A 37-year-old woman visits her physician because of a cough and fever of 1 weeks duration. On physical examination, her temperature is 38.3oC. She has diffuse crackles in all lung fields. A chest radiograph shows bilateral extensive infiltrates. CBC shows hemoglobin of 13.9 g/dL, hematocrit 42.0%, MCV 89 m3, platelet count 210,000/mm3, and WBC count 56,000/mm3 with 63% segmented neutrophils, 15% bands, 6% metamyelocytes, 3% myelocytes, 1% blasts, 8% lymphocytes, 2% monocytes, and 2% eosinophils. The peripheral blood leukocyte alkaline phosphatase score is increased. Which of the following is the most likely diagnosis?1. Chronic myelogenous leukemia

2. Hairy cell leukemia

3. Hodgkin disease, lymphocyte depletion type

4. Leukemoid reaction *5. Acute lymphoblastic leukemiaA 12-year-old boy is taken to the physician because he has had increasing abdominal distention and pain for the past 3 days. Physical examination shows lower abdominal tenderness, and the abdomen is tympanitic with reduced bowel sounds. An abdominal CT scan shows a 7-cm mass involving the region of the ileocecal valve. Surgery is performed to remove the mass. Histologic examination for the mass shows sheets of intermediate-sized lymphoid cells, with nuclei having coarse chromatin, several nucleoli, and many mitoses. A bone marrow biopsy sample is negative fro this cell population. Cytogenetic analysis of the cells from the mass shows a t(8;14) karyotype. Flow cytometric analysis reveals 40% of the cells are in S-phase. The tumor shrinks dramatically in size following a course of chemotherapy. Which of the following is the most likely diagnosis?1. Diffuse large B-cell lymphoma

2. Follicular lymphoma

3. Acute lymphoblastic leukemia

4. Burkitt lymphoma*A 53-year-old man comes to his physician because he felt a lump near his shoulder 1 week ago. On physical examination, there is an enlarged nontender, supraclavicular lymphnode, as well as enlargement of the Waldeyer ring of orophyngeal lymphoid tissue. There is no hepatosplenomegaly. CBC is normal except for findings of mild anemia. A lymph node biopsy specimen shows replacement by a monomorphous population of large lymphoid ells with enlarged nuclei and prominent nucleoli. Immunohistolchemical staining and flow cytometry of the node indicates that most lymphoid cells are CD19+, CD10+, CD3-, CS15- and terminal deoxynucleotidyl transferase negative (TdT). Which of the following is the most likely diagnosis?

1. Chronic lymphadenitis

2. Diffuse large B-cell lymphoma

3. Hodgkin disease*4. Lymphoblastic lymphoma

5. Small lymphocytic lymphomaA 63-year-old woman experiences a burning sensation in her hands and feet. Two months ago, she had an episode of swelling with tenderness in the right leg, followed by dyspnea and then right-sided chest pain. On physical examination, the spleen and liver now appear to be enlarged. CBC shows hemoglobin of 13.3 g/dL, hematocrit 40.1%. MCV 91 m3, platelet count 657,000/mm3, and WBC count 17,400/mm3. The peripheral blood smear shows abnormally large platelets. Which of the following is the most likely diagnosis?

1. Essential thrombocythemia*

2. Chronic myelogenous leukemia

3. Myelofibrosis with myeloid metaplasia

4. Acute myelogenous leukemia

5. Polycythemia vera

A 9-year-old boy living in Uganda has had increasing pain and swelling on the right side of his face over the past 8 months. On physical examination, there is a large, nontender mass involving the mandible, which deforms the right side of his face. There is no lymphadenopathy and no splenomegaly, and he is afebrile. A biopsy of the mass is performed. Microscopically, the specimen is composed of intermediate-sized lymphocytes with a high mitotic rate. A chromsosome analysis shows a 46,XY,t(8;14) karyotype in these cells. The hemoglobin concentration is 13.2 g/dL, platelet count 272,000/mm3, and WBC count 5820/mm3. Infection with which of the following is most likely to be causally related to the development of these findings?

