 9%. Using a normal haematocrit of 45% and a maturation (shift) correction of 2 days for this haematocrit, what is her reticulocyte production index?

A 5-year-old tribal child from Wayanad has had repeated painful swelling of the hands and feet since infancy. A sickling test is positive and HPLC shows mostly HbS with no HbA. Which change in the beta-globin chain causes his disease?

A 32-year-old man has passed dark urine in the mornings for several months and now has abdominal pain and ascites from hepatic vein thrombosis. Hb 8.4 g/dL, reticulocytes 6%, LDH high, haptoglobin low, DAT negative, platelets 92,000/µL. Which investigation confirms the likely diagnosis?

A 62-year-old woman with hypothyroidism has fatigue and a smooth, sore tongue. Hb 8.6 g/dL, MCV 116 fL and serum vitamin B12 is low. She is not vegetarian. Which test is most specific for the likely underlying cause?

A 2-year-old boy in Lucknow is pale and irritable. He drinks about a litre of cow's milk a day and eats little else. Hb 7.6 g/dL, MCV 58 fL, MCH 17 pg, RBC count 3.9 million/µL and RDW 19% (reference 11.5-14.5%). Which result most strongly favours iron deficiency over beta-thalassaemia trait?

A 40-year-old man in Nagpur has been on isoniazid, rifampicin, pyrazinamide and ethambutol for 4 months without pyridoxine. Hb 8.2 g/dL, MCV 70 fL, serum ferritin 420 ng/mL; Prussian blue stain of the marrow shows ringed sideroblasts. What is the mechanism of his anaemia?

A 6-year-old boy from Bhopal developed dark urine and jaundice three days after being given a drug for fever. On admission: Hb 7.0 g/dL, reticulocytes 12%, bite cells on smear. A quantitative G6PD assay done on the second day of the illness is reported as normal. What should be done next?

A 25-year-old woman at 10 weeks of pregnancy in Mumbai has Hb 9.2 g/dL, MCV 63 fL, RBC count 5.1 million/µL and serum ferritin 5 ng/mL. HPLC shows HbA2 3.2% (trait cut-off 3.5%). Her husband has beta-thalassaemia trait with HbA2 5.6%. What is the most appropriate next step?

A 12-year-old boy with sickle cell anaemia from Chhattisgarh has fever, pain and swelling over the lower tibia. X-ray shows periosteal reaction and the bone aspirate grows a Gram-negative bacillus. Which organism is classically more frequent as a cause of osteomyelitis in sickle cell disease?

A 30-year-old woman in a PHC in Odisha has Hb 8.2 g/dL with microcytic hypochromic cells and serum ferritin 6 ng/mL. She is started on oral ferrous sulphate and asked to return. Which result is the earliest evidence that she is responding?

A 38-year-old man who has worked for 10 years at a battery recycling unit in Meerut has colicky abdominal pain, constipation and a blue-grey line on his gums. Hb is 9.6 g/dL with microcytic cells. Which feature is expected on his peripheral smear?

A 48-year-old man with chronic heavy alcohol use and a poor diet has Hb 9.4 g/dL and MCV 112 fL with hypersegmented neutrophils. He has no neurological signs. Serum homocysteine is raised and serum methylmalonic acid is normal. Which deficiency is most likely?

A 19-year-old man in Kolkata has severe aplastic anaemia: ANC 300/µL, platelets 11,000/µL, absolute reticulocyte count 12,000/µL and a marrow cellularity of 10% with no abnormal cells or cytogenetic abnormality. His 22-year-old brother is a full HLA match. What is the best definitive treatment?

A 55-year-old man with fatigue has macrocytic anaemia and is suspected to have vitamin B12 deficiency. Consider these features: 1. Hypersegmented neutrophils. 2. Raised MCV. 3. Raised reticulocyte count. 4. Raised serum LDH. Which are expected in his blood?

A 58-year-old man in a medical ward in Chennai has Hb 7.8 g/dL, MCV 120 fL, hypersegmented neutrophils and tingling in both feet with reduced vibration sense. His serum B12 and folate reports will take 3 days. The intern wants to start folic acid alone today. What is the best course?

A 34-year-old vegan woman has Hb 7.2 g/dL, MCV 114 fL, reticulocytes 0.6%, serum LDH 2,100 U/L (reference up to 250) and raised unconjugated bilirubin. Her bone marrow is hypercellular with megaloblasts. What best explains the raised LDH and bilirubin?