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Abdel-Samiee M, Youssef MI, Elghamry F, Bazeed M, Al-Shorbagy M, Shalaby H, Shabana H, Abdelsameea E, Lashin HES, El Zamek HMF, Esam T, Alwaseef MAA, Helmy HA, Almarshad F, Khalaf FA, Yossef BWA, Kassem A, Gabr BM, Abdelfattah A, S AboShabaan H, Aboufarrag GA, Omar MM, Bakeer MS, Imam MS, Ibrahim ES, Kamel SY, Allisy T, Mohammed OS, Farahat A, El-Khayat MM, Sekeen MAH, Zaher EM, Said A, Abuamer A, Elmahdi E. A multicentric and nationwide predictive study role of T cell sub-population in the prevalence and prognosis of cryoglobulinemia among genotype 4 chronic hepatitis C patients. J Med Virol 2023; 95:e29248. [PMID: 38108641 DOI: 10.1002/jmv.29248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/01/2023] [Accepted: 11/11/2023] [Indexed: 12/19/2023]
Abstract
The infection caused by the hepatitis C virus (HCV) is a significant global health concern. The prevailing genotype of HCV in Egypt is 4a, commonly referred to as GT-4a. A significant proportion exceeding 50% of patients infected with HCV experience extrahepatic manifestations (EHMs), encompassing a diverse range of clinical presentations. These manifestations, including essential mixed cryoglobulinemia (MC), can serve as initial and solitary indicators of the disease. The complete understanding of the pathogenesis of EHM remains unclear, with autoimmune phenomena being recognized as the primary causative factor. In this study, we examined the predictive significance of T-cell subpopulations in relation to the occurrence and prognosis of cryoglobulinemia in HCV patients. A total of 450 CHC genotype four treatment naïve patients were enrolled in this analytic cross-sectional study after thorough clinical, laboratory, and radiological examinations. All patients underwent laboratory investigations, including testing for cryoglobulin antibodies and measurements of CD4 and CD8 levels; two groups were described according to their test results: Group 1 consists of patients who have tested positive for cryoglobulin antibodies and Group 2 consists of patients who have tested negative for cryoglobulin antibodies. The exclusion criteria encompassed individuals with HIV infection or chronic HBV infection. Additionally, pelvi-abdominal ultrasonography was performed. Our study included 450 treatment naïve CHC patients (59% male, mean age 50.8 years). The patients were categorized according to their cryoglobulin antibodys test results into two groups: group A, CHC patients with cryoglobulin antibodies (Abs) negative (364 patients), and group B, CHC patients with cryoglobulin Ab positive (86 patients). Group B demonstrated a higher average age, elevated international normalized ratio, more prolonged duration of HCV infection, lower albumin, higher alanine aminotransferase, higher aspartate aminotransferase, higher bilirubin, lower CD8, lower CD4, and lower CD4:CD8 ratio. In contrast, 27 out of 86 (31.40%) patients in group B had symptoms; 85.8% had purpura and arthralgia, 74.3% had paresthesias, 86.7% had weakness, and 12.2% had non-Hodgkin's lymphoma. The levels of CD4 and CD8 were found to be decreased in chronic HCV patients with MC. T-cell subpopulation serves as a reliable indicator for assessing the prevalence and prognosis of MC in individuals with genotype 4 chronic hepatitis C. However, additional research is needed to further understand the development and spread of various emerging infectious diseases. Nevertheless, it is noteworthy that a critical threshold may exist beyond which EHM reaches a point of no return.
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Affiliation(s)
- Mohamed Abdel-Samiee
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Mohamed I Youssef
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Fathy Elghamry
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mahmoud Bazeed
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Al-Shorbagy
- Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Helmy Shalaby
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Hossam Shabana
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Department of Internal Medicine, College of Medicine, Shaqra University, Dawadmi, Saudi Arabia
| | - Eman Abdelsameea
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | | | - Tarek Esam
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | - Housam Ahmed Helmy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Feras Almarshad
- Department of Internal Medicine, College of Medicine, Shaqra University, Dawadmi, Saudi Arabia
| | - Fatma A Khalaf
- Department of Clinical Biochemistry, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | - Arafat Kassem
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Basant Mostafa Gabr
- Department of Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed Abdelfattah
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Hind S AboShabaan
- Department of Clinical Pathology, National Liver Institute, Menoufia University, Menoufia, Egypt
| | | | - Marwa M Omar
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Mohammed Saied Bakeer
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohammed S Imam
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Shimaa Y Kamel
- Department of Tropical Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Talaat Allisy
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Omima Sayed Mohammed
- Department of Microbiology, College of Medicine, Najran University, Najran, Saudi Arabia
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ali Farahat
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohsen M El-Khayat
- Department of Tropical Medicine, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
| | | | - Eman Mohammed Zaher
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Ashraf Said
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Abuamer
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Essam Elmahdi
- Department of Internal Medicine, College of Medicine, Shaqra University, Dawadmi, Saudi Arabia
- Department of Internal medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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2
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Moretti R, Giuffrè M, Merli N, Caruso P, Di Bella S, Tiribelli C, Crocè LS. Hepatitis C Virus-Related Central and Peripheral Nervous System Disorders. Brain Sci 2021; 11:1569. [PMID: 34942871 PMCID: PMC8699483 DOI: 10.3390/brainsci11121569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 12/19/2022] Open
Abstract
Hepatitis C Virus (HCV), despite being a hepatotropic virus, is the causative agent of many systemic disorders, such as vasculitis, autoimmune diseases, lymphoproliferative disorders, and a broad spectrum of neurological and psychiatric manifestations. Although symptoms have been misdiagnosed or underdiagnosed, only recently, evidence of direct (inflammatory) or indirect (immune-mediated) HCV-dependent cerebral effects has been established. HCV infection can promote acute inflammatory response, pro-coagulative status and ischemic disorders, and neurodegeneration. These effects rely on cerebral HCV replication, possibly mediated by blood-brain barrier alterations. Further study is needed to better understand the HCV-related mechanisms of brain damage.
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Affiliation(s)
- Rita Moretti
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Mauro Giuffrè
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Nicola Merli
- Department Neurological Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Paola Caruso
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Stefano Di Bella
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | | | - Lory Saveria Crocè
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
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3
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Sy-Go JPT, Thongprayoon C, Herrera Hernandez LP, Zoghby Z, Leung N, Manohar S. Rituximab-Associated Flare of Cryoglobulinemic Vasculitis. Kidney Int Rep 2021; 6:2840-2849. [PMID: 34805636 PMCID: PMC8589694 DOI: 10.1016/j.ekir.2021.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022] Open
Abstract
Background Patients with cryoglobulinemic vasculitis (CV) can develop disease flare after rituximab administration. The objective of our study was to describe the prevalence, clinical characteristics, predisposing factors, and outcomes of patients with rituximab-associated flare of CV. Methods We conducted a retrospective study in a tertiary referral center until March 25, 2020. Results Among 64 patients with CV who received rituximab therapy in our center, 14 (22%) developed disease flare. Median age was 67.5 years. Seven patients (50%) had type II CV and the other half had either type I (n = 6) or type III (n = 1). Twelve patients (86%) had an underlying B-cell lymphoproliferative disorder as the cause of their CV. CV flare occurred after a median time of 5.5 days (range: 2–8 days). The organ systems most involved were the skin (n = 10), kidneys (n = 5), and peripheral nerves (n = 3). Five patients (36%) developed acute kidney injury (AKI), 3 of whom presented with nephritic syndrome secondary to biopsy-proven membranoproliferative glomerulonephritis. Treatment was directed against the underlying disease in addition to supportive care. Patients who developed flare were more likely to have B-cell lymphoproliferative disorder as the underlying etiology of their CV (P = 0.03). Eight patients (57%) died after a median time of 27 months. Conclusions Rituximab-associated flare can occur in all types of CV, tends to arise approximately 2 days and less than 1 week after rituximab administration, and is more likely to happen in patients with an underlying B-cell lymphoproliferative disorder. It does not indicate treatment failure, and rituximab should not be abandoned altogether. AKI is a common manifestation, and mortality rate at 2 years is high.
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Affiliation(s)
- Janina Paula T Sy-Go
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Charat Thongprayoon
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Loren P Herrera Hernandez
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ziad Zoghby
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sandhya Manohar
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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4
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de Boysson H, Pagnoux C. Vasculiti del sistema nervoso centrale. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Vasospastic disorders are prevalent in the general population and can affect individuals of any age. Primary (or idiopathic) vasospastic disorders often have a benign course; treatment focuses on the control of symptoms. Secondary vasospastic disorders occur owing to an underlying condition and have an increased risk of complications, including tissue loss and digital ulcerations; treatment should focus on the underlying condition. In this review, we discuss the pathophysiology, clinical presentation, diagnosis, and management of vasospastic disorders, including Raynaud syndrome, acrocyanosis, livedo reticularis, and pernio.