1. Cytomegalovirus

2. Epstein-Barr virus*3. Hepatitis B virus

4. HIV human papillomavirus

5. Respiratory syncytial virusA 26-year-old man has noted lumps in his neck that have been enlarging for the past 6 months. On physical examination, he has a group of enlarged, nontender right cervical lymph nodes. A biopsy of one of the lymph nodes shows scattered Reed-Sternberg cells, as well as macrophages, lymphocytes, neutrophils, eosinophils, and a few plasma cells. Which of the following factors elaborated by the Reed-Sternberg cells has led to the appearance of the eosinophils within this lesion?

1. Platelet-derived growth factor

2. TGF B

3. Interleukin-5

4. Trans-retinoic acid

5. Erythropoietin*A 65-year-old female is being evaluated for "generalized depression". The patient is feeling weak and fatigued, since her husband died 4 months ago. She does not have any suicidal thoughts but is losing interest in daily activities. She quit smoking 24 years ago, and drinks 1-2 beers/wk. On examination, she is pale with both cervical and supra-clavicular lymphadenopathy. Blood work reveals:

WBC 28,600mm3

Hematocrit 40%,: Platelets 96,000mm3

The distribution of leukocytes was as under

Lymphocytes 77%: Bands 6%: Neutrophils 16%

Some variants of lymphocytes and smudge type cells were also present. What is the most probable diagnosis?

1. Lymphoblastic lymphoma

2. Hodgkin's disease*3. Chronic lymphocytic leukemia

4. Chronic myeloid leukemia

Ms. Gunner, a 46-year-old female, is brought to ER because of visual blurring and altered mental status. Patient was recently treated for gout. Exam showed moderate to severe splenomegaly and positive sternal tenderness. Her labs showed WBC of 120,000/uL with left shifted myeloid series and basophilia. Bone marrow exam showed 3% blasts. A new set of CBC is ordered and a hematologist is called and he starts leukopharesis emergently. What other drug should be given immediately to this patient?

A. Cladribine

B. Hydroxyurea

C. Cyclophosphamide

D. Interferon alpha

E. Imatinib mesylate *F. Busulfan

A 70 year old man has experienced increasing fatigue for the past 6 months. On physical examination, he has nontender axillary and cervical lymphadenopathy, but ther is no hepatosplenomegaly. The hematoligic workup shows hemoglobin of 9.5 g.dL, hematocrit 28%, MCV 90 m3, platelet count 120,000/mm3, and WBC count 42,000/mm3. The peripheral blood smear shows a monotonous population of small, round, mature-looking lymphocytes. Flow cytometry shows these cells to be CD19+, and TdT-. Which of the following is most likely to be seen with cytoghenetic and molecular analysis of the cells in the patients blood?

1. T(9;22) leading to BCR-ABL rearrangement

2. Clonal rearrangement of immunologlobin genes

3. t(8;14) leading to C-MYC overexpression

4. t(14;18) leading to C-MYC overexpression* A 4 year old child has appeared listless for about 1 week. He now complains of pain when he is picked up by his mother, and he demonstrates irritability when his arms or legs are touched. In the past 2 days, several large ecchymoses have appeared on the right thigh and left shoulder. CBC shows hemoglobin of 10.2 g/dL, hematocrit 30.5%, MCV 96m3, platelet count 45,000/mm3, and WBC count 13,900/mm3. Examination of the peripheral blood smear shows blasts that lack peroxidase-positive granules but contain PAS-positive aggregates and stain positively for TdT. Flow cytometry shows the phenotype of blasts to be CD19+, CD3-. Which of the following is the most likely diagnosis?1. Chronic myelogenous leukemia

