Deck 12: Megaloblastic and Nonmegaloblastic Macrocytic Anemias

Question 1

It is much easier to become folate-deficient than B₁₂-deficient because:

A)The body utilizes folate quicker than it does vitamin B₁₂.
B)The body has larger vitamin B₁₂ stores than it does folate stores.
C)The body has a greater need for folate than for vitamin B₁₂.
D)It has not been determined why folate is needed by the body more so than vitamin B₁₂.

Answer 1

The body has larger vitamin B₁₂ stores than it does folate stores.

Question 2

Macrocytes are often seen in hospitalized alcoholics due to:

A)Alcohol toxicity on erythroid precursors.
B)Stimulated erythropoiesis.
C)Reticulocytosis.
D)Iron deficiency.

Answer 2

Alcohol toxicity on erythroid precursors.

Question 3

Which of the following is found in megaloblastic macrocytosis and not in nonmegaloblastic macrocytosis?

A)Decreased WBC count and vitamin B₁₂ levels
B)Decreased hemoglobin and hematocrit
C)Normal-to-decreased reticulocyte count
D)Serum bilirubin increased

Answer 3

Decreased WBC count and vitamin B₁₂ levels

Question 4

Patients with blind loop syndrome can have vitamin B₁₂ deficiency complications due to:

A)Inadequate diet.
B)Increased minimum daily requirements.
C)Malabsorption.
D)Biologic competition.

Question 5

Neurological symptoms are prevalent in Vitamin B₁₂ deficiency because of:

A)Antibodies to intrinsic factor.
B)Decreased secretion of intrinsic factor.
C)Improper fatty acid metabolism.
D)Improper metabolism of methionine.

Question 6

Vitamin B₁₂ is a cofactor used in the conversion of _______ to _______.

A)Hydrocobalamin; thymidine
B)5-methyltetrahydrofolate; tetrahydrofolate
C)Folate; methionine
D)Succinyl CoA; methylmalonic acid

Question 7

Deficiencies in folic acid lead to which of the following?

A)Nuclear cytoplasmic asynchrony
B)Absence of nuclear division
C)Excessive proliferation of myeloid precursors
D)Decreased proliferation of erythroid precursors

Question 8

The nuclear cytoplasmic asynchronous morphology in megaloblastosis is best characterized by:

A)Nuclear immaturity with cytoplasmic maturity.
B)Nuclear maturity with cytoplasmic immaturity.
C)Nuclear maturity with abundant cytoplasm.
D)Normal nuclear and cytoplasmic maturity.

Question 9

Which test is a better indicator of folate status in the body over the last month?

A)Folate level
B)RBC folate level
C)Vitamin B₁₂ level
D)MMA

Question 10

Use this case to answer the following questions. A 55-year-old male consulted his physician because of weakness, lightheadedness, vertigo, and angina. The patient also complained of sores on his tongue. The physical examination revealed jaundice. The pulse rate was increased, and the spleen and liver were slightly enlarged. The tongue appeared smooth and bright red in color. Family history revealed no clues. Neurological exam revealed quickening of reflex responses. Patient history indicated a total gastrectomy five years ago for stomach cancer and intermittent heart problems that had not required surgery. The physician ordered the following tests:
$\begin{array}{ll}\text { TEST } & \text { RESULTS } \\\text { WBC } & 3.1 \times 10^{9} / \mathrm{L} \\\text { RBC } & 2.45 \times 10^{12} / \mathrm{L} \\\text { HGB } & 10.5 \mathrm{gm} / \mathrm{dL} \\\text { HCT } & 29.0 \% \\\text { MCV } & 118 \mathrm{fl} \\\text { MCH } & 42.8 \mathrm{pg} \\\text { MCHC } & 36.2 \mathrm{gm} / \mathrm{dL} \\\text { RDW } & 15.7 \\\text { PLT } & 83 \times 10^{9} / \mathrm{L}\\\text { Differential: }\\\text { Polys } & 49 \% \\\text { Stabs } & 6 \% \\\text { Lymphs } & 30 \% \\\text { Mono } & 8 \% \\\text { Eos } & 5 \% \\\text { Basos } & 2 \%\end{array}$
Peripheral blood: macro-ovalocytes, no hypersegmentation noted.