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Affiliation(s)
- Ana I Casanegra
- Vascular Medicine Division, Cardiovascular Department, Gonda Vascular Center, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
| | - Roger F Shepherd
- Vascular Medicine Division, Cardiovascular Department, Gonda Vascular Center, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
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Taha A, Taha M, Ahmed R, Meckler G, Aeddula N, Meckler J. Polyneuropathy: A Rare and Challenging Presentation of Essential Mixed Cryoglobulinemia. J Investig Med High Impact Case Rep 2021; 9:23247096211026503. [PMID: 34151641 PMCID: PMC8216391 DOI: 10.1177/23247096211026503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 49-year-old male presented with acute chronic sensory motor bilateral lower extremity polyneuropathy. Electromyography showed bilateral acute sensory motor axonal polyneuropathy. Lumbar spine magnetic resonance imaging showed diffuse bone marrow replacement and bilateral ankylosing spondylitis. Laboratory workup revealed elevated inflammatory markers and low G6PD (glucose-6-phosphate dehydrogenase) level. Due to elevated acute phase reactants, inflammatory polyneuropathy was suspected; patient was treated accordingly with resolution of neuropathy. Three months later, he relapsed and presented with disabling polyneuropathy and renal impairment, which prompted renal biopsy. Renal histopathology revealed the, otherwise mysterious, etiology, essential mixed cryoglobulinemia. Essential mixed cryoglobulinemia was not considered initially due to the absence of classic systemic manifestations of autoimmune disorders.
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Affiliation(s)
- Ahmed Taha
- Indiana University, Indianapolis, IN, USA.,Deaconess Health System, Evansville, IN, USA
| | - Mohamed Taha
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Roaa Ahmed
- Ahfad University for Women, Omdurman, Sudan
| | | | - Narothama Aeddula
- Indiana University, Indianapolis, IN, USA.,Deaconess Health System, Evansville, IN, USA
| | - Jason Meckler
- Indiana University, Indianapolis, IN, USA.,Deaconess Health System, Evansville, IN, USA
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Mazzaro C, Dal Maso L, Gragnani L, Visentini M, Saccardo F, Filippini D, Andreone P, Zignego AL, Gattei V, Monti G, Galli M, Quartuccio L. Hepatitis B Virus-Related Cryoglobulinemic Vasculitis: Review of the Literature and Long-Term Follow-Up Analysis of 18 Patients Treated with Nucleos(t)ide Analogues from the Italian Study Group of Cryoglobulinemia (GISC). Viruses 2021; 13:v13061032. [PMID: 34070832 PMCID: PMC8226459 DOI: 10.3390/v13061032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 01/05/2023] Open
Abstract
Hepatitis B virus (HBV) chronic infection causes progressive liver damage, although about 20% of patients develop extrahepatic manifestations such as cryoglobulinemic vasculitis (CV). Clinical manifestations range from mild to moderate (purpura, asthenia, arthralgia) to severe (leg ulcers, peripheral neuropathy, glomerulonephritis, non-Hodgkin lymphoma). A comprehensive review of therapeutic options for HBV-related CV is lacking. Nucleos(t)ide analogues (NA) suppress HBV replication in 90–100% of cases and induce clinical response in most patients with mild-to-moderate CV. Plasma exchange can be performed in patients with severe CV and should be considered in severe or life-threatening cases combined with high doses of corticosteroids and antiviral treatment. A cautious use of rituximab can be considered only in association with NA treatment in refractory cases. A review of the literature and an analysis of data collected by six centers of the Italian Group for the Study of Cryoglobulinemia on 18 HBV-CV nucleotide/nucleoside analogues (NAs)-treated patients were carried out.
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Affiliation(s)
- Cesare Mazzaro
- Clinical Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico (CRO) IRCCS, 33081 Aviano, Italy;
- Correspondence: (C.M.); (L.Q.)
| | - Luigino Dal Maso
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico (CRO) IRCCS, 33081 Aviano, Italy;
| | - Laura Gragnani
- MASVE Interdepartmental Center, Department of Experimental and Clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, 50121 Firenze, Italy; (L.G.); (A.L.Z.)
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy;
| | - Francesco Saccardo
- Rheumatology Unit, Internal Medicine Unit, Presidio Ospedaliero di Saronno, ASST della Valle Olona, 21047 Saronno, Italy; (F.S.); (G.M.)
| | - Davide Filippini
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Pietro Andreone
- Division of Internal Medicine, Department of Medical and Surgical Sciences, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41124 Modena, Italy;
| | - Anna Linda Zignego
- MASVE Interdepartmental Center, Department of Experimental and Clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, 50121 Firenze, Italy; (L.G.); (A.L.Z.)
| | - Valter Gattei
- Clinical Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico (CRO) IRCCS, 33081 Aviano, Italy;
| | - Giuseppe Monti
- Rheumatology Unit, Internal Medicine Unit, Presidio Ospedaliero di Saronno, ASST della Valle Olona, 21047 Saronno, Italy; (F.S.); (G.M.)
| | - Massimo Galli
- Infectious Diseases, L. Sacco Hospital, Department of Biochemical and Clinical Sciences, University of Milan, 20157 Milan, Italy;
| | - Luca Quartuccio
- Rheumatology Clinic, Department of Medicine (DAME), ASUFC, University of Udine, 33100 Udine, Italy
- Correspondence: (C.M.); (L.Q.)
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8
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Chuang YC, Chen YR, Kuo TH. Cryoglobulinemic glomerulonephritis with underlying occult HBV infection and Waldenström macroglobulinemia: A case report. Medicine (Baltimore) 2021; 100:e24792. [PMID: 33607837 PMCID: PMC7899821 DOI: 10.1097/md.0000000000024792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/29/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Occult hepatitis B virus (HBV) infection, defined as negative hepatitis B surface antigen (HBsAg) but detectable HBV DNA in serum and liver tissue, has very rarely been described in cryoglobulinemia (CG) patients. This case report sheds light on the possible link between occult HBV infection and CG. PATIENT CONCERNS A 76-year-old man presented with rapidly deteriorating renal function within 1 year. DIAGNOSIS Cryoglobulinemic glomerulonephritis was diagnosed through renal biopsy. Initially, the patient tested negative for HBsAg, but a low HBV viral load was later discovered, indicating an occult HBV infection. Further studies also revealed Waldenström macroglobulinemia (WM). INTERVENTIONS We treated the patient as WM using plasma exchange and rituximab-based immunosuppressive therapy. OUTCOMES After 1 cycle of immunosuppressive treatment, there was no improvement of renal function. Shortly after, treatment was discontinued due to an episode of life-threatening pneumonia. Hemodialysis was ultimately required. CONCLUSION Future studies are needed to explore the link between occult HBV infection and CG, to investigate the mediating role of lymphomagenesis, and to examine the effectiveness of anti-HBV drugs in treating the group of CG patients with occult HBV infection. We encourage clinicians to incorporate HBV viral load testing into the evaluation panel for CG patients especially in HBV-endemic areas, and to test HBV viral load for essential CG patients in whom CG cannot be attributed to any primary disease.
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Affiliation(s)
- Yu-Che Chuang
- Education Center, National Cheng Kung University Hospital
| | - Ying-Ren Chen
- Department of Pathology, National Cheng Kung University Hospital
| | - Te-Hui Kuo
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Mariscal-Rodríguez A, Villar Guimerans L, López-Trascasa M, Hernández González M, Moga Naranjo E. Guía de laboratorio para el diagnóstico de pacientes con síndrome crioglobulinémico. Rev Clin Esp 2019; 219:505-513. [DOI: 10.1016/j.rce.2018.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022]
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10
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Laboratory guidelines for the diagnosis of patients with cryoglobulinemic syndrome. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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11
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Zhou K, Iqbal SM, Alameri A, Zhi C, Naeem A. Positive acute viral infection markers, autoimmune disease and type II mixed cryoglobulinemia: a rare concurrence. BMJ Case Rep 2019; 12:12/11/e230492. [PMID: 31780611 DOI: 10.1136/bcr-2019-230492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cryoglobulins are abnormal serum immunoglobulins that tend to precipitate in intravascular compartments at temperatures lower than 37°C causing blood flow restriction to vital organs. They are divided into type I, II and III based on the immunoglobulin subtypes of the cryoprecipitates. Type II cryoglobulinemia is most commonly associated with viral infections, autoimmune diseases and lymphoproliferative disorders. Here, we reported an 80-year-old man who presented with fatigue, acute kidney injury, palpable purpura, anaemia and altered mental status. He was diagnosed with type II cryoglobulinemia with concomitant positive autoimmune markers, varicella IgM antibody and IgM hepatitis B core antibody. The patient responded well to intravenous and oral steroid treatment.