2. Idiopathic thrombocytopenic purpura

3. Acute myelongenous leukemia

4. Chronic lymphocytic leukemia

5. Acute lymphoblastic leukemia*A 62 year old man visits his physician because of prolonged fever and a 4-kg weight loss over the past 6 months. On physical examination, his temperature is 38.60C. He has generalized nontender lymphadenopathy, and the spleen tip is palpable. Laboratory studies show hemoglobin of 10.1 g/dL, hematocrit 30.3%, platelet count 140,000/mm3, and WBC count 24,500/mm3 with 10% segmented neutorphils, 1% bands, 86% lymphocytes, and 3% monocytes. A cervical lymph node biopsy specimen shows a nodular pattern of small lymphoid cells. A bone marrow specimen shows infiltrates of similar small cells having surface immunoglobulin that are CD5+ but CD10-. Cytogenetic analysis indicated t(11;14) in these cells. Which of the following is the most likely diagnosis?

1. Mantle cell lymphoma*2. Follicular lymphoma

3. Acute lymphoblastic leukemia

4. Burkitt lymphoma

5. Small lymphocytic lymphoma

A 45 year old man has experienced recurrent fevers and a 60kg weight loss over the past 5 months. On physical examination, his temperature is 37.5oC, and has had cervical lymphadenopathy. The patient reports that the edenopathy becomes very tender after he drinks a six-pack of beer. A lymph node biopsy specimen shows effacement of the nodal architecture by a population of small lymphocytes, plasma cells, eosinophils, and macrophages. Which of the following additional cell types, which stains positively for CD15, is most likely to be found in this disease?

1. Reed-Sternberg cell*2. Immunoblast

3. Epitherlioid cell

4. Nuetorphils

5. Mast cellIn an experiment, cell samples are collected from the bone marrow aspirated of patients who were diagnosed with lymphoporliferative disorders. Cytogenetic analyses are performed on these cells, and a subset of the cases is found to have the BCR-ALB fusion gene from the reciprocal translocation t(9;22) (q34;11). The presence of this gene results in increased tyrosine kinase activity. Patients with which of the following conditions are most likely to have this gene?1. Follicualr lymphoma

2. Chronic myelogenous leukemia

3. Hodgkin disease, lymphocyte depletion type

4. Acute promyelocytric leukemia*5. Multiple myeloma

A 39 year old experiences sudden onset to a severe headache. Physical examination shows no localizing neurologic signs and no oranomegaly. A stool sample is positive for occult blood. Areas of purpura appear on the skin of his extremities. Laboratory studies show hemoglobin of 9.6 g/dL, hematocrit 28.9%, platelet count 26,400/mm3, and WBC count 75,000/mm3. The peripheral blood smear has the appearance shown above, and schistocytes are also seen. The plasma D dimer level (fibrin degradation products), prothrombin time, and partial thromboplastin time are all elevated. Cytogenetic analysis of cells from a bone marrow biopsy specimen is most likely to yield which of the following karyotypic abnormalities?

1. t(8;21

2. t(9;22)*3. t(14;18)

4. t(15;17)

5. t (8;14)A figure skater who won gold medals at the 1928, 1932, and 1936 Winter Olympic Games became progressively fatigued in her late fifties. On physical examination, she had palpable nontender axillary and inguinal lymph nodes, and the spleen tip was palpable. Laboratory studies showed hemoglobin of 10.1 g/dL, hematocrit 30.5%, MCV 90 jim3, platelet count 89,000/mm3. From the peripheral blood picture shown above, which of the following is the most likely diagnosis?1. Infectious mononucleosis

2. Chronic lymphocytic leukemia

3. Iron deficiency anemia

4. Leukemoid reaction

5. Acute lymphoblastic leukemiaA 22-year-old university student reports easy fatigability of 2 months' duration. On physical examination, she has no hepatosplenomegaly or lymphadenopathy. Mucosal gingival hemorrhages are noted. CBC shows hemoglobin of 9.5 g/dL, hematocrit 28.2%, MCV 94 1=3, platelet count 20,000/mm3, and WBC count 107,000/mm3. A bone marrow biopsy specimen shows that the marrow is 100% cellular with few residual normal hematopoietic cells. Most of the cells in the marrow are large, with nuclei having delicate chromatin and several nucleoli. The cytoplasm of these cells has azurophilic, peroxidase-positive granules. Which of the following is the most likely diagnosis?