-What is (are) the most appropriate reflex test(s)?

A)Iron studies
B)Bilirubin
C)Vitamin B?? and folate levels
D)Hemoglobin electrophoresis

Question 11

What can falsely elevate the serum folate level?

A)Hemolysis of the serum sample
B)Recent low dietary intake
C)Vitamin B₁₂ deficiency
D)Recent alcohol consumption

Question 12

Which clinical manifestation is common in vitamin B₁₂ deficiency but not in folate deficiency?

A)Glossitis
B)Pallor
C)Fatigue
D)Peripheral neuropathy

Question 13

Pernicious anemia is a disorder characterized by:

A)Anti-vitamin B₁₂ antibodies.
B)Lack of IF.
C)Improper dietary intake of vitamin B₁₂.
D)Increased absorption of vitamin B₁₂.

Question 14

Pernicious anemia is a malabsorption of vitamin B₁₂ due to what component deficiency?

A)Gastric juice
B)Intrinsic factor
C)Histamine
D)Folate

Question 15

A blood specimen is analyzed.The MCV is increased, the hemoglobin level is decreased, and the reticulocyte count is normal or low.What test could give more information on the cause of the anemia without drawing another blood specimen?

A)Serum iron
B)Vitamin B₁₂ assay
C)Blood smear morphological exam
D)Serum alcohol

Question 16

The reason that lack of vitamin B₁₂ causes megaloblastic changes is because vitamin B₁₂:

A)Is needed for the formation of nucleotide bases.
B)Is needed for the conversion of methionine to SAM.
C)Initiates mitosis.
D)Is needed for synthesis of intrinsic factor.

Question 17

Predict the levels of MMA and homocysteine in patients with Vitamin B₁₂ deficiency.

A)Both will be normal.
B)Both will be decreased.
C)Both will be increased.
D)MMA will be increased and homocysteine will be normal.

Question 18

Megaloblastic anemia is most often caused by deficiencies of what two components?

A)Iron and transferrin
B)Ferritin and hemoglobin
C)Vitamin B₁₂ and folate
D)Iron and liver disease

Question 19

All of the following disorders can lead to macrocytic anemia except:

A)Alcoholism.
B)Liver disease.
C)Hypothyroidism.
D)Iron deficiency.

Question 20

Megaloblastic anemia is characterized by:

A)Hypersegmentation of PMNs.
B)Presence of Heinz bodies.
C)Ve hypochromia.
D)Microcytosis.

Question 21

Explain how high alcohol intake can cause macrocytosis.

Question 22

Use this case to answer the following questions. A 55-year-old male consulted his physician because of weakness, lightheadedness, vertigo, and angina. The patient also complained of sores on his tongue. The physical examination revealed jaundice. The pulse rate was increased, and the spleen and liver were slightly enlarged. The tongue appeared smooth and bright red in color. Family history revealed no clues. Neurological exam revealed quickening of reflex responses. Patient history indicated a total gastrectomy five years ago for stomach cancer and intermittent heart problems that had not required surgery. The physician ordered the following tests:
$\begin{array}{ll}\text { TEST } & \text { RESULTS } \\\text { WBC } & 3.1 \times 10^{9} / \mathrm{L} \\\text { RBC } & 2.45 \times 10^{12} / \mathrm{L} \\\text { HGB } & 10.5 \mathrm{gm} / \mathrm{dL} \\\text { HCT } & 29.0 \% \\\text { MCV } & 118 \mathrm{fl} \\\text { MCH } & 42.8 \mathrm{pg} \\\text { MCHC } & 36.2 \mathrm{gm} / \mathrm{dL} \\\text { RDW } & 15.7 \\\text { PLT } & 83 \times 10^{9} / \mathrm{L}\\\text { Differential: }\\\text { Polys } & 49 \% \\\text { Stabs } & 6 \% \\\text { Lymphs } & 30 \% \\\text { Mono } & 8 \% \\\text { Eos } & 5 \% \\\text { Basos } & 2 \%\end{array}$
Peripheral blood: macro-ovalocytes, no hypersegmentation noted.

