1
|
Reiberger T, Lens S, Cabibbo G, Nahon P, Zignego AL, Deterding K, Elsharkawy AM, Forns X. EASL position paper on clinical follow-up after HCV cure. J Hepatol 2024; 81:326-344. [PMID: 38845253 DOI: 10.1016/j.jhep.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/05/2024] [Indexed: 07/26/2024]
Abstract
Following the advent of direct-acting antivirals (DAAs), hepatitis C virus (HCV) infection can be cured in almost all infected patients. This has led to a number of clinical questions regarding the optimal management of the millions of patients cured of HCV. This position statement provides specific guidance on the appropriate follow-up after a sustained virological response in patients without advanced fibrosis, those with compensated advanced chronic liver disease, and those with decompensated cirrhosis. Guidance on hepatocellular carcinoma risk assessment and the management of extrahepatic manifestations of HCV is also provided. Finally, guidance is provided on the monitoring and treatment of reinfection in at-risk patients. The recommendations are based on the best available evidence and are intended to help healthcare professionals involved in the management of patients after treatment for HCV.
Collapse
Affiliation(s)
- Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria. CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Sabela Lens
- Liver Unit, Hospital Clinic Barcelona. IDIBAPS. Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd). University of Barcelona. Spain
| | - Giuseppe Cabibbo
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties PROMISE, University of Palermo, Italy
| | - Pierre Nahon
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Unit, Bobigny; Université Sorbonne Paris Nord, F-93000 Bobigny; Inserm, UMR-1138 "Functional Genomics of Solid Tumors", Centre de Recherche des Cordeliers, Université de Paris, France
| | - Anna Linda Zignego
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Katja Deterding
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School. Germany
| | - Ahmed M Elsharkawy
- Liver Unit, Queen Elizabeth Hospital Birmingham. NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham, United Kingdom
| | - Xavier Forns
- Liver Unit, Hospital Clinic Barcelona. IDIBAPS. Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd). University of Barcelona. Spain.
| |
Collapse
|
2
|
Kapoor M, Reddel SW. Ways to think about vasculitic neuropathy. Curr Opin Neurol 2024:00019052-990000000-00185. [PMID: 39046107 DOI: 10.1097/wco.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
PURPOSE OF REVIEW Vasculitis as a pathomechanism for neuropathy can be isolated to the peripheral nervous system, a part of a systemic autoimmune condition or a component of another syndrome. This review aims to discuss the broad range of diagnoses in which vasculitic neuropathy can be encountered, highlight the progress in imaging techniques in identifying vasculitis, and the new drugs developed for other autoimmune diseases that may be applied to neurological conditions. RECENT FINDINGS Advances in imaging modalities, ultrasound, MRI and FDG-PET scanning for neuromuscular applications has redefined many aspects of vasculitic neuropathies. The benefit of dividing vasculitides by vessel size is becoming less absolute as diagnostic approaches advance. MRI and FDG-PET are widely used in diagnosis, defining extent of involvement of disease and monitoring. In neuralgic amyotrophy, the identification of hourglass-like constrictions on imaging has changed the treatment paradigm to include surgical interventions. These diagnostic approaches are supported by new immunomodulating and immunosuppression techniques. SUMMARY Vasculitic neuropathies are a broad group of conditions with a range of causes and associations. Increased use of imaging techniques impacts our traditional definitions and classifications. The growth in treatment options for other autoimmune conditions are likely to infiltrate the neurological landscape.
Collapse
Affiliation(s)
- Mahima Kapoor
- Department of Neurosciences, Central Clinical School, Monash University, Alfred Centre, Melbourne, Victoria
| | - Stephen W Reddel
- ANZAC Research Institute, Central Clinical School, University of Sydney, Sydney, Australia
| |
Collapse
|
3
|
Wang B, Schub M, Robinson DL, Howell DN. Infection as a trigger of acute, transient glomerular deposition of clonal immunoglobulins. Ultrastruct Pathol 2024; 48:304-309. [PMID: 38752567 DOI: 10.1080/01913123.2024.2356112] [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: 04/04/2024] [Accepted: 05/13/2024] [Indexed: 07/02/2024]
Abstract
Glomerular deposition of monoclonal IgM, frequently in the form of intracapillary pseudothrombi, can be seen in Waldenström macroglobulinemia (WM) and type I cryoglobulinemia (CG). They are typically associated with plasma cell or B-lymphoid neoplasms, particularly lymphoplasmacytic lymphoma (LPL). While infection is a frequent trigger of mixed (type II and III) CG, its association with type I CG is uncommon. We report two cases in which striking lambda-chain-restricted IgM deposits and acute kidney injury (AKI) occurred in the setting of known or suspected systemic infections, with prompt resolution on treatment of the infection.
Collapse
Affiliation(s)
- Bangchen Wang
- Department of Pathology, Duke University, Durham, NC, USA
| | - Micah Schub
- Division of Nephrology, Department of Internal Medicine, Duke University, Durham, NC, USA
| | | | - David N Howell
- Department of Pathology, Duke University, Durham, NC, USA
| |
Collapse
|
4
|
Miao J, Herrmann SM, Obaidi Z, Caza T, Bonilla M. Paraprotein-Mediated Glomerular Diseases. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:358-373. [PMID: 39084761 DOI: 10.1053/j.akdh.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 08/02/2024]
Abstract
Paraproteinemias are a group of complex diseases associated with an overproduction of a monoclonal immunoglobulin that can cause a diversity of kidney disorders and end-organ damage. In this review, we focus on paraprotein-mediated glomerular diseases. Kidney biopsy plays a crucial role in diagnosing these disorders, enabling the identification of specific histological patterns. These lesions are categorized into organized (such as amyloidosis, immunotactoid glomerulopathy, fibrillary glomerulonephritis, cryoglobulinemic glomerulonephritis, and monoclonal crystalline glomerulopathies) and nonorganized deposits (such as monoclonal Ig deposition disease and proliferative glomerulonephritis with monoclonal Ig deposits) based on the characteristics of immunofluorescence findings and the ultrastructural appearance of deposits on electron microscopy. This review aims to provide an update, highlight, and discuss clinicopathological aspects such as definition, epidemiology, clinical manifestations, mechanisms of kidney injury, histological features, and diagnostic procedures.
Collapse
Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Zainab Obaidi
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL
| | | | - Marco Bonilla
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL.
| |
Collapse
|
5
|
Zhang M, Han Z, Lin Y, Jin Z, Zhou S, Wang S, Tang Y, Li J, Li X, Chen H. Understanding the relationship between HCV infection and progression of kidney disease. Front Microbiol 2024; 15:1418301. [PMID: 39006752 PMCID: PMC11239345 DOI: 10.3389/fmicb.2024.1418301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/18/2024] [Indexed: 07/16/2024] Open
Abstract
Hepatitis C virus (HCV) can cause a range of kidney diseases. HCV is the primary cause of mixed cryoglobulinaemia, which leads to cryoglobulinaemic vasculitis and cryoglobulinaemic glomerulonephritis (GN). Patients with acute cryoglobulinaemic vasculitis often exhibit acute kidney disease due to HCV infection, which typically progresses to acute kidney injury (AKI). HCV also increases the risk of chronic kidney disease (CKD) and the likelihood of developing end-stage renal disease (ESRD). Currently, direct-acting antiviral agents (DAAs) can be used to treat kidney disease at different stages. This review focuses on key findings regarding HCV and kidney disease, discusses the impact of DAAs, and highlights the need for further research and treatment.
