Anatomy of Hematologic System

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A 13-year-old boy presents to the emergency department with complaints of headache and visual changes. History reveals progressive dyspnea on exertion, generalized fatigue, and increased bruising. His labs are significant for a WBC of 350,000/mcL, of which 80% are reported to be blasts and appear to be myeloblasts without the presence of Auer rods. His hemoglobin is 7.2 g/dL, and his platelets are 18,000/mcL. A CT scan of the head shows a small intracerebral hemorrhage. His coags are normal. Which of the following is the most appropriate therapy?

  • A. Start induction chemotherapy.
  • B. Perform emergent leukapheresis followed the next day by induction chemotherapy.
  • C. Perform emergent leukapheresis plus hydroxyurea.
  • D. Provide emergent cranial radiation plus hydroxyurea followed the next day by induction chemotherapy.
Correct Answer: C

Rationale: The most appropriate therapy in this scenario is emergent leukapheresis plus hydroxyurea (Choice C). Leukapheresis is needed to rapidly reduce the high white blood cell count, preventing further complications such as leukostasis and hyperviscosity syndrome. Hydroxyurea can help further control the rapid proliferation of blasts. Induction chemotherapy (Choice A) may lead to tumor lysis syndrome due to the high tumor burden. Performing leukapheresis alone without a subsequent therapy (Choice B) may not adequately address the underlying disease. Providing cranial radiation (Choice D) is not the initial management for acute myeloid leukemia.

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A 14-year-old male patient is diagnosed with very high risk acute lymphoblastic leukemia and is likely going to require an allogeneic hematopoietic stem cell transplant to cure his leukemia. Prior to going to transplant, he is likely to require multiple blood transfusions. Which of the following products or component modifications is the best way to prevent him from developing alloimmunization due to anti-HLA antibodies prior to transplant?

  • A. Frozen RBCs
  • B. Volume-reduced blood products
  • C. Irradiation of all blood products
  • D. Leukoreduced blood products
Correct Answer: D

Rationale: The correct answer is D: Leukoreduced blood products. Leukoreduction removes white blood cells, which are a major source of HLA antigens that can trigger alloimmunization. By using leukoreduced blood products, the risk of developing anti-HLA antibodies is significantly reduced, thus minimizing the potential for alloimmunization prior to transplant.

A: Frozen RBCs - Freezing does not eliminate HLA antigens and does not prevent alloimmunization.
B: Volume-reduced blood products - Reducing volume does not impact HLA antigens and thus doesn't prevent alloimmunization.
C: Irradiation of all blood products - While irradiation prevents graft-versus-host disease, it does not directly prevent the development of anti-HLA antibodies.

Increase Fe & normal TIBC are found in:

  • A. thalassemia major
  • B. haemosidrosis
  • C. rheumatoid arthritis
  • D. dissiminated malignancy
Correct Answer: C

Rationale: The correct answer is C: rheumatoid arthritis. In rheumatoid arthritis, there is chronic inflammation leading to elevated levels of ferritin (Fe) due to increased iron storage and a normal total iron-binding capacity (TIBC). This is because despite the increased iron stores, the body is unable to utilize it fully due to chronic inflammation.

Incorrect choices:
A: Thalassemia major would typically present with decreased TIBC due to increased iron absorption to compensate for the chronic anemia.
B: Haemosiderosis would show elevated Fe but a decreased TIBC due to iron overload.
D: Disseminated malignancy may show elevated Fe levels but typically with a decreased TIBC due to anemia of chronic disease.

A nurse is teaching a client about taking ferrous sulfate to treat iron deficiency anemia. Which of the following instructions should the nurse include? (Select All)

  • A. Eat iron-enriched foods.
  • B. Spread the dosage across each day.
  • C. Take the drug on an empty stomach.
  • D. Report dark green or black stools.
Correct Answer: A

Rationale: The correct answer is A: Eat iron-enriched foods. Iron-enriched foods help increase iron levels in the body, supporting the treatment of iron deficiency anemia. The rationale is that consuming foods rich in iron can complement the effects of ferrous sulfate, aiding in the replenishment of iron stores.

Summary:
- B: Spreading the dosage throughout the day can help with better absorption, but it is not the priority instruction.
- C: Taking the drug on an empty stomach can enhance absorption, but it may also cause stomach upset.
- D: Reporting dark green or black stools is important to monitor for possible gastrointestinal bleeding, but it is not an instruction for taking ferrous sulfate.

The mean cell volume of the patient is 90 fl and the reticulocyte production index is low. Which of the following is the most possible cause of anemia in this patient?

  • A. Thalassemia
  • B. Vitamin B12 deficiency
  • C. Aplastic anemia
  • D. Sideroblastic anemia
Correct Answer: C

Rationale: Rationale: A low reticulocyte production index indicates decreased bone marrow response to anemia. Aplastic anemia is characterized by bone marrow failure leading to pancytopenia, causing anemia. Thalassemia results in microcytic anemia, not macrocytic. Vitamin B12 deficiency causes macrocytic anemia due to impaired DNA synthesis. Sideroblastic anemia leads to microcytic anemia due to defective heme synthesis. Therefore, the most likely cause of anemia in this patient with a low reticulocyte production index and normal mean cell volume is aplastic anemia.

Waldeyer's ring does not include:

  • A. faucal tonsils
  • B. submandibular glands
  • C. adenoids
  • D. lingual tonsils
Correct Answer: B

Rationale: The correct answer is B: submandibular glands. Waldeyer's ring consists of a ring of lymphoid tissue in the pharynx, including the palatine tonsils (faucal tonsils), adenoids, and lingual tonsils. Submandibular glands are salivary glands located beneath the mandible and are not part of Waldeyer's ring. Therefore, B is the correct answer. Choices A, C, and D are incorrect because they are all components of Waldeyer's ring.

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