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Affiliation(s)
- Kehua Zhou
- Catholic Health System Internal Medicine Training Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Shumaila Muhammad Iqbal
- Catholic Health System Internal Medicine Training Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Ali Alameri
- Catholic Health System Internal Medicine Training Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Cassandra Zhi
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Ammad Naeem
- Catholic Health System Internal Medicine Training Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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12
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Lymphoma-Associated Monoclonal Cryoglobulinemic Glomerulonephritis and Relationship with Hepatitis C Virus Infection: A Case Report. Case Rep Nephrol 2019; 2019:7940291. [PMID: 31531252 PMCID: PMC6719345 DOI: 10.1155/2019/7940291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/17/2019] [Indexed: 12/04/2022] Open
Abstract
We report a case of type I cryoglobulinemic glomerulonephritis in a patient with chronic hepatitis C who presented with acute renal failure. The renal biopsy revealed membranoproliferative GN (MPGN) due to cryoglobulinemia with unexpected monoclonal Kappa restriction on immunofluorescence microscopy, suggesting an underlying hematopoietic malignancy. The bone marrow biopsy revealed presence of marginal zone lymphoma. Our case raises awareness regarding possibility of monoclonality in the renal biopsy of HCV-infected patients and exemplifies the crucial role the renal biopsy plays in detecting lymphoid malignancies where clinical features are ambiguous.
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13
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Silva F, Pinto C, Barbosa A, Borges T, Dias C, Almeida J. New insights in cryoglobulinemic vasculitis. J Autoimmun 2019; 105:102313. [PMID: 31383568 DOI: 10.1016/j.jaut.2019.102313] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/24/2019] [Accepted: 07/28/2019] [Indexed: 01/08/2023]
Abstract
Cryoglobulins are antibodies that precipitate at low temperatures and dissolve after rewarming. Cryoglobulinemia refers to the presence of circulating cryoglobulins and generally leads to a systemic inflammatory syndrome characterized by fatigue, arthralgia, purpura, ulcers, neuropathy and/or glomerulonephritis. The disease mainly involves small to medium-sized blood vessels and causes vasculitis due to cryoglobulin-containing immune complexes. Cryoglobulinemia is classified into three types (I, II and III) on the basis of immunoglobulin composition. Predisposing conditions include lymphoproliferative, autoimmune diseases and hepatitis C virus infection. The diagnosis of cryoglobulinemic syndrome is predominantly based on the presence of clinical features and laboratorial demonstration of serum cryoglobulins. The treatment strategy depends on the cause of cryoglobulinemia. For patients with chronic HCV infection, antiviral therapy is indicated. Immunosuppressive or immunomodulatory therapy, including steroids, plasmapheresis and cytotoxic agents, is reserved for organ-threatening manifestations. In this review, we discuss the main clinical presentations, diagnostic approach and treatment options.
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Affiliation(s)
- Filipa Silva
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Claudemira Pinto
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Arsénio Barbosa
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Tiago Borges
- Internal Medicine Department, Hospital Privado de Gaia, Gaia, Portugal
| | - Carlos Dias
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Coordinator of Autoimmune Diseases Unit, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jorge Almeida
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
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14
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Chen YP, Cheng H, Rui HL, Dong HR. Cryoglobulinemic vasculitis and glomerulonephritis: concerns in clinical practice. Chin Med J (Engl) 2019; 132:1723-1732. [PMID: 31283654 PMCID: PMC6759094 DOI: 10.1097/cm9.0000000000000325] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Cryoglobulinemia often causes systemic vasculitis, thereby damaging to skin and internal organs including kidneys, even life-threatening. This review aimed to introduce the advances in understanding, detection, and treatment of this disease in recent years, with a particular concern to clinical practice. DATA SOURCES All the data in this review were from the English or Chinese literature in the PubMed and China National Knowledge Infrastructure databases as of March 2019. STUDY SELECTION This review selected important original articles, meaningful reviews, and some reports on cryoglobulinemia published in recent years and in history, as well as the guidelines for treatment of underlying diseases which lead to cryoglobulinemia. RESULTS Diagnosis of cryoglobulinemia relies on serum cryoglobulin test, in which to ensure that the blood sample temperature is not less than 37°C in the entire pre-analysis phase is the key to avoid false negative results. Cryoglobulinemic vasculitis (Cryo Vas), including cryoglobulinemic glomerulonephritis (Cryo GN), usually occurs in types II and III mixed cryoglobulinemia, and can also be seen in type I cryoglobulinemia caused by monoclonal IgG3 or IgG1. Skin purpura, positive serum rheumatoid factor, and decreased serum levels of C4 and C3 are important clues for prompting types II and III Cryo Vas. Renal biopsy is an important means for diagnosis of Cryo GN, while membranous proliferative GN is the most common pathological type of Cryo GN. In recent years, great advances have been made in the treatment of Cryo Vas and its underlying diseases, and this review has briefly introduced these advances. CONCLUSIONS Laboratory examinations of serum cryoglobulins urgently need standardization. The recent advances in the diagnosis and treatment of Cryo Vas and GN need to be popularized among the clinicians in related disciplines.
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Affiliation(s)
- Yi-Pu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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15
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Albawaliz A, Bahaj W, Abughanimeh OK, Noman A, Kujtan L. A Case of Prostate Cancer Presenting with Rash. Cureus 2019; 11:e4734. [PMID: 31355093 PMCID: PMC6649886 DOI: 10.7759/cureus.4734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022] Open
Abstract
Mixed cryoglobulinemia (MC) is well known for its association with chronic hepatitis C virus (HCV) infection. However, it has also been linked to autoimmune disorders and hematological malignancies, particularly of B-cell lymphoid origin. Association with solid malignancies is poorly described in the literature. Non-HCV-related MC, in the setting of prostate cancer, has been reported only twice. Here, we describe a case of MC in a prostate cancer patient complicated by membranoproliferative glomerulonephritis (MPGN) that responded well to plasma exchange therapy and treatment with both corticosteroids and rituximab.
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Affiliation(s)
- Anas Albawaliz
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Waled Bahaj
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | | | - Anas Noman
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center, Kansas City, USA
| | - Lara Kujtan
- Hematology / Oncology, University of Missouri-Kansas City School of Medicine, Kansas City, USA
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16
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Severgina LO, Studennikova VV, Radenska-Lopovok SG, Kogan EA, Novikov PI, Korovin IA. [Essential cryoglobulinemic vasculitis with the development of mesenteric vascular thrombosis and intestinal gangrene]. Arkh Patol 2019; 80:40-45. [PMID: 30335059 DOI: 10.17116/patol20188005140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper describes a case of essential cryoglobulinemia unassociated with hepatitis B and C viruses. The morphological substrate of the disease was exclusively proliferative endothrombovasculitis without destructive changes in the walls of affected vessels. In addition, in the late stage of the disease, there was its unusual manifestation associated with inflammation of the mesentery arteriolar walls and with the formation of occlusive blood clots in their lumens, which led to severe abdominal diseases. The female patient showed a mosaic involvement of the loops of the bowel in the necrotic process as its separate segments, which was associated with damage to a large number of small vessels. The feature of the case is a set of 4 risk factors for a fatal disease outcome, such as age over 65 years, pulmonary, renal, and intestinal lesions.