Collapse
Affiliation(s)
- Meiqi Zhang
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhongyu Han
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Naniing Tongren Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yumeng Lin
- Naniing Tongren Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zi Jin
- Department of Anesthesiology and Pain Rehabilitation, Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
| | - Shuwei Zhou
- Jiangsu Key Laboratory of Molecular and Functional Imaging, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Siyu Wang
- Department of Gastroenterology, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Yuping Tang
- Hepatobiliary Department of the Third Affiliated Hospital of Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Jiaxuan Li
- School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Xueping Li
- School of Basic Medical Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Haoran Chen
- Department of General Surgery, Chengdu Xinhua Hospital Affiliated to North Sichuan Medical College, Chengdu, China
| |
Collapse
|
6
|
Dashjamts G, Ganzorig AE, Tsedendorj Y, Dondov G, Nergui O, Badamjav T, Huang CF, Liang PC, Lonjid T, Batsaikhan B, Dai CY. Post-Treatment Occurrence of Serum Cryoglobulinemia in Chronic Hepatitis C Patients. Diagnostics (Basel) 2024; 14:1188. [PMID: 38893714 PMCID: PMC11171999 DOI: 10.3390/diagnostics14111188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Persistent cryoglobulinemia after the completion of antiviral treatment is an important consideration of clinical management in chronic hepatitis C patients. We aimed to investigate the occurrence of serum cryoglobulinemia in chronic hepatitis C patients without cryoglobulinemia at the initiation of antiviral treatment. METHODS In total, 776 patients without cryoglobulinemia were assessed for serum cryoglobulinemia after the completion of anti-HCV treatment. Serum cryoglobulinemia precipitation was assessed upon both the initiation and the completion of the treatment and analyzed for the clinical laboratory factors associated with chronic hepatitis C. RESULTS One hundred eighteen (118) patients were checked for serum cryo-precipitation after the completion of the treatment, and eight patients (4.6%) were positive for serum cryoglobulinemia. The patients who tested positive for cryoglobulinemia included a higher proportion of liver cirrhosis patients (4/50%, p = 0.033) and other organ cancer patients (5/62.5%, p = 0.006) than patients who showed no signs of cryoglobulinemia after treatment. In a multivariate analysis, liver cirrhosis (odds ratio [OR]-17.86, 95% confidence interval [95% CI]-1.79-177.35, p = 0.014) and other organ cancer (OR-25.17 95% CI-2.59-244.23, p = 0.005) were independently and significantly associated with positive cryoglobulinemia 3 months after antiviral treatment. CONCLUSIONS Three months after the antiviral DAA therapy had concluded, eight patients tested positive for cryoglobulinemia, representing a 6.7% prevalence. Liver cirrhosis and other organ cancer were independently and significantly associated with positive cryoglobulinemia after antiviral treatment. Further investigation into the causes of positive cryoglobulinemia after DAA antiviral therapy is warranted.
Collapse
Affiliation(s)
- Gantogtokh Dashjamts
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Amin-Erdene Ganzorig
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Yumchinsuren Tsedendorj
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Ganchimeg Dondov
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Otgongerel Nergui
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Tegshjargal Badamjav
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
- Department of Biological Sciences, School of Life Sciences, Inner Mongolia University, Hohhot 010031, China
| | - Chung-Feng Huang
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Po-Cheng Liang
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Tulgaa Lonjid
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Batbold Batsaikhan
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
- Department of Health Research, Graduate School, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia
| | - Chia-Yen Dai
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Ph.D. Program in Environmental and Occupational Medicine, Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- College of Professional Studies, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan
| |
Collapse
|
7
|
Coorey CP, Aarabi A, Kumar K. Mixed cryoglobulinaemia vasculitis secondary to marginal zone lymphoma in a patient with end-stage renal failure on haemodialysis. CEN Case Rep 2024; 13:168-173. [PMID: 37801264 PMCID: PMC11144169 DOI: 10.1007/s13730-023-00823-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023] Open
Abstract
Cryoglobulinaemia vasculitis can present with a variety of symptoms and there is limited data on the incidence and presentation of cryoglobulinaemia vasculitis in haemodialysis patients. We report a case of a 63-year-old male who had a series of presentations with rash, visual changes, abdominal pain, weight loss, fevers and digital ischaemia. This is on a background of a congenital single kidney with end-stage renal failure secondary to diabetes and hypertension, receiving haemodialysis for nearly 5 years. He initially experienced a leukocytoclastic vasculitis rash confirmed on skin biopsy, followed by multiple hospital presentations for undifferentiated abdominal pain and fever of unknown source. Jejunal biopsy revealed intestinal vasculitis. His peripheral blood flow cytometry and bone marrow biopsy were consistent with marginal zone lymphoma (indolent subtype, IgM kappa clone). Further testing revealed a type II cryoglobulinaemia consisting of an IgM kappa monoclonal band with polyclonal IgG (cryocrit 5%). A diagnosis of cryoglobulinaemia vasculitis was established and he was treated with pulsed methylprednisolone and rituximab therapy. However, after receiving three doses of rituximab the patient developed a presumed vasculitis-associated pulmonary haemorrhage for which he received treatment with five sessions of plasma exchange. His symptoms resolved and cryocrit reduced to < 1% after his final dose of rituximab. The clinical features of cryoglobulinaemia may be difficult to detect in chronic haemodialysis patients and vigilance is required.
Collapse
Affiliation(s)
- Craig Peter Coorey
- Gosford Hospital, Gosford, New South Wales, Australia.
- School of Medicine, Western Sydney University, New South Wales, Australia.
| | | | - Karthik Kumar
- Gosford Hospital, Gosford, New South Wales, Australia
| |
Collapse
|
8
|
Li Y, Kong L. A case of diffuse large B-cell lymphoma with decompensated alcohol-related liver cirrhosis treated successfully by chemoimmunotherapy. Clin Case Rep 2024; 12:e8820. [PMID: 38659497 PMCID: PMC11039811 DOI: 10.1002/ccr3.8820] [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: 11/26/2023] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 04/26/2024] Open
Abstract
Key Clinical Message This report describes a case of diffuse large B-cell lymphoma with MYD88 L265P and KM2DT mutation and decompensated alcohol-related liver cirrhosis. And the treatment is successful in this patient, who had multiple complications and poor prognostic factors. Abstract This report describes a case of diffuse large B-cell lymphoma with MYD88 L265P and KM2DT mutation and decompensated alcohol-related liver cirrhosis. The lymphoma showed a complete response with no MYD88 L265P mutation after four courses of combination chemotherapy. Lymphoma is one of the most common malignant tumors, but cases of DLBCL with cirrhosis are much rarer especially with alcohol-related cirrhosis. And we reviewed the relevant mechanisms. Although we did not find a definite association between the pathogenesis of the patient's alcohol-related cirrhosis and that of diffuse large B-cell lymphoma, the treatment is successful in this patient, who had multiple complications and poor prognostic factors.
