1. A 45 year old male patient presents with eosinophilia and fever. Which of the following diagnosis is unlikely.
- Hodgkin lymphoma
- Typhoid fever
- Chronic Myeloid leukaemia
- Polyarteritis nodosa
2. 62 year old woman presents with prolonged fever. The differential leucocyte count shows monocytosis. Which of the following findings on clinical examination are important.
- Irregular pulse
- All of the above
3. A 22 year old woman presented to her family physician with fever, cervical lymphadenopathy and sore throat. She was treated with amoxicillin 250mg thrice a day. She developed a rash. Which of the following blood changes are likely
- Neutrophilic leucocytosis
4. A 47 year old man presents with acute pain and swelling of the right toe. He is prescribed medications for the same but returns after a week with skin rash and fever. What is the most likely finding on peripheral smear.
- None of the above
5. Which of the following about lymphocytosis is true
- The elderly show lymphocytosis in response to acute infections
- Infections are the only cause of reactive lymphocytosis
- Lymphocytosis is a feature of toxoplasmosis
- Lymphocytosis is not a feature of lymphoma but of leukaemia
Answer 1. B. All other conditions are characterised by eosinophilia. Patients with typhoid fever may have low to no eosinophils.
Answer 2. D. Pallor and clubbing are features of infective endocarditis. Irregular pulse may indicate atrial fibrillation. Atrial fibrillation may be caused by an underlying valvular heart disease that also predisposes to infective endocarditis. Patients with infective endocarditis may have monocytosis.
Answer 3. C. Infectious mononucleosis is a disease characterised by fever, tonsillitis, pharyngitis, lymphadenopathy, leukocytosis and hepatosplenomegaly. A proportion of lymphocytes may be atypical. Atypical lymphocytes are large lymphocytes with greater amount of cytoplasm and bizarre nuclear shapes. They are not blasts. Patimets with infectious mononucleosis have the risk of a maculopapular rash following therapy with amoxicillin. Atypical lymphocytes can be mistaken for monocytes by an inexperienced observer.
Answer 4. A: Fever and skin rash after drug therapy raises the possibility of drug rash with eosinophilia and systemic symptoms (DRESS). Acute pain and swelling of the greater toe in a middle aged man raises there possibility of gout. One of the common causes of DRESS is allopurinol. Other agents frequently implicated in DRESS are carbamazsipine, lamotrigine, phenytoin, sulfasalaziner, vancomycin, minocyclin, dapsone and sulfamethoxazole. DRESS is a serious condition that is associated with a 5-10% mortality.
Answer 5. C. Toxioplasmosis is associated with lymophocytosis and the presence of atypical lymphocytosis. It can cause a clinical picture resembling infectious mononucleosis. The response to acute infections is neutrophilic leucocytosis. Pertussis is commonly associated with lympocytosis but this is unlikely in the elderly. The causes of reactive leucocytosis include infections, allergic reactions and autoimmune disease. All non-hodgkin lymphomas have the potential to spread and enter a leukaemia phase. The risk of leukaemia phase varies with the subtype