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Affiliation(s)
- L O Severgina
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - V V Studennikova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - S G Radenska-Lopovok
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia; Focus 5 Diagnostic Consulting Center, Medical Center for Outpatient Care, EOOD, Sofia, Bulgaria
| | - E A Kogan
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - I A Korovin
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
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17
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Couronné L, Bachy E, Roulland S, Nadel B, Davi F, Armand M, Canioni D, Michot JM, Visco C, Arcaini L, Besson C, Hermine O. From hepatitis C virus infection to B-cell lymphoma. Ann Oncol 2019; 29:92-100. [PMID: 29045541 DOI: 10.1093/annonc/mdx635] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In addition to liver disorders, hepatitis C virus (HCV) is also associated with extrahepatic immune manifestations and B-cell non-Hodgkin lymphoma (NHL), especially marginal zone lymphoma, de novo or transformed diffuse large B-cell lymphoma and to a lesser extent, follicular lymphoma. Epidemiological data and clinical observations argue for an association between HCV and lymphoproliferative disorders. The causative role of HCV in NHL has been further supported by the response to antiviral therapy. Pathophysiological processes at stake leading from HCV infection to overt lymphoma still need to be further elucidated. Based on reported biological studies, several mechanisms of transformation seem however to emerge. A strong body of evidence supports the hypothesis of an indirect transformation mechanism by which sustained antigenic stimulation leads from oligoclonal to monoclonal expansion and sometimes to frank lymphoma, mostly of marginal zone subtype. By infecting lymphocytes, HCV could play a direct role in cellular transformation, particularly in de novo large B-cell lymphoma. Finally, HCV is associated with follicular lymphoma in a subset of patients. In this setting, it may be hypothesized that inflammatory cytokines stimulate proliferation and transformation of IgH-BCL2 clones that are increased during chronic HCV infection. Unraveling the pathogenesis of HCV-related B-cell lymphoproliferation is of prime importance to optimize therapeutic strategies, especially with the recent development of new direct-acting antiviral drugs.
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Affiliation(s)
- L Couronné
- Department of Hematology, Assistance Publique-Hôpitaux de Paris (APHP), Necker Hospital, Paris, France.,INSERM UMR 1163, CNRS ERL 8254, Imagine Institute, Paris, France.,Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - E Bachy
- Cancer Research Center of Lyon, INSERM U1052, CNRS UMR 5286, Lyon, France.,Department of Hematology, Lyon Sud Hospital, Lyon, France
| | - S Roulland
- Center of Immunology of Marseille-Luminy, Aix Marseille University, Marseille, France
| | - B Nadel
- Center of Immunology of Marseille-Luminy, Aix Marseille University, Marseille, France
| | - F Davi
- INSERM U1104, Marseille, France.,CNRS UMR 7280, Marseille, France.,Department of Hematology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France
| | - M Armand
- INSERM U1104, Marseille, France.,CNRS UMR 7280, Marseille, France.,Department of Hematology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France
| | - D Canioni
- Department of Pathology, Necker Hospital, AP-HP, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - J M Michot
- Department of Hematology and Drug Development, Gustave Roussy Institute, Villejuif; France
| | - C Visco
- Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - L Arcaini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Departement of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - C Besson
- Department of Hematology and Oncology, Hospital of Versailles, Le Chesnay, France.,University of Versailles Saint Quentin en Yvelines, Paris-Saclay University, Communauté Paris-Saclay, Paris, France.,INSERM U1184, Center for Immunology of Viral Infections and Autoimmune Diseases, Le Kremlin-Bicêtre, France
| | - O Hermine
- Department of Hematology, Assistance Publique-Hôpitaux de Paris (APHP), Necker Hospital, Paris, France.,INSERM UMR 1163, CNRS ERL 8254, Imagine Institute, Paris, France.,Paris Descartes-Sorbonne Paris Cité University, Paris, France
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18
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Riquelme-Mc Loughlin C, Gómez-Armayones S, Mascaró JM. Nonhealing ulcers in a young male. Australas J Dermatol 2018; 60:e76-e77. [PMID: 29901214 DOI: 10.1111/ajd.12865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Sara Gómez-Armayones
- Dermatology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - José Manuel Mascaró
- Dermatology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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19
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Khalighi MA, Al-Rabadi L, Chalasani M, Smith M, Kakani S, Revelo MP, Meehan SM. Staphylococcal Infection-Related Glomerulonephritis With Cryoglobulinemic Features. Kidney Int Rep 2018; 3:1128-1134. [PMID: 30197979 PMCID: PMC6127436 DOI: 10.1016/j.ekir.2018.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/07/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction Staphylococcal infection–related glomerulonephritis (GN) has been shown to represent a unique form of infection-related GN that contains IgA-dominant deposits and is often seen concurrently with the bacterial infection. Biopsies commonly reveal an endocapillary proliferative and/or exudative or mesangial proliferative GN. Rare cases have been reported to show cryoglobulin-like features, including hyaline pseudothrombi and wireloop deposits; however, detailed characterization of these cases is lacking. Methods The pathology archives from the University of Utah and Sharp Memorial Hospital were reviewed from January 2016 to September 2017 in search of cases with GN containing IgA-dominant deposits and features of cryoglobulinemia. Results Of 1965 native kidney biopsies, 5 showed IgA-dominant GN with cryoglobulinemic features. All patients had active staphylococcal infections at the time of biopsy. All presented with acute kidney injury (serum creatinine range: 1.7−6 mg/dl), and all had proteinuria and hematuria. All biopsies showed exudative GN, and 4 biopsies had focal crescents. All had focally prominent hyaline pseudothrombi with or without wireloop deposits, and all showed co-dominant staining for IgA and C3 on immunofluorescence microscopy. Serologic testing for cryoglobulinemia was performed in 3 patients and was transiently positive in 1 patient. Four patients required hemodialysis at last follow-up, whereas 1 patient returned to baseline kidney function. Conclusion IgA-dominant GN with cryoglobulinemic features is an uncommon but severe form of glomerular injury in patients with staphylococcal infections. Four of 5 patients had crescentic glomerular injuries, all of whom required hemodialysis at last follow-up. Patients with IgA-dominant GN with features of cryoglobulinemia should be evaluated for active staphylococcal infection.
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Affiliation(s)
- Mazdak A Khalighi
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Laith Al-Rabadi
- Department of Nephrology, University of Utah, Salt Lake City, Utah, USA
| | - Meghana Chalasani
- Department of Nephrology, University of Utah, Salt Lake City, Utah, USA
| | - Mark Smith
- Nephrology Associates, PC, Augusta, Georgia, USA
| | - Siddhartha Kakani
- Department of Nephrology, University of Utah, Salt Lake City, Utah, USA
| | - Monica P Revelo
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Shane M Meehan
- Department of Pathology, Sharp Memorial Hospital, San Diego, California, USA
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20
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van Hooff L, Barten DG, Potjewijd J, van Paassen P. Necrotizing vasculitis in immediate response to a shoulder dislocation. Am J Emerg Med 2018; 36:1523.e1-1523.e3. [PMID: 29691104 DOI: 10.1016/j.ajem.2018.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/17/2018] [Indexed: 12/01/2022] Open
Abstract
The shoulder is one of the most commonly dislocated joints in the human body. Complications usually represent local damage. However, it is unclear whether joint dislocations can have systemic sequellae as wSell. Here we present the case of an 86-year-old female who developed necrotizing cryoglobulinaemic vasculitis in immediate response to a shoulder dislocation. We hypothesize there might be a link between trauma and systemic disease.
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Affiliation(s)
- Loes van Hooff
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands.
| | - Judith Potjewijd
- Department of Internal Medicine, Division of Clinical and Experimental Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - P van Paassen
- Department of Internal Medicine, Division of Clinical and Experimental Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
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21
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Li SJ, Xu ST, Chen HP, Zhang MC, Xu F, Cheng SQ, Liu ZH. Clinical and morphologic spectrum of renal involvement in patients with HBV-associated cryoglobulinaemia. Nephrology (Carlton) 2018; 22:449-455. [PMID: 27062412 DOI: 10.1111/nep.12795] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/01/2016] [Accepted: 04/03/2016] [Indexed: 12/30/2022]
Abstract
AIM Cryoglobulinaemic glomerulonephritis related to hepatitis B virus (HBV) infection has been rarely reported. The aim of this study was to investigate the clinical features, renal biopsy findings in patients with HBV-associated cryoglobulinaemia. METHODS Twelve patients with HBV-associated cryoglobulinaemia were identified in this study. The demographic, clinical, pathological characteristics, treatment and follow-up data were analyzed. RESULTS Renal involvement was characterized by nephrotic range proteinuria with microscopic haematuria in all patients, and impaired renal function in nine patients (75%). Purpuric rash was the main extrarenal manifestation (58.3%). Type II cryoglobulinaemia was presented in three patients and type III in nine patients. Hypocomplementaemia and positive of rheumatoid factors were present in all patients. Membranoproliferative glomerulonephritis (MPGN) was observed in all kidney specimens. Seven patients also had evidence of prominent cryoglobulins thrombi on renal biopsy, but only three patients had HBV antigen deposits in renal tissues. Antiviral and steroids or immunosuppressive agents have been used in most of patients. During follow-up, two patients died, and four reaching end-stage renal disease; three patients had complete remission, and three patients had renal function improved after therapy. CONCLUSIONS Nephrotic syndrome with haematuria and renal insufficiency are the main clinical manifestation; cryoglobulinaemic glomerulonephritis are the main renal lesion in patients with HBV-Associated cryoglobulinaemia; half of patients have poor outcome even with antiviral and immunosuppressive therapy. The results of this study indicate that cryoglobulins should be detected in hepatitis B virus-Associated nephropathy in endemic area.