Collapse
Affiliation(s)
- Yan Li
- Department of HaematologyHebei General HospitalShijiazhuangHebeiPeople's Republic of China
| | - Ling‐zhijie Kong
- Department of HaematologyHebei General HospitalShijiazhuangHebeiPeople's Republic of China
- Department of Graduate SchoolHebei North UniversityZhangjiakouHebeiPeople's Republic of China
| |
Collapse
|
9
|
Ogrič M, Švec T, Poljšak KM, Lakota K, Podovšovnik E, Kolopp-Sarda MN, Hočevar A, Čučnik S. Insights into the immunological description of cryoglobulins with regard to detection and characterization in Slovenian rheumatological patients. Immunol Res 2024; 72:185-196. [PMID: 37993756 PMCID: PMC11031437 DOI: 10.1007/s12026-023-09434-9] [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: 09/29/2023] [Accepted: 11/06/2023] [Indexed: 11/24/2023]
Abstract
The detection of cryoglobulins (CG) used to diagnose cryoglobulinemic vasculitis requires strict adherence to protocol, with emphasis on the preanalytical part. Our main objectives were to introduce a more sensitive and specific protocol for the detection of CG and to characterize CG in Slovenian patients diagnosed with cryoglobulinemic vasculitis, other vasculitides, connective tissue diseases or non-rheumatic diseases examined at the Department of Rheumatology (University Medical Centre Ljubljana). Samples were routinely analyzed for the presence of CG with the protocol using the Folin-Ciocalteu reagent. In the newly introduced protocol, the type of CG was determined by immunofixation on visually observed positive samples and the concentration of CG in the cryoprecipitate and rheumatoid factor (RF) activity were measured by nephelometry. RF, C3c and C4 were measured in patients` serum and a decision tree analysis was performed using all results. The agreement between negative and positive results between the two protocols was 86%. Of the 258 patient samples tested, we found 56 patients (21.7%) with positive CG (37.5% - type II, 62.5% - type III). The RF activity was observed in 21.4% of CG positive subjects. The median concentration of type II CG was significantly higher than that of type III CG (67.4 mg/L vs. 45.0 mg/L, p = 0.037). Patients with type II had lower C4 concentrations and higher RF compared to patients with type III CG. In the decision tree, C4 was the strongest predictor of cryoglobulinemia in patients. With the newly implemented protocol, we were able to improve the detection and quantification of CG in the samples of our rheumatology patients and report the results to adequately support clinicians.
Collapse
Affiliation(s)
- Manca Ogrič
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tinka Švec
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katjuša Mrak Poljšak
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katja Lakota
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- FAMNIT, University of Primorska, Koper, Slovenia
| | | | - Marie Nathalie Kolopp-Sarda
- Immunogenomics and Inflammation Research, University of Lyon, Lyon, France
- Immunology Laboratory, University Hospital Lyon, Lyon, France
| | - Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Saša Čučnik
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia.
| |
Collapse
|
10
|
Luna-Ceron E, Kattamuri L, Vidal K, Aguirre-Vera GDJ, Lehker A. Unveiling Mixed Cryoglobulinemia in Suspected Sepsis Without a Source. Cureus 2024; 16:e57684. [PMID: 38707103 PMCID: PMC11070222 DOI: 10.7759/cureus.57684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/05/2024] [Indexed: 05/07/2024] Open
Abstract
Cryoglobulinemia is an uncommon condition characterized by the presence of cryoprecipitable immune complexes in circulation, leading to clinical symptoms like purpura, muscle weakness, and joint pain. Specifically, mixed cryoglobulinemia involves the formation of these complexes due to rheumatoid factors, mainly IgM, occasionally IgG or IgA. Previously, Hepatitis C (HCV) was a common cause of mixed cryoglobulinemia, as the chronic HCV infection triggered immune responses that resulted in cryoglobulin formation. However, the emergence of direct-acting antivirals (DAAs) for HCV treatment has shifted the landscape, with autoimmune and lymphoproliferative disorders becoming more prominent etiological factors for mixed cryoglobulinemia. This case report features a 67-year-old woman with a history of Hepatitis C-related cirrhosis. She presented at the emergency department with signs of septic shock and widespread joint pain, particularly in the knees, shoulders, and neck. Effective sepsis management was achieved using antibiotics, albumin infusion, and midodrine. Nonetheless, significant cervical and bilateral knee pain persisted. Further examination uncovered hypocomplementemia and positive results for rheumatoid factors (IgA, IgM, IgG) and cryoglobulin agglutination, confirming the diagnosis of mixed cryoglobulinemia. This case emphasizes the importance of considering mixed cryoglobulinemia in chronic Hepatitis C patients displaying fatigue and joint pain, even in the absence of the traditional clinical manifestations. Moreover, the case underscores the dual benefits of DAA treatment for Hepatitis C in individuals with mixed cryoglobulinemia by achieving viral eradication and alleviating cryoglobulinemia-related symptoms, thus preventing further organ damage.
Collapse
Affiliation(s)
- Eder Luna-Ceron
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Lakshmi Kattamuri
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Katherine Vidal
- Clinical Sciences, Escuela de Medicina y Ciencias de la Salud Tecnologico de Monterrey, Mexico, MEX
| | | | - Angelica Lehker
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| |
Collapse
|
11
|
Mehdipour Dalivand M, Woddor N, Makuria A, Aggarwal A, Nava VE. IgA plasma cell myeloma presenting as cold agglutinin-induced haemolytic transfusion reaction. BMJ Case Rep 2024; 17:e251638. [PMID: 38423573 PMCID: PMC10910471 DOI: 10.1136/bcr-2022-251638] [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] [Indexed: 03/02/2024] Open
Abstract
Cold agglutinins produced in the setting of B cell neoplasms, such as lymphoplasmacytic lymphoma and plasma cell myeloma, can mediate autoimmune haemolytic anemia. Transfusion of these patients can exacerbate cold agglutinin-mediated haemolysis. Moreover, the workup for these reactions represents a diagnostic challenge due in part to false negative direct antiglobulin tests (DATs). Here, we report an anaemic patient who after a red blood cell (RBC) transfusion performed without blood warming, experienced a DAT-negative haemolytic transfusion reaction, and was later diagnosed with IgA-multiple myeloma, which showed an uncommon granular pattern by CD138 immunohistochemistry. Extensive workup excluded other diagnostic possibilities, including the presence of Donath-Landsteiner antibodies and cryoglobulins. Successful treatment with CyBorD (cyclophosphamide, bortezomib and dexamethasone) achieved complete remission, and additional RBC transfusions using warmers were completed uneventfully.
