| Abstract|| |
Cryoglobulinemia is one of the most common forms of extrahepatic manifestation of chronic hepatitis infection. The phenomenon is generally seen after several years of chronicity predominantly in the female population resulting in arthralgias, purpuras, and other symptoms, due to vasculitis. Here we present a case of incomplete mixed cryoglobulinemia Type III (as per Brouet's classification) in a young boy aged 13 years who presented with an unusual symptom of pruritus. Diagnosis was confirmed by cryoprecipitation test followed by immunofixation. We aim to highlight the difficulty in diagnosis of this rare case/presentation, important investigation pitfalls and how to avoid them.
Keywords: Cryoglobulinemia, cryoprecipitation test, hepatitis C, immunofixation, pruritus
|How to cite this article:|
Krishnamurthy K, Mohapatra S, Mishra T K, Jha N. Early onset mixed cryoglobulinemia in hepatitis C. Indian J Pathol Microbiol 2015;58:381-3
| Introduction|| |
Cryoglobulinemia is the presence of one or more immunoglobulins, in serum, which precipitate at temperatures <37°C and redissolve on rewarming.
Essential mixed cryoglobulinemia (MC) usually presents as a systemic leukocytoclastic vasculitis involving small vessels, damaged by deposition of immune complexes on their walls with activation of complement.
The main clinical features of MC are purpura, arthralgias, weakness, liver involvement, renal involvement, peripheral neuropathy, and cutaneous lesions. Long standing cases can develop B-cell lymphoproliferative disorders.
Essential MC shows strong association with hepatitis C infection.  The average age of incidence of cryoglobulinemia in hepatitis C virus (HCV) patients is 51 years, after a mean disease duration of 11.9 years, showing female preponderance. Even in HCV patients, Type III cryoglobulinemia is less common. 
We present a case of HCV-associated Type III cryoglobulinemia in a 13 years boy with undefined disease duration. Patient presented with a primary complaint of pruritus, seen only in 15% cases,  causing considerable confusion in diagnosis.
| Case Report|| |
A 13-year-old known case of hepatitis C, presented with generalized pruritus since 2 months.
He was diagnosed with hepatitis C 2 months back. He had no past blood transfusions or major invasive procedures. Both parents tested negative for HCV.
On local examination, maculopapular scaly lesions were seen on bilateral lower limbs, which dermatological referral confirmed as tinea corporis. Lesions resolved on the antifungal institution. Systemic examination was normal.
Blood counts revealed hemoglobin of 13.2 g%, total leukocyte count of 9400 cells/mm, 3 and normal platelet count. ESR was 13 mm/1 h. Metabolic panel revealed normal urea and creatinine levels. The results of liver function test were as follows-total bilirubin 0.4 mg/dl, AST 62 U/L, ALT 305 U/L (raised), ALP 253 U/L, total protein of 8.9 g/dl, and albumin 3.8 g/dl. Urine dipstick was negative for sugar and albumin. His HCV Type I RNA/viral load was 5991 IU/ml.
Ultrasound abdomen revealed the liver span of 14.6 cm with normal echotexture, classified as hepatomegaly in this age group. The patient was admitted for workup for suspected leukocytoclastic vasculitis. Liver biopsy revealed chronic hepatitis, Ishak's grading = 1 + 0 + 1 + 2 = 4 with stage 1 fibrosis [Figure 1].
|Figure 1: Liver biopsy showing mild chronic periportal inflammation, occasional foci of lobular inflammation and mild ballooning of hepatocytes (Ishak's grading = 4)|
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To rule out essential MC, cryoprecipitation test was done which was positive. Blood was drawn using a 5 ml syringe from the median cubital vein. It did not coagulate while drawing. Blood was collected in a plain vial prewarmed to 37°C and allowed to clot at 37°C for 30-60 min. Serum, separated by warm centrifugation for 10 min at 2500 rpm was divided into two parts. One part was kept at 4°C and inspected for cryoprecipitation daily for 7 days-significant cryoprecipitate was noted after 4 days. The other part was used for serum electrophoresis, which revealed a dense band in beta-2 region and diffuse hypergammaglobulinemia, raising suspicion of a paraprotein [Figure 2]. On immunofixation of the cryoprecipitate, polyclonal immunoglobulin G (IgG) and Immunoglobulin A with both lambda and kappa light chains were seen [Figure 3]. Rheumatoid factor (RF) tested positive in patient's serum.