-What would be the results of vitamin B?? and/or folate levels in a diagnosis of pernicious anemia?

A)Increased folate
B)Increased vitamin B??
C)Decreased vitamin B??
D)Decreased folate and vitamin B??

Question 23

Explain why patients undergoing gastric bypass surgery are prone to developing pernicious anemia.

Question 24

Explain how vitamin B₁₂ deficiency can cause folate deficiency.

Question 25

How can infection with the Epstein-Barr virus (EBV) lead to aplastic anemia?

A)EBV causes defects in precursor cells.
B)EBV infects stem cells, and an immune response is initiated that destroys the stem cells.
C)EBV creates immune complexes on the surface of the stem cell that damages it.
D)Infection with the virus shuts down cytokine production by macrophages.

Question 26

Which of the following is found in megaloblastic anemia but not nonmegaloblastic macrocytic anemia?

A)Macrocytic erythrocytes
B)Howell-Jolly bodies
C)Heniz bodies
D)Hypochromia

Question 27

What diagnosis is suggested if part II of the Schilling test is more than 7.5% when part I was 1%?

A)Sprue
B)Pernicious anemia
C)Renal disease
D)Celiac disease

Question 28

The majority of PA patients have antibodies against what component necessary for vitamin B₁₂ absorption?

A)Parietal cells
B)Vitamin B₁₂
C)Intrinsic factor
D)Blocking antibody

Question 29

Which CDA is characterized by a positive Ham test and a negative sucrose lysis test?

A)CDA I
B)CDA II
C)CDA III
D)CDA IV

Question 30

Use this case to answer the following questions. A 55-year-old male consulted his physician because of weakness, lightheadedness, vertigo, and angina. The patient also complained of sores on his tongue. The physical examination revealed jaundice. The pulse rate was increased, and the spleen and liver were slightly enlarged. The tongue appeared smooth and bright red in color. Family history revealed no clues. Neurological exam revealed quickening of reflex responses. Patient history indicated a total gastrectomy five years ago for stomach cancer and intermittent heart problems that had not required surgery. The physician ordered the following tests:
$\begin{array}{ll}\text { TEST } & \text { RESULTS } \\\text { WBC } & 3.1 \times 10^{9} / \mathrm{L} \\\text { RBC } & 2.45 \times 10^{12} / \mathrm{L} \\\text { HGB } & 10.5 \mathrm{gm} / \mathrm{dL} \\\text { HCT } & 29.0 \% \\\text { MCV } & 118 \mathrm{fl} \\\text { MCH } & 42.8 \mathrm{pg} \\\text { MCHC } & 36.2 \mathrm{gm} / \mathrm{dL} \\\text { RDW } & 15.7 \\\text { PLT } & 83 \times 10^{9} / \mathrm{L}\\\text { Differential: }\\\text { Polys } & 49 \% \\\text { Stabs } & 6 \% \\\text { Lymphs } & 30 \% \\\text { Mono } & 8 \% \\\text { Eos } & 5 \% \\\text { Basos } & 2 \%\end{array}$
Peripheral blood: macro-ovalocytes, no hypersegmentation noted.

-All of the following are expected laboratory findings of PA except:

A)Decreased vitamin B?? levels.
B)Increased MMA in the urine.
C)Part I of Schilling test = 5%; part II of Schilling test = 10%.
D)Part I of Schilling test = 2.5%; part II of Schilling test = 2.5%.

Question 31

The defect in DNA synthesis associated with megaloblastic anemia affects which cells?

A)Only erythrocytes
B)Only gastric cells and WBCs
C)Only neurological cells
D)All dividing cells

Question 32

Aplastic anemia is most often caused by:

A)Drugs.
B)Radiation.
C)Unknown causes.
D)Infectious agents.

Question 33

Autoantibodies against parietal cells and intrinsic factor are associated with:

A)Grave's disease.
B)Hashimoto's thyroiditis.
C)Addison's disease.
D)Pernicious anemia.

Question 34

Hypoproliferative anemia is defined as:

A)Decreased hematopoiesis in the bone marrow.
B)Decreased hematopoiesis in the liver.
C)Decreased erythropoiesis in the bone marrow.
D)Ineffective erythropoiesis in the bone marrow.

