MEQ

Case 1

Question 1.1

Question 1.2

Question 1.3

Question 1.4

SBA
Case 1
Howard Johnson is a 75 year old man who attends your general practice
usually only for his annual influenza vaccination. Today he complains of a
cough and runny nose over the last few days. He is afebrile and auscultation
of his chest is normal. On further examination you notice pronounced
enlargement of lymph nodes over all of his body. The full blood count
reveals a total white cell count of 92.0 x 109/L, containing predominantly
lymphocytes.
Question 1.1
What is the most likely underlying diagnosis in this man?
A) Influenza
B) Non-Hodgkins lymphoma
C) Infectious mononucleosis
D) Chronic lymphocytic leukemia

Question 1.2
Which one of the following is NOT generally associated with lymphadenopathy?
A) Myelofibrosis
B) Sarcoidosis
C) Tuberculosis
D) Epstein Barr virus

Question 1.3
In normal lymph nodes:
A) Immunoglobulin genes can mutate following antigenic stimulation
B) Germinal centres contain predominantly plasma cells
C) Follicles contain predominantly T cells
D) Parafollicular zones contain predominantly B cells.

One year after diagnosis, Mr Johnson returns with symptoms of lethargy,

palpitations and dyspnoea on exertion. He has noted dark urine for one
week. Blood tests show the following:
Haemoglobin

70 g/L

(normal range: 130 182 g/L)

MCV

92 fL

(normal range: 80 96 fL)

MCH

31.2 pg

White cell count

120 x 10 /L (normal range:4.0 11.0 x 109/L)

(normal range: 27 32 pg)

9

Differential: Neutrophils 10 x 109/L, lymphocytes 108 x 109/L and

monocytes 2 x 109/L
Platelets

545 x 109/L (normal range: 150 450 x 109/L)

ESR

68 mm/hour

Direct Antiglobulin Test - Strongly positive

Question 1.4
What is the best interpretation of these results?
A) Anaemia of chronic disease
B) Iron deficiency anaemia
C) Hereditary spherocytosis
D) Autoimmune haemolytic anaemia

Question 1.5
In chronic anaemia:
A) Red cell 2,3-diphosphoglycerate is increased
B) The heart rate is decreased
C) The cardiac output is reduced
D) The symptoms will be greater than in acute anaemia

Question 1.6
The therapeutic option of most likely benefit would be:
A) Plasmapheresis
B) Corticosteroid therapy
C) Intravenous iron
D) Folic acid supplementation

Mr Johnsons condition deteriorated, with increasing left upper quadrant

pain, and a falling haemoglobin level. A CT scan was performed which
showed splenic rupture with intra-abdominal haemorrhage. A splenectomy
was performed.
Question 1.7
Which one of the following statements is correct with respect to splenectomy?
A) Post-splenectomy patients are susceptible to infection by unencapsulated bacteria
B) An increase in blood leucocytes can occur after a splenectomy
C) Post-splenectomy patients have increased resistance to malaria
D) Portal hypertension can occur as a complication of splenectomy

Case 2
John OSullivan, a 65 year old man, presented to his GP with several lumps
under both axillae. He said that he has felt more lethargic in the last 18
months. Although previously very well, he has experienced several episodes
of severe upper respiratory tract infections in the last 6 months. On
examination, he had generalized lymphadenopathy in the cervical, axillary
and inguinal regions, and splenomegaly of 5 cm below the costal margin.
The blood film showed a lymphocytosis with smudge cells. Results of a Full
Blood Count are given in the table below.
Indices

Mr OSullivans results

Normal range

Haemoglobin

100 g/L

130 180 g/L

White cells

73 x 109/L

4.0 11 x 109/L

Neutrophils

2.5 x 109/L

2.0 7.5 x 109/L

Lymphocytes

70 x 109/L

1.5 4.0 x 109/L

Platelets

73 x 109/L

150 400 x 109/L

Question 2.1
With respect to splenomegaly, which one of the following is correct?
A) Increased red cell destruction contributes to the associated anaemia
B) Massive enlargement is indicative of malignant disease
C) Pancytopenia is invariably present
D) Red cell inclusions (Howell-Jolly bodies) are frequently seen in peripheral blood
films