Collapse
Affiliation(s)
- Maryam Mehdipour Dalivand
- Pathology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Navitha Woddor
- Pathology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Addisalem Makuria
- Department of Pathology, Brody School of Medicine, Greenville, NC, USA
| | - Anita Aggarwal
- Hematology and Oncology, DC VA Medical Center, Washington, District of Columbia, USA
| | - Victor Eduardo Nava
- Department of the Pathology, George Washington University Medical Faculty Associates, Washington, District of Columbia, USA
- Washington DC VA Medical Center, Washington, District of Columbia, USA
| |
Collapse
|
12
|
Kikuchi R, Onozawa M, Nagai J, Okada S, Hasegawa Y, Ohigashi H, Mitamura S, Maeda T, Takakuwa E, Fujieda Y, Goto H, Hashimoto D, Matsuno Y, Teshima T. Type 1 Cryoglobulinemic Vasculitis Due to Monoclonal Gammopathy of Undetermined Significance Successfully Treated by Bortezomib Plus Dexamethasone. Intern Med 2024; 63:541-545. [PMID: 37316269 PMCID: PMC10937136 DOI: 10.2169/internalmedicine.2053-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/10/2023] [Indexed: 06/16/2023] Open
Abstract
Cryoglobulins are immunoglobulins that precipitate in cold conditions. Type I cryoglobulinemic vasculitis is associated with hematological malignancies. We herein report a case of steroid-resistant type 1 cryoglobulinemic vasculitis associated with monoclonal gammopathy of undetermined significance (MGUS) in a 47-year-old woman. By immunofixation of cryoglobulin, we found that the main component of cryoglobulin was the M protein due to MGUS, so treatment of MGUS was needed. Bortezomib+dexamethasone therapy resulted in a rapid decrease in cryoglobulin and improvement in the symptoms of cryoglobulinemic vasculitis. In refractory type I cryoglobulinemic vasculitis, treatment of the underlying gammaglobulinopathy should be considered.
Collapse
Affiliation(s)
- Ryo Kikuchi
- Department of Hematology, Hokkaido University Hospital, Japan
| | | | - Jun Nagai
- Department of Hematology, Hokkaido University Hospital, Japan
| | - Satomi Okada
- Department of Hematology, Hokkaido University Hospital, Japan
| | - Yuta Hasegawa
- Department of Hematology, Hokkaido University Hospital, Japan
| | | | | | - Taku Maeda
- Division of Plastic Surgery, Hokkaido University Hospital, Japan
| | - Emi Takakuwa
- Department of Surgical Pathology, Hokkaido University Hospital, Japan
| | - Yuichiro Fujieda
- Department of Rheumatology and Nephrology, Hokkaido University Hospital, Japan
| | - Hideki Goto
- Department of Hematology, Hokkaido University Hospital, Japan
| | - Daigo Hashimoto
- Department of Hematology, Hokkaido University Hospital, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Japan
| | | |
Collapse
|
13
|
Dammacco R, Cimino L, De Simone L, Alessio G, Dammacco F. Ocular manifestations of cryoglobulinemia: a reappraisal. Eye (Lond) 2024; 38:585-593. [PMID: 37813978 PMCID: PMC10858169 DOI: 10.1038/s41433-023-02738-y] [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: 08/03/2022] [Revised: 05/15/2023] [Accepted: 09/08/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND/OBJECTIVES To describe frequency and type of ocular manifestations in patients with cryoglobulinemic vasculitis (CV), as well as management approaches and outcomes. SUBJECTS/METHODS This was a retrospective, observational, cohort study of patients who were diagnosed with CV at a single center and regularly underwent a comprehensive ocular assessment. RESULTS Ophthalmologic manifestations were recorded in 16 patients (28%). The diagnoses included dry eye disease and primary Sjögren syndrome in 5 and 2 patients, respectively; peripheral ulcerative keratitis and anterior scleritis in 1 patient each; hyperviscosity syndrome and hypertensive retinopathy in 2 patients each; and Purtscher- like retinopathy in 3 patients. Twelve patients (75%) were anti-HCV/HCV RNA-positive, 11 of whom achieved a sustained virologic response (SVR) following treatment with interferon-α2b plus ribavirin or direct-acting antivirals. All patients were treated with ocular lubricants. Systemic therapeutic measures, including glucocorticoids, immunosuppressive and biologic agents, induced the disappearance or ≥50% reduction of cryoglobulins and major signs of vasculitis in 11 patients (68.7%). In the remaining 5 patients (31.3%), cryoglobulins and CV manifestations remained unchanged or decreased by <50%. The corresponding ophthalmologic assessment showed a variable degree of improvement in the ocular symptoms in all but 2 patients (87.5%). The best corrected visual acuity following treatment improved in 26 eyes, was unchanged in 3 eyes, and worsened in 3 eyes. CONCLUSIONS Eye involvement is not a rare event in CV patients. A timely diagnosis and the correct employment of the available therapeutic measures may result in a favorable outcome of the ocular and extra-ocular manifestations.
Collapse
Affiliation(s)
- Rosanna Dammacco
- Department of Ophthalmology and Neuroscience, University of Bari "Aldo Moro", Medical School, Bari, Italy.
| | - Luca Cimino
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Ocular Immunology Unit, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Luca De Simone
- Ocular Immunology Unit, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Giovanni Alessio
- Department of Ophthalmology and Neuroscience, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Medical School, Bari, Italy
| |
Collapse
|
14
|
Verheyden MJ, Yu SP. A rare entity: Progressive multisystem involvement in type 1 cryoglobulinaemia. Australas J Dermatol 2024; 65:85-87. [PMID: 37997690 DOI: 10.1111/ajd.14191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/29/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Matthew J Verheyden
- Department of Rheumatology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Shirley P Yu
- Department of Rheumatology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Medicine, Sydney Musculoskeletal Health, The Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
15
|
Saha MK. Overview of Vasculitides in Adults. Neuroimaging Clin N Am 2024; 34:1-12. [PMID: 37951696 DOI: 10.1016/j.nic.2023.07.007] [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] [Indexed: 11/14/2023]
Abstract
Vasculitis is characterized by the inflammation of blood vessels. Vasculitides refers to the different forms of vasculitis, often classified according to the size of the blood vessel that is involved. Vasculitis may occur as a primary process or secondary to many systemic diseases. This topic provides an overview of the clinical features, diagnosis, and classification of the different forms of vasculitides.
Collapse
Affiliation(s)
- Manish K Saha
- Division of Nephrology, University of North Carolina, Chapel Hill, NC, USA.
| |
Collapse
|
16
|
Rose K, Iking-Konert C. [Secondary vasculitides]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:129-136. [PMID: 38265457 DOI: 10.1007/s00108-023-01654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
Vasculitides that occur in association with underlying primary diseases are called secondary vasculitides. In the diverse differential diagnostics of vasculitides, a large variety of secondary vasculitides have to be considered. Secondary vasculitides cover the full spectrum of vasculitides, presenting in manifold clinical manifestations. This article provides an overview of systemic diseases and etiological factors, such as infections, drugs, and malignancies, which can be associated with vasculitides. The possible associations with infectious agents are too numerous to be comprehensively covered and are discussed in an exemplary fashion and with a western European focus. Especially in atypical and refractory disease courses, a secondary vasculitis should be considered. In light of the diversity of differential diagnoses and the particular challenges posed by secondary vasculitides, interdisciplinary collaboration is the key for an accurate and early diagnosis as well as for successful treatment management. Treatment of the primary disease should always be prioritized and, if a drug-induced vasculitis is suspected, immediate cessation of the culprit drug is mandatory.