Question 35

A patient taking chloramphenicol is at risk for developing aplastic anemia because of which of the following?

A)The drug promotes an immune response against stem cells.
B)The drug is toxic to the bone marrow.
C)It results in stem cell resistance to essential cytokines.
D)It causes decreased cytokine production.

Question 36

Explain why peripheral neuropathy is a common finding in vitamin B₁₂ deficiency.

Question 37

Name three causes of folate deficiency.How would they differ in results in regards to serum and RBC folate levels?

Question 38

What conditions listed can result in macrocytic anemia without megaloblastosis?

A)Diabetes
B)Liver disease
C)Myelodysplastic syndrome
D)Pernicious anemia

Question 39

Fanconi's syndrome is an example of:

A)Constitutional aplastic anemia.
B)Acquired aplastic anemia.
C)Constitutional anemia due to external stimuli.
D)Acquired aplastic anemia due to external exposure.

Question 40

Which of the following are key features found in nonmegaloblastic macrocytosis?

A)Oval red blood cells
B)Hypersegmented neutrophils
C)Jaundice, glossitis, and neuropathy
D)Round macrocytes

Question 41

Which of the following describe the bone marrow in a patient with Fanconi's syndrome?

A)Hypercellular with erythroid hyperplasia
B)Hypocellular with normal M:E ratio
C)Normocellular with decreased M:E ratio
D)Hypocellular with elevated M:E ratio

Question 42

What is a viable explanation as to why some individuals suffer stem cell damage when exposed to chemical agents and others do not?

A)Longer life span of some red cells
B)Superior detoxification
C)Autoimmune disorders
D)Lack of exposure

Question 43

Which of the following is a contributor to the production of a hypocellular bone marrow?

A)Damage to the stem or progenitor cells in the bone marrow
B)Iron storage disease
C)Gene mutations
D)Hemoglobinopathy

Question 44

A 5-year-old boy with malformed thumbs and microcephaly has been suffering from prolonged bleeding episodes, extreme fatigue, and persistent repetitive infections.Cytogenetic analysis shows increased chromosome breakage with the addition of diepoxybutane.Based on these findings, what is the patient most likely suffering from?

A)CDA II
B)Pure red cell aplasia
C)Diamond Blackfan anemia
D)Fanconi's syndrome

Question 45

The cytopenias associated with MDS are due to:

A)Dyshematopoiesis.
B)Bone marrow replacement.
C)Hypoplasia of the bone marrow.
D)Decreased cytokine production.

Question 46

What CBC parameter would help differentiate Fanconi's syndrome from Diamond Blackfan anemia?

A)MCV
B)WBC and PLT counts
C)RBC counts
D)Differential

Question 47

Anemia in hypersplenism differs from anemia found in true hypoproliferative anemias because in hypersplenism there is:

A)Reticulocytosis.
B)Ineffective hematopoiesis.
C)Dyshematopoiesis.
D)Hypoplastic bone marrow.

Question 48

Diamond-Backfan syndrome anemia is a rare congential progressive erythrocyte aplasia.What is the most probable defect causing this rare disorder?

A)Deficiency of erythropoietin
B)Antibodies against erythropoietin
C)Intrinsic defect of erythroid progenitor cells
D)Increased reticulocytes

Question 49

The presence of what poikilocyte would lead to a suspicion of myelophthisic anemia rather than pure red cell aplasia?

A)Dacryocyte
B)Drepanocyte
C)Schistocyte
D)Stomatocyte

Question 50

Recent evidence suggests that the pathophysiology of most cases of acquired aplastic anemia is most likely:

A)Drug exposure.
B)Viral infections.
C)Defective stem cells.
D)Immunologic suppression of hematopoiesis.

Question 51

Aplastic anemia usually is first noted by bleeding and the presence of petechial hemorrhages.What clinical sign in the early stages of the disease should bring doubt to the diagnosis of aplastic anemia?

A)Hepatosplenomegaly
B)Splenomegaly
C)Lymph node enlargement
D)Fever

Question 52

Which of the following treatments offers the best prognosis for aplastic anemia?