1. Chronic lymphocytic leukemia

2. Acute myelogenous leukemia

3. Acute megakaryocytic leukemia*4. Chronic myelogenous leukemia

5. Acute lymphoblastic leukemiaA 60year old woman is referred to an oncologist with painless peripheral adenopathyin cervical, axillary, inguinal and femoral regions. She has had lymphnode enlargements that has been present for long periods of time but the nodes have waxed and waed over the past 5 years. After a cytogenetic study and further evaluation she has been diagnosed with B lymphocute lymphoma of the follicular type. This type overexpresses the gene bcl2. Which of the following is the normal function of the protein encoded by bcl2?

1. Cellular adhesion

2. DNA repair

3. Inhibition of apoptosis*4. Inhibition of signal transduction

5. Positive regulation of signal transduction. A 50 year old man comes to the physician because of gingival bleeding, epistaxis and fever for 2 days. He appears acutely ill. His temperature is 39C (102 F).blood pressure is 120/70 mm of Hg. His pulse is 120/min and resp is 22/min. Bilateral rhonchi are heard on chest examination. He is admitted for further evaluation. Chest x ray shows bibasilar infiltrates consistent with bronchopneumonia. Blood tests show 12,000leucocytes/mm3. A bone marrow biopsy shows hypercellular marrowwith 35% blasts. Elongated cytoplasmic inclusions consistent auer rods are appreciated in peripheral and marrow blasts. Which of the following is the most likely diagnosis?

1. Acute lymphocytic leukemia

2. Acute myelogenous leukemia*3. Chronic myelogenous leukemia

4. Leukemoid reaction

A 67-year-old man has had increasing weakness, fatigue, and weight loss over the past 5 months. He now has decreasing vision in both eyes and has headaches and dizziness. His hands are sensitive to cold. On physical examination, he has generalized lymphadenopathy and hepatosplenomegaly. Laboratory studies indicate hyperproteinemia with a serum protein level of 15.5 g/dL and albumin concentration of 3.2 g/dL. A bone marrow biopsy is performed, and microscopic examination of the specimen shows infiltration of small plasmacytoid lymphoid cells with Russell bodies in their cytoplasm. Which of the following findings is most likely to be reported for this patient?

1. Monoclonal IgM spike in serum

2. WBC count of 255,000/mm3

3. Hyperccalcemia

4. Bence Jones proteinuria

5. Karyotype with t(14;18) translocation BIn which of the following clinical scenarios would the patient most likely have an increase in the leukocyte shown in the photograph?

DA 50-year-old man with polycythemia vera presents with a severe right upper quadrant pain. Physical examination reveals an enlarged, painful liver; ascites; and splenomegaly. Serum transaminases are markedly increased. What is the most likely diagnosis?

+5CIn which of the following clinical scenarios would the patient most likely have an increase in the leukocyte shown in the photograph?

EA 2-year-old boy with Bruton's agammaglobulinemia has recurrent pneumonia caused by Streptococcus pneumoniae. Which of the following defects is the most likely cause of increased susceptibility to bacterial infections?

AThe photograph shows a leukocyte abnormality in a 3-year-old boy, who has recurrent Staphylococcus aureus infections. Specialized studies show bactericidal and chemotaxis defects. What is the most likely diagnosis?

A 52-year-old woman had a modified radical mastectomy 12 years ago. She now has pain in the pelvic girdle and point tenderness over the lower lumbar vertebra. A complete blood cell count shows a mild normocytic anemia, a slightly increased total WBC count, and a normal platelet count. There is no hepatosplenomegaly. The photograph shows a representative section of the peripheral blood smear. Which of the following is the most likely diagnosis?