Collapse
Affiliation(s)
- Katharina Rose
- Abteilung für Rheumatologie, Stadtspital Zürich, Birmensdorferstraße 497, 8063, Zürich, Schweiz.
| | - Christof Iking-Konert
- Abteilung für Rheumatologie, Stadtspital Zürich, Birmensdorferstraße 497, 8063, Zürich, Schweiz
| |
Collapse
|
17
|
Ammendola S, Romeo S, Cattazzo F, Mantovani A, Ieluzzi D, Paon V, Montagnana M, Pecori S, Tomezzoli A, Dalbeni A, Sacerdoti D. Cholestatic HCV Cryoglobulinemia: A New Clinical and Pathological Entity before and after Direct-Acting Antiviral Therapies-A Case-Control Study. Int J Mol Sci 2024; 25:784. [PMID: 38255857 PMCID: PMC10815098 DOI: 10.3390/ijms25020784] [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: 11/26/2023] [Revised: 01/03/2024] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Twenty-nine patients with HCV infection (HCV+) and mixed cryoglobulinemia (MC+) were retrospectively selected and matched for age and sex with 31 HCV+ MC- patients. Biomarkers of cholestasis (direct bilirubin, alkaline phosphatase, and gamma-glutamyl transferase), HCV-RNA and genotype, and plasma cryoprecipitates were measured before and after virus eradication; liver histology and plasma cells (aggregation and distribution), observed blinded by two pathologists, were analyzed. Sixty participants (mean age: 56.5; range: 35-77, males: 50%) with HCV infection were enrolled. Cholestasis (≥2 pathologically increased cholestasis biomarkers) was significantly higher in the MC group (p = 0.02) and correlated with cryoglobulinemia (OR 6.52; p = 0.02). At liver histological assessment, plasma cells were significantly increased in the MC+ group (p = 0.004) and tended to form aggregates more than the control group (p = 0.05). At multivariate analysis with MC, age, HCV-RNA, HBV diabetes, and cirrhosis, cholestasis was only significantly correlated to MC (OR 8.30; p < 0.05). In 25% patients, MC persisted after virus eradication with new antiviral treatment. Our study identified for the first time an association between MC, cholestasis, and an increased number of intrahepatic plasma cells in chronic hepatitis C (CHC) patients before virus eradication. Future studies are required to understand how MC contributes to liver damage and how its persistence affects the patients' follow-up after antiviral therapies.
Collapse
Affiliation(s)
- Serena Ammendola
- Division of Pathology, Department of Diagnostics and Public Health, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.P.); (A.T.)
| | - Sara Romeo
- Division of General Medicine C, Department of Medicine, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.R.); (F.C.); (A.M.); (D.I.); (V.P.); (A.D.)
- Liver Unit, Department of Medicine, University of Verona, 37129 Verona, Italy;
| | - Filippo Cattazzo
- Division of General Medicine C, Department of Medicine, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.R.); (F.C.); (A.M.); (D.I.); (V.P.); (A.D.)
- Liver Unit, Department of Medicine, University of Verona, 37129 Verona, Italy;
| | - Anna Mantovani
- Division of General Medicine C, Department of Medicine, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.R.); (F.C.); (A.M.); (D.I.); (V.P.); (A.D.)
- Liver Unit, Department of Medicine, University of Verona, 37129 Verona, Italy;
| | - Donatella Ieluzzi
- Division of General Medicine C, Department of Medicine, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.R.); (F.C.); (A.M.); (D.I.); (V.P.); (A.D.)
- Liver Unit, Department of Medicine, University of Verona, 37129 Verona, Italy;
| | - Veronica Paon
- Division of General Medicine C, Department of Medicine, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.R.); (F.C.); (A.M.); (D.I.); (V.P.); (A.D.)
- Liver Unit, Department of Medicine, University of Verona, 37129 Verona, Italy;
| | - Martina Montagnana
- Section of Clinical Biochemistry, Department of Neurological, Biomedical and Movement Sciences, University of Verona, 37129 Verona, Italy;
| | - Sara Pecori
- Division of Pathology, Department of Diagnostics and Public Health, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.P.); (A.T.)
| | - Anna Tomezzoli
- Division of Pathology, Department of Diagnostics and Public Health, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.P.); (A.T.)
| | - Andrea Dalbeni
- Division of General Medicine C, Department of Medicine, Azienda Ospedaliera Universitaria Integrata of Verona, 37134 Verona, Italy; (S.R.); (F.C.); (A.M.); (D.I.); (V.P.); (A.D.)
- Liver Unit, Department of Medicine, University of Verona, 37129 Verona, Italy;
| | - David Sacerdoti
- Liver Unit, Department of Medicine, University of Verona, 37129 Verona, Italy;
| |
Collapse
|
18
|
Ponomarev AB, Pashayeva KR, Feyziyeva NY. [Comparative analysis of the development mechanisms of cryoglobulinemic vasculitis and Sjögren's syndrome]. Arkh Patol 2024; 86:52-56. [PMID: 38319273 DOI: 10.17116/patol20248601152] [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] [Indexed: 02/07/2024]
Abstract
Cryoglobulinemic vasculitis is a disease characterized by damage of small vessels and in some cases can be a manifestation of mixed cryoglobulinemia. Mixed cryoglobulinemia is a condition in which immunoglobulins in the blood serum form precipitates at temperatures below 37 °C and dissolve again when it rises. Currently, hepatitis C (HCV) is considered the most common etiological factor of mixed cryoglobulinemia. In addition, mixed cryoglobulinemia may be associated with other infectious agents, as well as autoimmune and lymphoproliferative diseases. In the absence of such association, we can talk about essential mixed cryoglobulinemia. To understand how different nosologies in their clinical and morphological picture lead to the development of mixed cryoglobulinemia, it is necessary to carefully analyze the mechanisms of the development of some of them, namely, HCV-associated cryoglobulinemic vasculitis and Sjögren's syndrome. It is noteworthy that mixed cryoglobulinemia in relation to Sjögren's syndrome can be perceived both as its consequence and as a manifestation of the underlying disease. Such an ambiguous nature of mixed cryoglobulinemia makes it currently impossible to select clear diagnostic criteria. For this reason, it is necessary to carry out a comparison between different immunopathogenesis of mixed cryoglobulinemia in order to identify the features that form its classical manifestations.
Collapse
Affiliation(s)
- A B Ponomarev
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - K R Pashayeva
- The Baku Branch, I.M. Sechenov First Moscow State Medical University, Baku, Azerbaijan
| | - N Yu Feyziyeva
- The Baku Branch, I.M. Sechenov First Moscow State Medical University, Baku, Azerbaijan
| |
Collapse
|
19
|
De La Flor JC, Sulca JDM, Rodríguez P, Villa D, Sandoval E, Zamora R, Monroy-Condori M, Lipa R, Perez H, Cieza M. Waldenström's Macroglobulinemia and Cryoglobulinemic Glomerulonephritis: An Unusual Case of Monoclonal Gammopathy of Renal Significance. Med Sci (Basel) 2023; 11:77. [PMID: 38132918 PMCID: PMC10744997 DOI: 10.3390/medsci11040077] [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: 10/16/2023] [Revised: 11/10/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Cryoglobulins are immunoglobulins that precipitate at temperatures below 37 °C and dissolve upon reheating. They can induce small-vessel vasculitis with renal involvement. Cryoglobulinemic glomerulonephritis is a rare manifestation that occurs in patients with monoclonal gammopathy, specifically Waldenström's macroglobulinemia. We present the case of a 52-year-old patient with a history of cutaneous vasculitis and hypothyroidism, who presented with generalized edema, moderate anemia, hypercholesterolemia, nephrotic range proteinuria of 12.69 g/day, microhematuria, arterial hypertension, and hypocomplementemia via the classical pathway, without acute kidney injury and with negative serological studies and positive cryoglobulins in the second determination. Serum and urine protein electrophoresis and immunofixation studies showed a monoclonal band of IgM and kappa light chain. Renal biopsy was consistent with cryoglobulinemic glomerulonephritis. In the context of dysproteinemia and cryoglobulinemic glomerulonephritis, bone-marrow aspiration and biopsy were performed, leading to the diagnosis of Waldenström's macroglobulinemia. Monoclonal gammopathies have been described in association with type I cryoglobulinemias. This described association is uncommon, which is why we present this case, along with a review of the literature.