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Affiliation(s)
- Shi-Jun Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Shu-Tian Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Hui-Ping Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ming-Chao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Shui-Qin Cheng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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22
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Voma CB, Levinson SS. Analysis, detection and quantitation of mixed cryoglobulins in HCV infection: brief review and case examples. Clin Chem Lab Med 2017; 54:1853-1859. [PMID: 27049619 DOI: 10.1515/cclm-2015-1143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 03/01/2016] [Indexed: 11/15/2022]
Abstract
Considering the high incidence of cryoglobulins in hepatitis C virus (HCV) infection together with the high worldwide prevalence of HCV infection, identification of clinically apparent mixed cryoglobulinemia syndrome is increasingly important as most patients who are identified can now be successfully treated. Different approaches for the detection, analysis and reporting of cryoglobulins have been described and there is a wide variation in results reported, ranging from a qualitative "negative" or "positive", to a quantitative report including cryoglobulin type and the total protein. Protein and immunofixation (IFE) electrophoresis are generally used to identify and characterize cryoglobulins, as these methods quantify and phenotype. Here, we present a brief review of the literature and demonstrate a case oriented approach for identifying mixed cryoglobulinemia from the preanalytical phase, leading up to and including the analytical phase with characterization by IFE. Most patients with mixed cryoglobulinemia can now be treated with success. Nevertheless, the high cost may limit treatment of those with symptoms unless there is laboratory evidence for mixed cryoglubulinemia. Low levels of cryoglobulins can be associated with severe symptoms; as a result, accurate identification of cryoglobulins may be of increasing importance since clear identification may be a good reason to initiate treatment.
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23
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Giménez-Roca C, Iglesias E, Vicente MA, Bou R, Calzada-Hernández J, Prat C, García M, Antón J. Pediatric cryoglobulinemic vasculitis successfully managed with rituximab. Dermatol Ther 2016; 30. [PMID: 27791307 DOI: 10.1111/dth.12430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/26/2016] [Accepted: 08/31/2016] [Indexed: 11/29/2022]
Affiliation(s)
- C Giménez-Roca
- Pediatric Rheumatology Unit, Department of Pediatrics, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - E Iglesias
- Pediatric Rheumatology Unit, Department of Pediatrics, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - M A Vicente
- Department of Pediatric Dermatology, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - R Bou
- Pediatric Rheumatology Unit, Department of Pediatrics, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - J Calzada-Hernández
- Pediatric Rheumatology Unit, Department of Pediatrics, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - C Prat
- Department of Pediatric Dermatology, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain.,Department of Dermatology, Hospital Universitario de la Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - M García
- Department of Pediatrics, Hospital Universitario de la Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - J Antón
- Pediatric Rheumatology Unit, Department of Pediatrics, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
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24
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Chang Y, Dabiri G, Damstetter E, Baiyee Ebot E, Powers JG, Phillips T. Coagulation disorders and their cutaneous presentations: Pathophysiology. J Am Acad Dermatol 2016; 74:783-92; quiz 793-4. [PMID: 27085225 DOI: 10.1016/j.jaad.2015.08.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 12/21/2022]
Abstract
Hypercoagulable states are inherited or acquired predispositions to venous or arterial thromboses that are best understood in the context of the coagulation cascade. Dermatologists can play a critical role in diagnosing and treating patients with hypercoagulable states because cutaneous symptoms may be a presenting manifestation, thereby reducing morbidity and mortality related to these conditions. This review focuses on the epidemiology and pathophysiology of hypercoagulable states, while the accompanying article iterates the basic clinical features, diagnostic testing, and management of patients who have these conditions.
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Affiliation(s)
- Yunyoung Chang
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Ganary Dabiri
- Department of Dermatology and Skin Surgery, Roger Williams Medical Center/Boston University School of Medicine, Providence, Rhode Island
| | - Elizabeth Damstetter
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Emily Baiyee Ebot
- Department of Hematology and Oncology, University Medical Group, Providence, Rhode Island
| | | | - Tania Phillips
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts.
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25
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Arora S, Levitan D, Regmi N, Sidhu G, Gupta R, Nicastri AD, Saggi SJ, Braverman A. Cryoglobulinemia in a patient with chronic lymphocytic leukemia - A case report and review of literature of renal involvement in CLL. Blood Cells Mol Dis 2016; 60:7-11. [PMID: 27519936 DOI: 10.1016/j.bcmd.2016.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/21/2016] [Accepted: 05/21/2016] [Indexed: 10/21/2022]
Abstract
The incidence of glomerulonephritis, as a manifestation of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), has always been considered low. Though renal infiltration is usually detected at post-mortem, it does not often interfere with kidney function [1]. Though immunoglobulin (Ig) levels in most CLL patients are subnormal, small monoclonal Ig peaks are occasionally detected in serum. They were present in a number of reported CLL nephropathy patients, and not all were cryoglobulins; serum and glomerular staining were concordant for Ig type [2,3,4]. Myeloma, which secretes monoclonal light chains, causes nephropathy in 25% of patients. But the little presumably secreted by small plasma cell clones, without myeloma, may also be nephrotoxic. The same is true of the low secretory CLL cells, which may occasionally be associated with cryoglobulins and other nephrotoxic Igs [5]. We report a patient with early stage CLL (Rai stage 0) with cryoglobulins, which led to membranoproliferative glomerulonephritis (MPGN), and death. We located reports of 51 patients with CLL-associated nephrotic syndrome or nephropathy, mostly from MPGN related to local Ig deposits. In those patients screened for cryoglobulins, about half tested positive. Many were early stage cases, where MPGN developed long after CLL presentation, and responded to its treatment. As early diagnosis and treatment CLL-related nephropathy may be curative, we propose a prospective study to determine the incidence of hyperalbuminuria development after presentation.
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Affiliation(s)
- Swaty Arora
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA.
| | - Daniel Levitan
- Department of Pathology, State University New York, Downstate, USA
| | - Narottam Regmi
- Department of Nephrology, Department of Medicine, State University New York, Downstate, USA
| | - Gurinder Sidhu
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA
| | - Raavi Gupta
- Department of Pathology, State University New York, Downstate, USA
| | | | - Subodh J Saggi
- Department of Nephrology, Department of Medicine, State University New York, Downstate, USA
| | - Albert Braverman
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA
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Raynaud Phenomenon With Severe Ulcers Associated With Cryoglobulins in an HIV+ but HCV Negative Patient. J Clin Rheumatol 2016; 22:335-7. [PMID: 27433994 DOI: 10.1097/rhu.0000000000000431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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27
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Herrera GA, Ojemakinde KO, Turbat-Herrera EA, Gu X, Zeng X, Iskandar SS. Immunotactoid Glomerulopathy and Cryoglobulinemic Nephropathy: Two Entities with Many Similarities. A Unified Conceptual Approach. Ultrastruct Pathol 2016; 39:270-80. [PMID: 26270724 DOI: 10.3109/01913123.2015.1017070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Immunotactoid glomerulopathy is a rare disorder that has been characterized at the ultrastructural level. Due to its rarity, there are few comprehensive studies relating to this disorder. Electron microscopy essentially characterizes this disease. The glomerular electron dense deposits which are typical of this condition consist of aggregates of highly organized microtubular structures of various diameters, but generally measuring 30-50 nm in width with a propensity to dispose themselves in parallel bundles intersecting in different planes. This study compares a large series of patients with cryoglobulinemic nephropathy with a series of patients with immunotactoid glomerulopathy to address whether there may be similarities that warrant considering these two entities part of a spectrum. This study reviews the clinicopathologic features of both entities and emphasizes ultrastructural findings that characterize them. Significant immunomorphologic overlap was found when these two disorders were compared in this study. There were also striking similarities in clinical presentation/behavior, laboratory findings and prognosis. Proteomic analysis has also demonstrated similar spectra for both entities. We postulate that immunotactoid glomerulopathy and cryoglobulinemic nephropathy are part of the spectrum of renal manifestations in patients with circulating cryoglobulins and renal disease.