A)Synthetic cytokines
B)Bone marrow transplant
C)Immunosuppressive therapy
D)Stem cell transplant

Question 53

Aplastic anemia in the acquired form can result from drugs or chemical agent exposure.If the link cannot be made to any environmental factor, what form of anemia does the client have?

A)Pure red cell aplasia
B)Anemia of chronic renal disease
C)Idiopathic
D)Chronic

Question 54

What congenital defects are found in Fanconi's syndrome?

A)Hypergonadism
B)Skin hypopigmentation
C)Mental retardation
D)Thrombocytopurpura

Question 55

Which of the following tests would help differentiate TEC from DBA?

A)RBC count and RBC indices
B)Bone marrow cellularity and M:E ratio
C)Fetal erythrocyte characteristics
D)Ham test

Question 56

Which of the following is among the diagnostic criteria for aplastic anemia?

A)Granulocyte count greater than 0.5 x 109/L
B)Platelet count less than 20 x 109/L
C)Anemia
D)Anemia with

Question 57

Patients with renal disease are at risk for developing megaloblastic anemia due to:

A)Decreased EPO production and utilization.
B)Increased NADPH production.
C)Folate deficiency.
D)Acute blood loss.

Question 58

A 3-month-old infant is exhibiting pallor and fatigue.The pediatrician orders a CBC, which displays a low RBC count, H&H, and normal WBC and PLT counts.EPO levels are increased.BM aspirate shows prominent erythroid hypoplasia.Cytogenetic analysis reveals the presence of RPS19 mutation.Based on these findings, what is the patient most likely suffering from?

A)CDA II
B)Pure red cell aplasia
C)Diamond Blackfan anemia
D)Fanconi's syndrome

Question 59

A 5-year-old boy with malformed thumbs and microcephaly has been suffering from prolonged bleeding episodes, extreme fatigue, and persistent repetitive infections.His CBC reveals pancytopenia.Cytogenetic analysis shows increased chromosome breakage with the addition of diepoxybutane.Based on these findings, what is the patient most likely suffering from?

A)CDA II
B)Pure red cell aplasia
C)Diamond Blackfan anemia
D)Fanconi's syndrome

Question 60

A 55-year-old male is undergoing dialysis to treat his renal failure.Routine blood examination shows a low RBC count, low H&H, and a normal MCV.What is the most important factor contributing to this anemia?

A)Ineffective erythropoiesis
B)Hemolysis
C)Decreased erythropoietin production
D)Presence of cytotoxic antibodies to erythropoietin-sensitive cells

Question 61

Define constitutional aplastic anemia, and give an example.

Question 62

Acquired chronic pure red cell aplasia is a rare disorder encountered in association with several autoimmune disorders.What does the mechanism appear to be?

A)B cell-mediated immunosuppression of neutrophils
B)T cell-mediated immunosuppression of erythropoiesis
C)Cytokine-mediated immunosuppression of erythropoiesis
D)Increased serum erythropoietin

Question 63

Chronic renal disease is a common cause of anemia.Which of following is one of the possible causes of anemia in chronic renal disease?

A)Increased erythropoietin production
B)Increased erythrocyte survival
C)Blood loss
D)Iron production

Question 64

All of the following are considered diagnostic criteria for aplastic anemia except:

A)Granulocyte count 0.3 x 109/L.
B)Platelet count 5 x 109/L.
C)Anemia with absolute reticulocyte count of 22 x 109/L.
D)BM cellularity of 32%.

Question 65

Correlate the prognosis associated with the following treatments for aplastic anemia.

A)Bone marrow transplant
B)Cytokine therapy
C)Stem cell transplant
D)Immunosuppression therapy

Question 66

Explain how exposure to the following can lead to aplastic anemia.

A)Chloramphenicol
B)Benzene
C)Gamma radiation
D)Starvation

Question 67

Laboratory findings include a blood urea nitrogen greater than 30 mg/dL, serum ferritin levels higher than normal, and a normocytic, normochromic morphology.What cause can be attributed to the anemia?

A)Chronic renal disease
B)Iron deficiency
C)Diamond-Blackfan anemia
D)Falconi's syndrome