EIn which of the following clinical scenarios would the patient most likely have an increase in the leukocyte shown in the photograph?

The photograph shows a kidney removed at autopsy from a 55-year-old woman. Laboratory studies prior to death showed a hemoglobin level of 20 g/dL and the presence of RBCs in the urine sediment. Which of the following laboratory findings was most likely present prior to death?

C48-year-old man has fever, weight loss, sweating, and a dragging sensation in the abdomen. Physical examination shows generalized lymphadenopathy and massive hepatosplenomegaly. Laboratory studies reveal a moderately severe normocytic anemia, thrombocytopenia, and a WBC count of 110,000/mm3. A bone marrow biopsy shows hypercellularity and the presence of neutrophils at all stages of development. Less than 2% of the WBCs in the bone marrow are myeloblasts. The photograph shows a representative section of the bone marrow smear. Which of the following laboratory test findings is most likely to be present?

CA 22-year-old man has fever, fatigue, and a sore throat. Findings on physical examination include exudative pharyngitis, hepatosplenomegaly, and painful generalized lymphadenopathy. Laboratory findings show an increased WBC count, normal hemoglobin concentration, and normal platelet count. The photograph shows one of many similar WBCs in the peripheral blood of the patient. Which of the following laboratory studies would be most useful in confirming the diagnosis in this patient?

BA 22-year-old man has blood oozing from his nose and mouth. Physical examination shows petechiae and ecchymoses distributed over most of his body. There is generalized lymphadenopathy and hepatosplenomegaly. Laboratory studies show a moderately severe normocytic anemia, thrombocytopenia, and a WBC count of 32,000/mm3. The d-dimer blood test is increased and both the prothrombin and partial thromboplastin times are increased. The photograph shows the peripheral blood smear. What chromosome translocation is most likely to be present in this patient?

EA 58-year-old man complains of frequent headaches and generalized itching after bathing. Physical examination shows congestion of the retinal vessels, a ruddy complexion, and splenomegaly. Initial laboratory studies show an RBC count of 8 million/mm3, a WBC count of 15,000/mm3, and a platelet count of 500,000/mm3. The WBC differential count shows an increase in normal-appearing segmented neutrophils. Which of the following sets of laboratory results is most likely to be reported?

RBC massPlasma volumeO2 saturationEPO concentration

A.IncreasedIncreasedNormalDecreased

B.IncreasedNormalDecreasedIncreased

C.IncreasedNormalNormalIncreased

D.NormalDecreasedNormalNormal A

EPO, erythropoietin.

In which of the following clinical scenarios would the patient most likely have an increase in the leukocyte shown in the photograph?

C?A 65-year-old man has fever, fatigue, hepatosplenomegaly, and generalized nontender lymphadenopathy. A complete blood cell count shows a mild normocytic anemia and thrombocytopenia, and the total WBC count is 60,000/mm3. Serum protein electrophoresis shows a flat -globulin peak. The photograph shows a representative section of the peripheral blood smear. Which of the following is the most likely diagnosis?

BA 59-year-old man complains of painful joints, fullness in the right upper quadrant, and a rash. Physical examination reveals palpable purpura and hepatosplenomegaly. There is no evidence of lymphadenopathy. His CBC shows a hemoglobin of 8 gm/dL, platelet count of 75,000/mm3, and a WBC count of 3500/mm3. Abnormal cells are present in the peripheral blood (see photograph). A bone marrow biopsy reveals a monomorphic infiltrate of cells with abundant cytoplasm. The patient is scheduled for a splenectomy. What is the most likely diagnosis?

a. Acute promyelocytic leukemia

EIn which of the following clinical scenarios would the patient most likely have an increase in the leukocyte shown in the photograph?

A