Collapse
Affiliation(s)
- José C. De La Flor
- Department of Nephrology, Hospital Central Defense Gomez Ulla, 28047 Madrid, Spain
| | - Jesús de María Sulca
- Department of Nephrology, Hospital Cayetano Heredia, Lima 15002, Peru; (J.d.M.S.); (H.P.); (M.C.)
| | - Pablo Rodríguez
- Department of Nephrology, Guadalajara Center Dialysis, AVERICUM, 19003 Guadalajara, Spain;
| | - Daniel Villa
- Department of Nephrology, Clínica Universidad de Navarra, 31008 Navarra, Spain;
| | - Edna Sandoval
- Department of Hematology, Hospital Central Defense Gomez Ulla, 28047 Madrid, Spain;
| | - Rocío Zamora
- Department of Nephrology, Hospital Universitario General Villalba, 28400 Madrid, Spain;
| | - Maribel Monroy-Condori
- Department of Nephrology, Hospital General Universitario Nuestra Señora del Prado, 45600 Talavera de la Reina, Spain;
| | - Roxana Lipa
- Department of Anatomical Pathology, Instituto Nacional de Salud del Niño-San Borja, Lima 15037, Peru;
| | - Henry Perez
- Department of Nephrology, Hospital Cayetano Heredia, Lima 15002, Peru; (J.d.M.S.); (H.P.); (M.C.)
| | - Michael Cieza
- Department of Nephrology, Hospital Cayetano Heredia, Lima 15002, Peru; (J.d.M.S.); (H.P.); (M.C.)
| |
Collapse
|
20
|
Zhong JL, Zhao LW, Chen YH, Luo YW. Acute-on-chronic liver failure induced by antiviral therapy for chronic hepatitis C: A case report. World J Clin Cases 2023; 11:7463-7468. [PMID: 37969459 PMCID: PMC10643071 DOI: 10.12998/wjcc.v11.i30.7463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/30/2023] [Accepted: 09/26/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND There have been no reports of acute-on-chronic liver failure (ACLF) during treatment of chronic hepatitis C (CHC) with direct-acting antivirals (DAAs). CASE SUMMARY We report a 50-year-old male patient with CHC. The patient sought medical attention from the Department of Infectious Diseases at our hospital due to severe yellowing of the skin and sclera, which developed 3 mo previously and attended two consecutive hospitals without finding the cause of liver damage. It was not until 1 mo ago that he was diagnosed with CHC at our hospital. After discharge, he was treated with DAAs. During treatment, ACLF occurred, and timely measures such as liver protection, enzyme lowering, anti-infective treatment, and suppression of inflammatory storms were implemented to control the condition. CONCLUSION DAA drugs significantly improve the cure rate of CHC. However, when patients have factors such as autoimmune attack, coinfection, or unclear hepatitis C virus genotype, close monitoring is required during DAA treatment.
Collapse
Affiliation(s)
- Jiang-Li Zhong
- Department of Infectious Diseases, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ling-Wei Zhao
- Department of Hematology, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ying-Hua Chen
- Department of Infectious Diseases, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ya-Wen Luo
- Department of Infectious Diseases, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| |
Collapse
|
21
|
Miao J, Krisanapan P, Tangpanithandee S, Thongprayoon C, Cheungpasitporn W. Efficacy of Therapeutic Apheresis for Cryoglobulinemic Vasculitis Patients with Renal Involvement: A Systematic Review. Blood Purif 2023; 53:1-9. [PMID: 37852193 DOI: 10.1159/000534102] [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: 05/22/2023] [Accepted: 09/10/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Therapeutic apheresis (TA) is commonly used for cryoglobulinemic vasculitis (CV) patients, but its efficacy remains uncertain. This systematic review aimed to assess the efficacy of different TA modalities, such as plasma exchange (PE), plasmapheresis (PP), and cryofiltration (CF), in treating CV patients with renal involvement. METHODS Literature search of MEDLINE, EMBASE, and Cochrane Databases was conducted up to December 2022. Studies that reported the outcomes of TA in adult CV patients with renal involvement were assessed. The protocol for this systematic review has been registered with PROSPERO (No. CRD42023417727). The quality of each study was evaluated by the investigators using the validated methodological index for non-randomized studies (minors) quality score. RESULTS 154 patients who encountered 170 episodes of serious events necessitating TA were evaluated across 76 studies. Among them, 51% were males, with a mean age ranging from 49 to 58 years. The CV types included 15 type I, 97 type II, and 13 type III, while the remaining patients exhibited mixed (n = 17) or undetermined CV types (n = 12). Among the treatment modalities, PE, PP, and CF were performed in 85 (56%), 52 (34%), and 17 patients (11%), respectively, with no identical protocol for TA treatment. The overall response rate for TA was 78%, with response rates of 84%, 77%, and 75% observed in type I, II, and III patients respectively. Most patients received steroids, immunosuppressants, and treatment targeting the underlying causative disease. The overall long-term renal outcome rate was 77%, with type I, II, and III patients experiencing response rates of 89%, 76%, and 90%, respectively. The renal outcomes in patients receiving PE, PP, and CF were comparable, with rates of 78%, 76%, and 81%, respectively. CONCLUSIONS This study presents compelling evidence that combination of TA with other treatments, especially immunosuppressive therapy, is a successful strategy for effectively managing severe renal involvement in CV patients. Among the TA modalities studied, including PE, PP, and CF, all demonstrated efficacy, with PE being the most frequently employed approach.
Collapse
Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA,
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
- Division of Nephrology, Department of Internal Medicine, Thammasat University Hospital, Pathum Thani, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
22
|
Leleux C, Zerbib Y, Pommerolle P, Da Rocha A, Serpier M, Caillard P. Rare manifestations of cryoglobulinemic vasculitis: a case report. Front Immunol 2023; 14:1271584. [PMID: 37901234 PMCID: PMC10611471 DOI: 10.3389/fimmu.2023.1271584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Cryoglobulinemic vasculitis is a type of small vessel vasculitis diseases that can cause dysfunction in multiple organs. It is characterized by general symptoms, often accompanied by nonspecific cutaneous, articular, neurological, and renal manifestations. Diagnosing cryoglobulinemia through biological testing can be time-consuming and sometimes yields negative results, making diagnosis challenging. There are also other potentially life-threatening complications that can significantly impact prognosis and delay urgent treatment, including digestive manifestations and heart failure. Case presentation We report the case of a 60-year-old male patient with a medical history of rheumatoid arthritis. He was admitted to the Nephrology Department for investigation of necrotic vascular purpura, acute kidney injury, and pancytopenia. Laboratory tests revealed consumption of the C3 and C4 complement fractions and the presence of mixed-type III cryoglobulinemia. Despite the initiation of the treatment, the patient rapidly developed multiple severe organ failures, including renal, cardiac, respiratory, and finally digestive complications. Acute colic ischemia led to emergency surgery and the patient was transferred to the Intensive Care Unit. Despite surgical intervention and hemodynamic support, the patient experienced multi-visceral organ failure and died two hours after admission. Discussion Mixed cryoglobulinemia vasculitis may result in rare cases of acute and life-threatening organ damage, such as cardiac or respiratory failure with pulmonary hemorrhage, gastrointestinal ischemia, and neurological disorders. These severe manifestations are associated with a poor prognosis and it is crucial to promptly initiate an aggressive therapeutic strategy.