Question 2.2
The most likely cause of the enlarged spleen in Mr OSullivan is:
A) Infiltration by neutrophils
B) Recurrent upper respiratory tract infections
C) Infiltration by platelets
D) Infiltration by lymphocytes

Question 2.3
The most likely cause of Mr OSullivans anaemia is:
A) Bone marrow infiltration
B) Haemolysis
C) Iron deficiency
D) Myelodysplasia

Question 2.4
Which one of the following is most likely to contribute to his recurrent infections?
A) Tonsillar atrophy
B) Hypogammaglobulinaemia
C) Hyperviscosity caused by the lymphocytosis
D) Neutropenia

Case 3
Mr George White, a 65 year old man, presents to his GP with several lumps
under both axillae. He has felt more lethargic in the last 18 months.
Although previously very well, he has experienced several episodes of
severe upper respiratory tract infections in the last 6 months. On
examination, he has generalized lymphadenopathy in the cervical, axillary
and inguinal regions, and splenomegaly of 5 cm below the costal margin.
The blood film shows a lymphocytosis with smudge cells. Results of a Full
Blood Count are given in the table below.
Test

Mr Whites results

Normal range

Haemoglobin

100 g/L

130 180 g/L

White cells

73 x 109/L

4.0 11 x 109/L

Neutrophils

2.5 x 109/L

2.0 7.5 x 109/L

Lymphocytes

70 x 109/L

1.5 4.0 x 109/L

Platelets

73 x 109/L

150 400 x 109/L

Question 3.1
The most important diagnostic investigation is:
A) Liver spleen scan
B) Quantitation of immunoglobulin levels
C) Immunophenotype of peripheral lymphocytes
D) Beta-2-microglobulin level

Question 3.2
The most likely cause of his lymphocytosis is:
A) Glandular fever (EBV infection)
B) Chronic myelocytic leukaemia
C) Chronic lymphocytic leukaemia
D) Tuberculosis

Question 3.3
B-lymphocytes:
A) Are functionally indistinguishable from T-lymphocytes
B) Have a multilobed nucleus in their mature state
C) Phagocytose bacterial pathogens
D) Are involved in humoral immunity

Question 3.4
After antigenic stimulation in normal lymph nodes:
A) Follicles contain predominantly T cells
B) Parafollicular zones contain predominantly B cells
C) Germinal centres contain predominantly plasma cells
D) Mutation of immunoglobulin genes occurs

Question 3.5
Which one of the following is NOT generally associated with lymphadenopathy?
A) Sarcoidosis
B) Tuberculosis
C) Epstein Barr Virus
D) Myelofibrosis

Case 4
Lily Klein is a 72 year old woman who presents for medical assessment
prior to admission for hip replacement. Her clinical examination reveals a 2
cm anterior cervical lymph node but no other lymphadenopathy or
hepatosplenomegaly. She is noted on full blood count to have a white cell
count of 25 x 109/L (reference range 4 - 11 x 109/L) with predominant
lymphocytosis of 19.8 x 109/L (reference range 1.5 - 4.0 x 109/L), but
normal haemoglobin and platelets. The blood film comment states:
consistent with chronic lymphocytic leukaemia.
Question 4.1
Regarding T-lymphocytes, which one of the following is NOT correct? They:
A) Secrete antibodies into the circulating blood
B) Interact with macrophages by secreting interleukins
C) Attack virus-infected cells by releasing perforin
D) Attack transplanted cells displaying non-self antigens

Question 4.2
The thoracic duct:
A) Is located in the posterior mediastinum
B) Normally drains into the azygos vein
C) Passes through the diaphragm with the inferior vena cava
D) Drains directly into the spleen