|Figure 3: Immunofixation of cryoprecipitate showing polyclonal bands of Immunoglobulin G and Immunoglobulin A with both kappa and lambda light chains|
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A diagnosis of Type III MC (Brouet classification), possible incomplete MC (1 major + 1 minor clinical + 1 minor pathological finding)  was made. Patient was started on pegylated interferon-alpha and ribavirin therapy.
| Discussion|| |
Hepatitis C is an infection of the liver by HCV, spread primarily by blood contact. Vertical transmission occurs in <10% pregnancies. 
Acute infection causes mild, vague symptoms, which undergo spontaneous resolution. Eighty percent exposures lead to chronic infection, defined as detectable viral replication for 6 months, resulting eventually in cirrhosis and liver cancer. There are several extrahepatic manifestations of chronic infection, most common being MC, usually Type II, to a lesser extent, Type III. It is found in 40-90% HCV cases-wide variation in estimates stemming from population selection/lead time biases. 
In cryoglobulinemia, cold-insoluble immune complexes of RF, polyclonal IgG, and HCV RNA precipitate on vascular endothelium, causing vasculitis. These may present as purpura, arthralgia, generalized weakness (Meltzer triad), less commonly, as Sicca syndrome (30% cases), peripheral neuropathy, liver involvement (>50% cases) or more severe manifestations such as cryoglobulinemic nephropathy (20-30% cases) and B-cell lymphoproliferative disorders (5-10% cases). In the early stages of the disease, only serological alterations may be present. As this case presented with complaints of pruritus, atypical cutaneous vasculitis was suspected.
Cryoglobulins are grouped as per Brouet classification  as Type I (monoclonal Ig only), Type II (monoclonal Ig, usually IgM RF, and polyclonal IgG) and Type III (polyclonal Ig, usually IgM, and polyclonal IgG). Types II and III have a RF activity and bind to polyclonal immunoglobulins. These two types are referred to as MC. It is important to differentiate between the types of cryoglobulinemia because Type II has a higher risk of developing into lymphoma as compared to relatively benign Type III  . In addition, the lab test for cryoglobulins is prone to false negative results due to strict prerequisites for sampling, storage, and processing, leading to significant inter/intra-laboratory variations.
The main prerequisite for the test is that blood should be collected in a prewarmed tube and kept at 37°C during transit and in the laboratory to avoid premature precipitation of immunoglobulin and therefore, a false-negative test.
A cryocrit of >2% is positive.  The cryoprecipitate is washed and dissolved by re-warming and subjected to immunoanalysis.
Since HCV represents the main causative factor of the disease by exerting a chronic stimulus on the immune system, an attempt at HCV eradication via alpha-interferon and ribavirin therapy  is the mainstay of HCV-associated MC. Other anti-inflammatory and immunosuppressive drugs such as corticosteroids and cyclophosphamide are employed in nonresponders and life-threatening vasculitic complications. Rituximab, anti-CD 20 antibody, which selectively suppresses B cell clones, is proving to be a safe and effective alternative.
| Conclusion|| |
Hepatitis C virus infection has been recognized as a major trigger and maintenance factor for MC. Thus, in the absence of standard clinical criteria, a high index of suspicion should be instituted for MC in HCV positive cases, even if of atypical presentation or short chronicity. Isolated serological findings may serve as an early marker of cryoglobulinemic vasculitis in HCV positive cases, aiding in the early institution of antiviral regimen and prevention of serious vasculitic complications.
In case of a negative result but continuing clinical suspicion, the possibility of false negative should be excluded by careful repeat sampling and testing with detailed attention to processing prerequisites.
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Dr. Kritika Krishnamurthy
Department of Biochemistry, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi - 110002
Source of Support: Department of Biochemistry, Maulana Azad medical
College, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]