Collapse
Affiliation(s)
- Charlotte Leleux
- Department of Internal Medicine, Amiens University Hospital, Amiens, France
| | - Yoann Zerbib
- Department of Intensive Care Unit, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| | - Pierre Pommerolle
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| | - Audrey Da Rocha
- Department of Hematology, Amiens University Hospital, Amiens, France
| | - Marine Serpier
- Department of Internal Medicine, Amiens University Hospital, Amiens, France
| | - Pauline Caillard
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| |
Collapse
|
23
|
Edmiston M, Darehzereshki A, Badhwar V, Mehaffey JH. Perioperative management of cryoglobulinemia in patients requiring cardiac surgery. JTCVS Tech 2023; 21:92-94. [PMID: 37854811 PMCID: PMC10580163 DOI: 10.1016/j.xjtc.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Michael Edmiston
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Ali Darehzereshki
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - J. Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| |
Collapse
|
24
|
Punchoo R. Through the looking crystal: clarifying the pathogenesis and laboratory work-up of cryocrystalglobulinaemia. J Clin Pathol 2023; 76:658. [PMID: 34893519 DOI: 10.1136/jclinpath-2021-207585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/08/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Rivak Punchoo
- Chemical Pathology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Chemical Pathology, Tshwane Academic Divsion, National Health Laboratory Service, Pretoria, South Africa
| |
Collapse
|
25
|
Guenther A, Tierens A, Malecka A, Delabie J. The Histopathology of Cold Agglutinin Disease-Associated B-Cell Lymphoproliferative Disease. Am J Clin Pathol 2023; 160:229-237. [PMID: 37253147 DOI: 10.1093/ajcp/aqad048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/17/2023] [Indexed: 06/01/2023] Open
Abstract
OBJECTIVES Primary cold agglutinin disease is a type of autoimmune hemolytic anemia caused by circulating antibodies against I antigen, a carbohydrate expressed on most cells, including red blood cells. The underlying disease has been characterized in recent years as a distinct B-cell lymphoproliferative disease of the bone marrow, occurring mostly in the elderly. The disease has been now been included as a separate entity in the most recent classifications of mature B-cell neoplasms. METHODS A review of the characteristics of cold agglutinin disease is provided, with an emphasis on the pathology features. RESULTS A detailed description of the histopathology, immunophenotype, and genetics of cold agglutinin disease is provided and compared to other B-cell lymphoproliferative diseases in the bone marrow with similar features. CONCLUSIONS Recognition of the pathology features of cold agglutinin disease allows to distinguish it from other diseases, especially lymphoplasmacytic lymphoma and marginal zone lymphoma.
Collapse
Affiliation(s)
- Angela Guenther
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Canada
| | - Anne Tierens
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Canada
| | | | - Jan Delabie
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Canada
| |
Collapse
|
26
|
Othman AM, Al-Hnhna AA, Al-Huraibi BS, Assayaghi RM, Al-Qahtani TY, Jahzar KH, Al-Huthaifi MM. Prevalence of hepatitis C virus among patients with arthralgia: is it logic for screening? Virol J 2023; 20:162. [PMID: 37480120 PMCID: PMC10360329 DOI: 10.1186/s12985-023-02124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) is well-known to be associated with multiple extrahepatic manifestations such as arthralgia, myalgia, arthritis, and vasculitis. Many studies reported frequent rheumatologic manifestations among patients infected by HCV. The purpose of this study was to determine the prevalence of HCV among chronic unexplained arthralgia patients in order to aid in the early detection and treatment of silent HCV infection. METHODS This study was a cross-sectional observational study conducted from July 2020 to May 2022. It included 145 individuals suffering from chronic unexplained arthralgia, with vast majority having oligoarticular joint pain (110, 75.9%). They were 103 (71%) females and 42 (29%) males. Serum samples from all patients were examined for the presence of anti-HCV antibodies using a rapid immunochromatographic assay. Seropositive samples were further examined using polymerase chain reaction (PCR) for detection of HCV RNA to confirm HCV infection. RESULTS Out of 145 patients who complained of arthralgia, seven patients tested positive for anti-HCV with a seroprevalence of 4.8% while five patients tested positive for HCV-RNA with a molecular prevalence of 3.4%. All positive patients were males (11.9%) with high statistical significance (χ2 = 12.7 and p = 0.002). No association was found between HCV infection and age, blood transfusion, surgery, using personal shaving tools, or being a health-care worker. CONCLUSIONS The prevalence of HCV was high among males who complained of arthralgia. Patients with arthralgia, especially male patients, are recommended to perform HCV screening test.
Collapse
Affiliation(s)
- Arwa Mohammed Othman
- Microbiology and Immunology Department, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen.
| | - Asma'a Ahmed Al-Hnhna
- Gastroenterology and Hepatology, Medicine department, 21 September University, Sana'a, Yemen
| | - Belques Sharaf Al-Huraibi
- Microbiology and Immunology Department, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a-Yemen, Yemen
| | - Rowa Mohammed Assayaghi
- Microbiology and Immunology Department, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a-Yemen, Yemen
| | - Talal Yahya Al-Qahtani
- Microbiology and Immunology Department, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a-Yemen, Yemen
| | - Kamal Hamoud Jahzar
- Biomedical sciences department, Lebanese International University, Sana'a Compass, Yemen
| | - Marwan Mohammed Al-Huthaifi
- Microbiology and Immunology Department, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a-Yemen, Yemen
| |
Collapse
|
27
|
Roma K, Chandler TM, Dossaji Z, Patel A, Gupta K, Minacapelli CD, Rustgi V, Gish R. A Review of the Systemic Manifestations of Hepatitis B Virus Infection, Hepatitis D Virus, Hepatocellular Carcinoma, and Emerging Therapies. GASTRO HEP ADVANCES 2023; 3:276-291. [PMID: 39129946 PMCID: PMC11308766 DOI: 10.1016/j.gastha.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/26/2023] [Indexed: 08/13/2024]
Abstract
Chronic hepatitis B virus (HBV) infection affects about 262 million people worldwide, leading to over 820,000 deaths each year primarily due to cirrhosis and hepatocellular carcinoma. The World Health Organization has pledged to eliminate HBV as a health threat by 2030, but currently, no countries are on track to achieve this goal. One of the barriers to HBV elimination is stigma, causing shame, denial, self-isolation, self-rejection, and depression leading to those with chronic HBV less likely to get tested or seek treatment and more likely to conceal their infection. Other barriers include limited access to care and complicated and restrictive clinical practice guidelines. Increasing public and political efforts are necessary to raise awareness, increase access to care, and change screening and treatment guidelines. The current guidance of the American Association for the Study of Liver Diseases (AASLD) recommends testing only if patients are considered at risk, but this has proven to be ineffective. We propose a simplified "test all and treat all" approach with a 5-line guideline for HBV infection. Universal screening and treatment of adults is cost-effective and can prevent transmission by effectively managing chronic HBV. All patients who are hepatitis B surface antigen (HBsAg) positive with detectable HBV-DNA should receive treatment until HBsAg is undetectable for 12 months, as HBV-DNA transmission via blood transfusion can occur even at low viral loads of 16 copies/mL, and mother-to-child transmission is still a risk even with passive-active immunoprophylaxis. Furthermore, clinical outcomes after HBsAg clearance are significantly better than the clinical outcomes of those who remain HBsAg positive.