Question 4.3
With respect to chronic myeloid leukaemia (CML) and / or chronic lymphocytic
leukaemia (CLL) which one of the following is correct?
A) CML typically exhibits a characteristic chromosomal translocation
B) CLL patients have no increase in bacterial infections
C) CLL can always be distinguished from lymphomas by examination of blood films
D) In patients with CLL the incidence of carcinomas of skin and lung is not increased

Question 4.4
Which one of the following infections is commonly associated with severe
neutropaenia from leukaemia chemotherapy?
A) Listeria monocytogenes
B) Mycobacterium tuberculosis
C) Pseudomonas aeruginosa
D) Herpes simplex virus

Case 5
Ernesto Bertucinni, a 65 year old man, presented to his general practitioner
with several lumps under both axillae. Mr Bertucinni said that he has felt
more lethargic in the last 18 months. Although previously very well, he has
experienced several episodes of severe upper respiratory tract infections in
the last 6 months. On examination, Mr Bertucinni had generalized
lymphadenopathy in the cervical, axillary and inguinal regions, and
splenomegaly of 5 cm below the costal margin.
The blood film showed a lymphocytosis with smudge cells. Results of a Full
Blood Count are given in the table below.
Indices

Mr Bertucinnis results

Normal range

Haemoglobin

*100 g/L

130 180 g/L

White cells

*73 x 109/L

4.0 11 x 109/L

Neutrophils

2.5 x 109/L

2.0 7.5 x 109/L

Lymphocytes

*70 x 109/L

1.5 4.0 x 109/L

Platelets

*73 x 109/L

150 400 x 109/L

Question 5.1
The most likely cause of the enlarged spleen in Mr Bertucinni is:
A) Infiltration by lymphocytes
B) Infiltration by neutrophils
C) Infiltration by platelets
D) Recurrent upper respiratory tract infections

Question 5.2
With respect to splenomegaly, which one of the following is correct?
A) Increased red cell destruction contributes to the associated anaemia
B) Massive enlargement is indicative of malignant disease
C) Pancytopenia is invariably present
D) Red cell inclusions (Howell-Jolly bodies) are frequently seen in peripheral blood
films

Question 5.3
The most likely cause of Mr Bertuccinis anaemia is:
A) Bone marrow infiltration
B) Haemolysis
C) Iron deficiency
D) Myelodysplasia

10

Question 5.4
Which one of the following is most likely to contribute to Mr Bertuccinis recurrent
infections?
A) Hyperviscosity caused by the lymphocytosis
B) Hypogammaglobulinaemia
C) Neutropenia
D) Tonsillar atrophy

Question 5.5
Which of the following CD markers would be consistent with a diagnosis of B-CLL in
Mr Bertuccini?
A) CD3 and CD4
B) CD4 and CD19
C) CD5 and CD19
D) CD8 and CD19

Question 5.6
Which one of the following statements regarding the lymphatic system is NOT
correct?
A) Lymph vessels commence as blind-ended structures
B) Lymph vessels contain numerous valves
C) Lymph vessels drain eventually into the arteries at the root of the neck
D) Lymph from the left side of the body drains to the thoracic duct

11

Case 6

Question 6.1

Question 6.2

Question 6.3

12

Case 7

Question 7.1

Question 7.2

Question 7.3

13

Question 7.4

14

Case 8
Mr Dragan Ilic, aged 62, tells you he has been unwell for 2 weeks, with
bruising and recurrent epistaxis. He was told he was anaemic several years
ago at a Blood Bank, but he failed to attend for follow-up. He has a palpable
spleen on inspiration. You arrange a full blood count and the results are
given in the table below.
You make a provisional diagnosis of acute myeloid leukaemia progressing
from myelodysplasia and admit him to hospital. After a further work-up and
identification of the leukaemia he commences chemotherapy.
Indices