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28
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Management of Vasculitic Glomerulonephritis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016. [DOI: 10.1007/s40674-016-0049-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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30
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Glavey SV, Leung N. Monoclonal gammopathy: The good, the bad and the ugly. Blood Rev 2015; 30:223-31. [PMID: 26732417 DOI: 10.1016/j.blre.2015.12.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is a condition characterized by the presence of a monoclonal gammopathy (MG) in which the clonal mass has not reached a predefined state in which the condition is considered malignant. It is a precursor to conditions such as multiple myeloma or lymphoma at a rate of ~1%/year. Thus, from a hematologic standpoint, MGUS is a fairly benign condition. However, it is now recognized that organ damage resulting from just the MG without the need MM or lymphoma can occur. One of the most recognized is nephropathy secondary to monoclonal gammopathy of renal significance (MGRS). Other well-recognized conditions include neuropathies, oculopathies and dermopathies. Some conditions such as autoimmune diseases and coagulopathies are less common and recognized. Finally, systemic involvement of multiple organs is well described in several entities. In all of these conditions, the role of the MG is no longer insignificant. Thus, the term MGUS should be avoided when describing these entities.
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Affiliation(s)
- Siobhan V Glavey
- Department of Hematology, National University of Ireland, Galway, Ireland
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Hermouet S, Bigot-Corbel E, Gardie B. Pathogenesis of Myeloproliferative Neoplasms: Role and Mechanisms of Chronic Inflammation. Mediators Inflamm 2015; 2015:145293. [PMID: 26538820 PMCID: PMC4619950 DOI: 10.1155/2015/145293] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 08/19/2015] [Indexed: 12/18/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) are a heterogeneous group of clonal diseases characterized by the excessive and chronic production of mature cells from one or several of the myeloid lineages. Recent advances in the biology of MPNs have greatly facilitated their molecular diagnosis since most patients present with mutation(s) in the JAK2, MPL, or CALR genes. Yet the roles played by these mutations in the pathogenesis and main complications of the different subtypes of MPNs are not fully elucidated. Importantly, chronic inflammation has long been associated with MPN disease and some of the symptoms and complications can be linked to inflammation. Moreover, the JAK inhibitor clinical trials showed that the reduction of symptoms linked to inflammation was beneficial to patients even in the absence of significant decrease in the JAK2-V617F mutant load. These observations suggested that part of the inflammation observed in patients with JAK2-mutated MPNs may not be the consequence of JAK2 mutation. The aim of this paper is to review the different aspects of inflammation in MPNs, the molecular mechanisms involved, the role of specific genetic defects, and the evidence that increased production of certain cytokines depends or not on MPN-associated mutations, and to discuss possible nongenetic causes of inflammation.
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Affiliation(s)
- Sylvie Hermouet
- Inserm UMR 892, CNRS UMR 6299, Centre de Recherche en Cancérologie Nantes-Angers, Institut de Recherche en Santé, Université de Nantes, 44007 Nantes, France
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Nantes, 44093 Nantes Cedex, France
| | - Edith Bigot-Corbel
- Inserm UMR 892, CNRS UMR 6299, Centre de Recherche en Cancérologie Nantes-Angers, Institut de Recherche en Santé, Université de Nantes, 44007 Nantes, France
- Laboratoire de Biochimie, Centre Hospitalier Universitaire de Nantes, 44093 Nantes Cedex, France
| | - Betty Gardie
- Inserm UMR 892, CNRS UMR 6299, Centre de Recherche en Cancérologie Nantes-Angers, Institut de Recherche en Santé, Université de Nantes, 44007 Nantes, France
- Ecole Pratique des Hautes Etudes, Laboratoire de Génétique Oncologique, 44007 Nantes, France
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Olson N, Yerrabothala S, Dunbar N. Successful use of cryocrit for monitoring response to therapeutic plasma exchange in type 1 cryoglobulinemia. J Clin Apher 2015; 31:403-4. [PMID: 26194475 DOI: 10.1002/jca.21414] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/04/2015] [Indexed: 11/08/2022]
Abstract
Waldenstrom macroglobulinemia (WM) is a clinical syndrome that is defined as lymphoplasmacytic lymphoma with bone marrow involvement and IgM monoclonal gammopathy of any level. In some instances WM can result in a type I cryoglobulinemia with very high cryocrits, which is unusual in type II and III cryoglobulinemia. We describe a case of an 80 year old male with WM, severe type I cryoglobulinemia, and an extremely elevated cryocrit (69%). Over the course of five weeks we performed nine therapeutic plasma exchanges (TPE), and after seven treatments his cryocrit had decreased to 6% with improvement in his symptoms. By monitoring his cryocrit throughout his TPE sessions, we were able to assess his response to treatment, determine the ideal length of treatment in addition to his symptomatic improvement. J. Clin. Apheresis 31:403-404, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Nicholas Olson
- Department of Pathology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Swaroopa Yerrabothala
- Department of Hematology and Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nancy Dunbar
- Department of Pathology and Transfusion Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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Kraushaar T, Brückner S, Veelders M, Rhinow D, Schreiner F, Birke R, Pagenstecher A, Mösch HU, Essen LO. Interactions by the Fungal Flo11 Adhesin Depend on a Fibronectin Type III-like Adhesin Domain Girdled by Aromatic Bands. Structure 2015; 23:1005-17. [DOI: 10.1016/j.str.2015.03.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 03/06/2015] [Accepted: 03/25/2015] [Indexed: 12/23/2022]
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Porres-Aguilar M, Rodriguez-Castro CE, Osvaldo P, Saifuddin F, Siddiqui T, Fan J, Mukherjee D, Pema K, Abbas A. Finger necrosis due to cryoglobulinemic vasculitis in association with membranous nephropathy. Proc AMIA Symp 2015; 28:72-4. [PMID: 25552807 PMCID: PMC4264719 DOI: 10.1080/08998280.2015.11929195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cryoglobulinemic vasculitis is a small vessel vasculitis that has been associated with chronic infections and autoimmune, lymphoproliferative, and neoplastic disorders. When no significant etiological factors are identified, it is called essential mixed cryoglobulinemia. A detailed and thorough laboratory investigation is required to exclude all possible causes of cryoglobulin formation. Although cryoglobulin testing is simple, careful temperature regulation is needed to avoid false-negative results. Consensus diagnosis should be developed and implemented for appropriate cryoglobulin detection and accurate clinical diagnosis for cryoglobulinemic vasculitis. Here we present an interesting, first-ever case report of a 54-year-old Hispanic-American woman with essential mixed cryoglobulinemia presenting with significant digital necrosis in association with membranous nephropathy.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Carlos E Rodriguez-Castro
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Padilla Osvaldo
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Fátima Saifuddin
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Tariq Siddiqui
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Jerry Fan
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Debabrata Mukherjee
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Kanchan Pema
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Aamer Abbas
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
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Tripon S, Francoz C, Albuquerque A, Paradis V, Boudjema H, Voitot H, Belghiti J, Valla D, Durand F. Interactions between virus-related factors and post-transplant ascites in patients with hepatitis C and no cirrhosis: role of cryoglobulinemia. Transpl Int 2014; 28:162-9. [PMID: 25267442 DOI: 10.1111/tri.12466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/02/2014] [Accepted: 09/21/2014] [Indexed: 12/11/2022]
Abstract
Refractory ascites may appear in liver transplant recipients with recurrence of hepatitis C virus infection, even in the absence of advanced fibrosis. The mechanisms are unclear. The aim was to determine whether post-transplant cryoglobulinemia could be a predisposing factor for ascites in this population. Retrospective data of 82 liver transplant recipients with HCV recurrence surviving more than 1 year were collected. Cryoglobulinemia was systematically tested after transplantation. All patients had 1-year protocol biopsy with assessment of sinusoidal distension, perisinusoidal fibrosis, and centrolobular necrosis. Additional biopsies were performed when needed. Fourteen of 82 patients (17%) developed refractory ascites. When ascites appeared, fibrosis was stage F0-F1 in 36% and F2-F3 in 57%. Factors independently associated with post-transplant ascites were pretransplant refractory ascites (P = 0.001), fibrosis ≥stage 2 at 1 year (P = 0.002), perisinusoidal fibrosis at 1 year (P = 0.02), and positive cryoglobulinemia (P = 0.02). Patients with ascites had a significantly worse prognosis compared to those without ascites. Refractory ascites may occur in liver transplant recipients with HCV recurrence in the absence of advanced fibrosis. The finding that both positive cryoglobulinemia and perisinusoidal fibrosis at 1 year were significantly associated with ascites suggests that liver microangiopathy is involved in the mechanisms of HCV-related ascites.