Mr Ilic's Results

Normal range

Haemoglobin

*96 g/L

130180 g/L

WCC

*2.6 x 109/L with 30% blasts

4.011.0 x 109/L

Platelets

*41 x 109/L

150450 x 109/L

Question 8.1
Regarding Mr Ilics diagnosis of acute myeloid leukaemia, which of the following is
correct?
A) Mr Ilics diagnosis of acute leukaemia is unlikely to be correct, as leukaemia is a
disease of excess white blood cells whereas Mr Ilic has a low white cell count
B) The primary reason for a diagnosis of acute leukaemia, rather than chronic
leukaemia, is the presence of anaemia and thrombocytopenia
C) Thrombocytopenia in patients with acute leukaemia is usually due to immune
destruction of platelets
D) Mr Ilic is unlikely to be cured of his leukaemia because of his age and preceding
myelodysplasia

15

Question 8.2
Which one of the following statements is correct regarding myelodysplasia and acute
leukaemia?
A) In the vast majority of patients with myelodysplasia the disease will transform
eventually into an acute leukaemia
B) In patients under 60 years of age who develop acute leukaemia, most will achieve
a complete remission if treated with combination chemotherapy
C) The optimal time to perform allogeneic stem cell transplantation for patients with
acute leukaemia is immediately after the diagnosis is confirmed
D) Patients whose leukaemic cells contain either a Philadelphia chromosome
[t(9;22)] or monosomy 7 are likely to respond better to chemotherapy than patients
whose chromosomes are normal

Question 8.3
Mutation of which one of the following genes interferes with normal check-point
control over the cell cycle (a form of tumour suppression)?
A) bcl-2
B) c-erbB
C) c-ras
D) p53

16

Case 9
Frank Gauci, a 65 year old man, presented to his GP with several lumps
under both axillae. He said that he has felt more lethargic in the last 18
months. Although previously very well, he has experienced several episodes
of severe upper respiratory tract infections in the last 6 months. On
examination, he had generalized lymphadenopathy in the cervical, axillary
and inguinal regions, and splenomegaly of 5 cm below the costal margin.
The blood film showed a lymphocytosis with smudge cells. Results of a Full
Blood Count are given in the table below.
Indices

Mr Gaucis results

Normal range

Haemoglobin

*100 g/L

130 180 g/L

White cells

*73 x 109/L

4.0 11 x 109/L

Neutrophils

2.5 x 109/L

2.0 7.5 x 109/L

Lymphocytes

*70 x 109/L

1.5 4.0 x 109/L

Platelets

*73 x 109/L

150 400 x 109/L

Question 9.1
With respect to splenomegaly, which one of the following is correct?
A) Increased red cell destruction contributes to the associated anaemia
B) Massive enlargement is indicative of malignant disease
C) Pancytopenia is invariably present
D) Red cell inclusions (Howell-Jolly bodies) are frequently seen in peripheral blood
films

Question 9.2
The most likely cause of the enlarged spleen in Mr Gauci is:
A) Infiltration by neutrophils
B) Recurrent upper respiratory tract infections
C) Infiltration by platelets
D) Infiltration by lymphocytes

Question 9.3
The most likely cause of Mr Gaucis anaemia is:
A) Bone marrow infiltration
B) Haemolysis
C) Iron deficiency
D) Myelodysplasia

17

Question 9.4
Which one of the following is most likely to contribute to his recurrent infections?
A) Tonsillar atrophy
B) Hypogammaglobulinaemia
C) Hyperviscosity caused by the lymphocytosis
D) Neutropenia

Question 9.5
Which of the following CD markers would be consistent with a diagnosis of B-CLL in
Mr Gauci?
A) CD3 and CD4
B) CD4 and CD19
C) CD5 and CD19
D) CD8 and CD19

Question 9.6
Which one of the following statements regarding the lymphatic system is NOT
correct?
A) Lymph vessels commence as blind-ended structures
B) Lymph vessels contain numerous valves
C) Lymph vessels drain eventually into the arteries at the root of the neck
D) Lymph from the left side of the body drains to the thoracic duct

18