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Affiliation(s)
- Simona Tripon
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France
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Klein R, Templeton DM, Schwenk M. Applications of immunochemistry in human health: advances in vaccinology and antibody design (IUPAC Technical Report). PURE APPL CHEM 2014. [DOI: 10.1515/pac-2013-1028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
This report discusses the history and mechanisms of vaccination of humans as well as the engineering of therapeutic antibodies. Deeper understanding of the molecular interactions involved in both acquired and innate immunity is allowing sophistication in design of modified and even synthetic vaccines. Recombinant DNA technologies are facilitating development of DNA-based vaccines, for example, with the recognition that unmethylated CpG sequences in plasmid DNA will target Toll-like receptors on antigen-presenting cells. Formulations of DNA vaccines with increased immunogenicity include engineering into plasmids with “genetic adjuvant” capability, incorporation into polymeric or magnetic nanoparticles, and formulation with cationic polymers and other polymeric and non-polymeric coatings. Newer methods of delivery, such as particle bombardment, DNA tattooing, electroporation, and magnetic delivery, are also improving the effectiveness of DNA vaccines. RNA-based vaccines and reverse vaccinology based on gene sequencing and bioinformatic approaches are also considered. Structural vaccinology is an approach in which the detailed molecular structure of viral epitopes is used to design synthetic antigenic peptides. Virus-like particles are being designed for vaccine deliveries that are based on structures of viral capsid proteins and other synthetic lipopeptide building blocks. A new generation of adjuvants is being developed to further enhance immunogenicity, based on squalene and other oil–water emulsions, saponins, muramyl dipeptide, immunostimulatory oligonucleotides, Toll-like receptor ligands, and lymphotoxins. Finally, current trends in engineering of therapeutic antibodies including improvements of antigen-binding properties, pharmacokinetic and pharmaceutical properties, and reduction of immunogenicity are discussed. Taken together, understanding the chemistry of vaccine design, delivery and immunostimulation, and knowledge of the techniques of antibody design are allowing targeted development for the treatment of chronic disorders characterized by continuing activation of the immune system, such as autoimmune disorders, cancer, or allergies that have long been refractory to conventional approaches.
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Ojemakinde K, Turbat-Herrera EA, Zeng X, Gu X, Herrera GA. The many faces of cryoglobulinemic nephropathy: a clinico-pathologic study of 47 cases with emphasis on the value of electron microscopy. Ultrastruct Pathol 2014; 38:367-76. [PMID: 25191813 DOI: 10.3109/01913123.2014.952803] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The clinical and pathologic manifestations of cryoglobulinemic nephropathy (CN) are heterogeneous. The role that electron microscopy plays in the diagnosis of CN has not been properly evaluated. The main objective of this study was to define the value of ultrastructural evaluation in the diagnosis of CN. Although most of the CN cases in this series exhibited glomerular pathology with a membranoproliferative pattern, a significant number of the cases showed less well-defined morphologic patterns on light microscopic examination (i.e. mesangial proliferation, hyaline thrombi in glomerular capillaries without significant cellular proliferation, exudative glomerulonephritis, etc). Immunofluorescence microscopy also revealed variable immunoglobulin and complement component patterns, some with "full-house" expression of immunoreactants. A subset of these CN cases was associated with light chain restriction. Thus, differential diagnosis can be a challenge as many other glomerulonephritis overlap in immunomorphologic characteristics. Because the immunomorphologic manifestations of CN are so varied, confirmation of a suspected diagnosis of CN or making a diagnosis in a less than a typical immunomorphologic setting required careful ultrastructural evaluation to find unequivocal diagnostic findings or at least supportive evidence in the form of detection of substructure in the electron dense glomerular deposits consistent with cryoglobulins. Even in cases where the light and immunofluorescence findings in suspicious clinical situations were quite consistent with CN, electron microscopy provided the final proof to substantiate the diagnosis in the great majority of the cases.
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Affiliation(s)
- Kunle Ojemakinde
- Department of Pathology, Louisiana State University Health Sciences Center , Shreveport , USA
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Comar M, Zanotta N, Del Savio R, Vascotto F, Calabrese N, Zorat F, Pozzato G. No evidence of Polyomavirus and EBV infections in Italian patients with mixed cryoglobulinemia infected chronically with HCV. J Med Virol 2013; 86:666-71. [DOI: 10.1002/jmv.23867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2013] [Indexed: 12/31/2022]
Affiliation(s)
- Manola Comar
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo,”; Trieste Italy
- Department of Medical Sciences Clinical Unit of Hygiene; University of Trieste; Trieste Italy
| | - Nunzia Zanotta
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo,”; Trieste Italy
| | - Rossella Del Savio
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo,”; Trieste Italy
| | - Fulvia Vascotto
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo,”; Trieste Italy
| | - Nadia Calabrese
- Department of Medical Sciences Clinical Unit of Haematology; University of Trieste; Trieste Italy
| | - Francesca Zorat
- Department of Medical Sciences Clinical Unit of Haematology; University of Trieste; Trieste Italy
| | - Gabriele Pozzato
- Department of Medical Sciences Clinical Unit of Haematology; University of Trieste; Trieste Italy
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Abstract
A 50-year-old man with a history of hepatitis C presented with recurrent episodes of abdominal pain, arthralgia, and weakness. Although these symptoms seemed rather non-specific, a purpuric rash of the lower extremities was the final clue to diagnosis. The diagnosis was then confirmed by histopathologic and serologic testing.
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Affiliation(s)
- Donald Mebust
- Emergency Physician at the San Diego Medical Center in CA. E-mail:
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40
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El Habr C, Sammour R, El-Murr T, Nasser S, Abi-Nasr T, Medawar C. Acrocyanosis and necrotic purpura: a manifestation of multiple myeloma and Type I cryoglobulinemia. Int J Dermatol 2013; 54:946-50. [DOI: 10.1111/ijd.12232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 12/08/2012] [Accepted: 02/15/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Constantin El Habr
- Division of Dermatology; Saint George Hospital University Medical Center; Beirut Lebanon
| | - Rita Sammour
- Division of Dermatology; Saint George Hospital University Medical Center; Beirut Lebanon
| | - Toni El-Murr
- Division of Internal Medicine; Middle East Hospital; Beirut Lebanon
| | - Selim Nasser
- Division of Pathology; Clemenceau Medical Center; Beirut Lebanon
| | | | - Charbel Medawar
- Division of Plastic Surgery; Saint George Hospital University Medical Center; Beirut Lebanon
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Hepatitis C Virus-related Heat-insoluble Cryoglobulinemia and Thrombotic Microangiopathy. Am J Med Sci 2013; 346:345-8. [DOI: 10.1097/maj.0b013e318293cdee] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lauletta G, Russi S, Conteduca V, Sansonno L, Dammacco F, Sansonno D. Impact of Cryoglobulinemic Syndrome on the Outcome of Chronic Hepatitis C Virus Infection: A 15-Year Prospective Study. Medicine (Baltimore) 2013; 92:245-256. [PMID: 23982056 PMCID: PMC4553977 DOI: 10.1097/md.0b013e31829d2abc] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We evaluated the influence of cryoglobulinemic syndrome (CS) on the outcome of chronic hepatitis C virus (HCV) infection in a 15-year prospective study. We assessed a cohort of 950 chronically HCV-infected patients, collected from the beginning of 1990 to the end of 2010. All patients had received a liver histologic diagnosis. Mixed cryoglobulinemia (MC) was determined in 246 patients (25.8%), of whom 184 also had CS. They were assessed every 3 months for 15 years, at least; 141 patients with CS and 601 without MC completed the study.No spontaneous clearance of cryoglobulins was noted. Type II to type III spontaneous switching was ascertained in 1.6% (0.08%/yr) patients. The estimated progression rate of liver fibrosis was lower in CS(+) than in MC(-) patients (p < 0.05). The 15-year cumulative probability of developing cirrhosis and/or hepatocellular carcinoma was higher in MC(-) than in CS(+) patients (24.9% vs. 14.2%, p < 0.005 and 20.3% vs. 7.5%, p = 0.003, respectively). Renal insufficiency, neurologic impairment, or B-cell non-Hodgkin lymphoma were significantly more frequent in CS(+) than in MC(-) patients (32.6% vs. 3%, p < 0.0001; 31.2% vs. 4.8%, p < 0.0001; and 15% vs. 7.1%, p = 0.003, respectively). However, in spite of different morbidity features and causes of death, the 15-year survival rate was similar in the 2 groups (70.2% vs. 71.7%). Antiviral therapy had an undisputable impact on patient outcome.This 15-year prospective cohort study shows that, although CS has no influence on the overall survival of HCV-infected patients, it significantly modifies the natural history of chronically HCV-infected patients.
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Affiliation(s)
- Gianfranco Lauletta
- From the Liver Unit (GL, SR, FD, DS), Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari; Department of Medical Sciences (VC), and Medical Genetics (LS), Department of Biomedical Sciences, University of Foggia Medical School, Foggia, Italy
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Khalighi MA, Lassman CR. Hepatitis C-associated cryoglobulinemic glomerulonephritis with crystalline deposits. Am J Kidney Dis 2013; 62:384-9. [PMID: 23548556 DOI: 10.1053/j.ajkd.2013.02.354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 02/15/2013] [Indexed: 11/11/2022]
Abstract
Infection with hepatitis C virus has been associated with a number of extrahepatic manifestations, including kidney disease. Of the glomerular pathologic states described with hepatitis C virus infection, cryoglobulinemic glomerulonephritis is the most prevalent. On kidney biopsy, cryoglobulinemic glomerulonephritis has a variable appearance, with a membranoproliferative pattern of injury as the most common light microscopic finding. Ultrastructurally, curved and paired microtubules are the most characteristic finding, but these also can be variable. We present a case of cryoglobulinemic glomerulonephritis with distinct and highly unusual ultrastructural findings.
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Affiliation(s)
- Mazdak A Khalighi
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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44
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de Boysson H, Pagnoux C, Zuber M. Vasculiti del sistema nervoso centrale. Neurologia 2013. [DOI: 10.1016/s1634-7072(12)63926-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
Waldenström macroglobulinemia is a lymphoplasmacytic lymphoma. A serum monoclonal IgM protein is required to establish this diagnosis. The clinical features patients develop include normochromic normocytic anemia, thrombocytopenia, hepatosplenomegaly, lymphadenopathy and signs of hyperviscosity. The International Staging System for Waldenström macroglobulinemia divides patients prognostically based on age, hemoglobin, platelet count, IgM level, and β(2) microglobulin. Some patients with Waldenström macroglobulinemia have a smoldering form and can be observed without intervention. Active agents in the treatment of Waldenström macroglobulinemia include rituximab, chlorambucil, cyclophosphamide, fludarabine, bortezomib, lenalidomide, bendamustine, everolimus, and alemtuzumab. The current preferred Mayo Clinic non-study treatment is rituximab, cyclophosphamide, and dexamethasone. The median survival associated with this disease is now over 10 years.
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Affiliation(s)
- Morie Gertz
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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46
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Abou El Azm AR, El-Bate H, Abo-Ali L, Mansour N, Ghoraba H, Salem ML. Correlation of viral load with bone marrow and hematological changes in pale patients with chronic hepatitis C virus. Arch Virol 2012; 157:1579-86. [PMID: 22569886 DOI: 10.1007/s00705-012-1321-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 03/21/2012] [Indexed: 02/07/2023]
Abstract
Liver is considered the target of hepatitis C virus (HCV), which has marked tropism for hepatocytes. In this study, we investigated changes in bone marrow (BM) and blood and their correlation with viremia level in 30 pale patients with chronic HCV who were selected before antiviral therapy. Patients with BM positive for HCV RNA (53.33 %) showed moderate to high viremia, while patients with BM negative for RNA (46.67 %) had low viremia. There was no significant difference in the liver histopathology between patients with HCV-RNA-negative and positive BM. Patients with BM positive for HCV RNA showed significant changes in BM cells, including the degree of immune complex deposition and alterations in peripheral blood counts compared to patients with BM negative for RNA and healthy controls, suggesting that BM changes could be a sequel or a reservoir for HCV viremia.
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47
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Bournia VK, Vlachoyiannopoulos PG. Subgroups of Sjögren syndrome patients according to serological profiles. J Autoimmun 2012; 39:15-26. [PMID: 22575069 DOI: 10.1016/j.jaut.2012.03.001] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Sjögren Syndrome (SS) is a systemic, autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands. Different clinical associations have been described for each of the diverse autoantibodies found in SS patients. Antibodies directed against the Ro/La ribonucleoprotein complexes have been correlated with younger age, more severe dysfunction of the exocrine glands and a higher prevalence of extraglandular manifestations. Anti-nuclear antibodies and rheumatoid factors have been associated to extraglandular manifestations and an active immunological profile, while cryoglobulins are markers of more severe disease and correlate to lymphoma development and death. Antibodies to cyclic citrullinated peptides are scarce in SS and have been linked in some cases to the development of non-erosive arthritis. Furthermore, the presence of anti-mitochondrial antibodies and anti-smooth muscle antibodies in the sera of primary SS patients is considered indicative of primary biliary cirrhosis and autoimmune hepatitis, respectively. In addition, anti-centromere antibodies have been associated with a clinical phenotype intermediate between primary SS and systemic sclerosis, while antibodies against carbonic anhydrase have been related to renal tubular acidosis. Finally, an association of anti-muscarinic antibodies with cytopenias and a higher disease activity has also been described in primary SS. In conclusion, although not all of the above mentioned antibodies are useful for predicting distinct patient subgroups in SS, knowledge of the clinical associations of the different autoantibody specificities encountered in SS can advance our understanding of the disease and improve patient management.
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Affiliation(s)
- Vasiliki-Kalliopi Bournia
- Department of Pathophysiology, Medical School, University of Athens, Mikras Asias 75, 115 27 Athens, Greece
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Zaidan M, Mariotte E, Galicier L, Arnulf B, Meignin V, Vérine J, Mahr A, Azoulay É. Vasculitic emergencies in the intensive care unit: a special focus on cryoglobulinemic vasculitis. Ann Intensive Care 2012; 2:31. [PMID: 22812447 PMCID: PMC3488028 DOI: 10.1186/2110-5820-2-31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 06/24/2012] [Indexed: 12/25/2022] Open
Abstract
Vasculitis is characterized by the infiltration of vessel walls by inflammatory leukocytes with reactive damage and subsequent loss of vessel integrity. The clinical course of systemic vasculitis may be punctuated by acute life-threatening manifestations that require intensive care unit (ICU) admission. Furthermore, the diagnosis may be established in the ICU after admission for a severe inaugural symptom, mostly acute respiratory failure. Among the systemic vasculitides, cryoglobulinemic vasculitis (CV) has been rarely studied in an ICU setting. Severe CV-related complications may involve the kidneys, lungs, heart, gut, and/or central nervous system. The diagnosis of CV in the ICU may be delayed or completely unrecognized. A high level of suspicion is critical to obtain a timely and accurate diagnosis and to initiate appropriate treatment. We describe severe acute manifestations of CV based on six selected patients admitted to our ICU. That all six patients survived suggests the benefit of prompt ICU admission of patients with severe CV.
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Affiliation(s)
- Mohamad Zaidan
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Eric Mariotte
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Bertrand Arnulf
- Department of Immuno-Hematology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Véronique Meignin
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Jérôme Vérine
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Alfred Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Élie Azoulay
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France
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Payet J, Livartowski J, Kavian N, Chandesris O, Dupin N, Wallet N, Karras A, Salliot C, Suarez F, Avet-Loiseau H, Alyanakian MA, Nawakil CA, Park S, Tamburini J, Roux C, Bouscary D, Sparsa L. Type I cryoglobulinemia in multiple myeloma, a rare entity: analysis of clinical and biological characteristics of seven cases and review of the literature. Leuk Lymphoma 2012; 54:767-77. [DOI: 10.3109/10428194.2012.671481] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
Cryoglobulins are immunoglobulins that precipitate in vitro at temperatures less than 37°C and produce organ damage through two main pathways: vascular sludging (hyperviscosity syndrome, mainly in type I cryoglobulinaemia) and immune-mediated mechanisms (principally vasculitis, in mixed cryoglobulinaemia). Cryoglobulinaemia is associated with many illnesses, which can be broadly grouped into infections, autoimmune disorders, and malignancies; the most common cause is infection with hepatitis C virus. Mixed cryoglobulinaemic syndrome is diagnosed when a patient has typical organ involvement (mainly skin, kidney, or peripheral nerve) and circulating cryoglobulins. Cutaneous purpura is the most common manifestation of cryoglobulinaemic vasculitis. The most frequently affected internal organs are the peripheral nerves, kidneys, and joints. The course varies widely and prognosis is influenced by both cryoglobulinaemic damage to vital organs and by comorbidities associated with underlying diseases. More than 90% of cases of cryoglobulinaemia have a known underlying cause; therefore treatment is focused on the cause of the disorder rather than merely symptomatic relief. Studies suggest that both combined or sequential antiviral therapies and targeted biological treatments might be more effective than monotherapy.
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Affiliation(s)
- Manuel Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, Institut Clínic de Medicina I Dermatologia, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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