Collapse
Affiliation(s)
- Katerina Roma
- Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Nevada
| | - Toni-Marie Chandler
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Zahra Dossaji
- Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Nevada
| | - Ankoor Patel
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, New Jersey
| | - Kapil Gupta
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Carlos D. Minacapelli
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
- Center for Liver Diseases and Masses, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Vinod Rustgi
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
- Center for Liver Diseases and Masses, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Robert Gish
- Hepatitis B Foundation, Doylestown, Pennsylvania
| |
Collapse
|
28
|
Treppo E, Quartuccio L, De Vita S. Recent updates in the diagnosis and management of cryoglobulinemic vasculitis. Expert Rev Clin Immunol 2023; 19:1457-1467. [PMID: 37698547 DOI: 10.1080/1744666x.2023.2249609] [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: 04/27/2023] [Accepted: 08/15/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Cryoglobulinemic vasculitis (CV), also known as mixed cryoglobulinemic syndrome (MCS), is a systemic vasculitis that affects small blood vessels. It exhibits a wide range of clinical manifestations, making its treatment a continuing challenge for physicians. AREAS COVERED We conducted a comprehensive review to evaluate the current status of diagnosis, management, and treatment of mixed cryoglobulinemia (MC). The accurate clinical and serological evaluation plays a vital role in diagnosing MC, identifying potential comorbidities, and monitoring its main manifestations and complications. Treatment strategies should be individualized based on the underlying etiopathogenesis, the severity of organ involvement, and the associated underlying disease. At present, the two mainstays of CV treatment are direct antiviral agents (for HCV-related CV) and B-cell-targeted therapy. EXPERT OPINION MC remains one of the few autoimmune diseases where the etiology is known, at least for the majority of patients. Its pathogenetic mechanism offers a unique opportunity to investigate the interplay between infections and the immune system. Moving forward, the primary challenge will continue to lie in the treatment of resistant or refractory cases of CV, particularly those associated with autoimmune diseases, or cases classified as 'essential' CV.
Collapse
Affiliation(s)
- Elena Treppo
- Rheumatology Unit, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
| | - Luca Quartuccio
- Rheumatology Unit, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
| | - Salvatore De Vita
- Rheumatology Unit, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
| |
Collapse
|
29
|
Ashruf OS, Mirzai S, George LL, Anwer F. Beyond monoclonal gammopathy of undetermined significance, clinical spectrum of immunoglobulin M gammopathy: a case series with focus on the diagnostic and management challenges. Int J Hematol Oncol 2023; 12:IJH44. [PMID: 37304326 PMCID: PMC10248588 DOI: 10.2217/ijh-2022-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/30/2023] [Indexed: 06/13/2023] Open
Abstract
Immunoglobulin M monoclonal gammopathy is detected in Waldenström macroglobulinemia (WM), a rare lymphoplasmacytic lymphoma with serum immunoglobulin M. We report three rare presentations with focus on diagnostic and management challenges of type I cryoglobulinemia, type II cryoglobulinemia, and Bing-Neel syndrome. In approximately 10% of WM cases, macroglobulins can precipitate to cryoglobulins. Type I and II cryoglobulinemia, representing 10-15% and 50-60% of WM cases, respectively, present with vasculitis and renal failure. Bing-Neel syndrome, representing 1% of WM patients, is a rare neurological complication with lymphoplasmacytic infiltration in the brain. WM diagnosis includes bone marrow biopsy, immunophenotypic analysis, and MYD88 L265P mutation. We initiated management of cryoglobulinemia with dexamethasone, rituximab, and cyclophosphamide; in Bing-Neel, bortezomib and dexamethasone, followed by a Bruton tyrosine kinase inhibitor.
Collapse
Affiliation(s)
- Omer S Ashruf
- Northeast Ohio Medical University, Rootstown, OH 44139, USA
| | - Saeid Mirzai
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Laeth L George
- Division of Hematology & Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Faiz Anwer
- Division of Hematology & Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| |
Collapse
|
30
|
Rossotti R, Merli M, Baiguera C, Bana NB, Rezzonico LF, D'Amico F, Raimondi A, Moioli MC, Chianura LG, Puoti M. Impact of treatment with direct-acting antivirals on inflammatory markers and autoantibodies in HIV/HCV co-infected individuals. J Viral Hepat 2023; 30:530-539. [PMID: 36773329 DOI: 10.1111/jvh.13818] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/22/2022] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
HCV infection could have extrahepatic manifestations due to an aberrant immune response. HCV/HIV co-infection increases such persistent immune activation. Aim of the present study is to describe the evolution of inflammatory markers used in clinical practice, mixed cryoglobulinemia (MC) and autoantibody reactivity in co-infected individuals who achieved sustained virological response (SVR) after DAA treatment. This prospective, observational study included all HIV/HCV co-infected subjects who started any DAA regimen from 2015 to 2020. Samples for laboratory measurements (ferritin, C reactive protein, C3 and C4 fractions, rheumatoid factor, MC, anti-thyroglobulin Ab, anti-thyroid peroxidase Ab, ANCA, ASMA, anti-LKM, anti-DNA, AMA, ANA, T CD4+ and CD8+ cell count, and CD4/CD8 ratio) were collected at baseline, after 4 weeks, at end of treatment, and at SVR12. The analysis included 129 individuals: 51.9% with a F0-F3 fibrosis and 48.1% with liver cirrhosis. Cryocrit, C3 fraction, and rheumatoid factor significantly improved at week 4; ferritin, anti-thyroglobulin Ab, and C4 fraction at EOT; total leukocytes count at SVR12. MC positivity decreased from 72.8% to 35.8% (p < .001). T CD4+ cell slightly increased at SVR12, but with an increase also in CD8+ resulting in stable CD4/CD8 ratio. Autoantibody reactivity did not change significantly. ANA rods and rings positivity increased from 14.8% to 28.6% (p = .099): they were observed in three subjects without exposure to RBV. DAA therapy may lead to improvement in inflammatory markers and MC clearance but without significant changes in autoantibodies reactivity and CD4/CD8 ratio over a follow up of 12 weeks.
Collapse
Affiliation(s)
- Roberto Rossotti
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Merli
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Baiguera
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nicholas Brian Bana
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine, University of Milan-Bicocca, Milan, Italy
| | - Leonardo Francesco Rezzonico
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine, University of Pavia, Pavia, Italy
| | - Federico D'Amico
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Raimondi
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Cristina Moioli
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Massimo Puoti
- Department of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine, University of Milan-Bicocca, Milan, Italy
| |
Collapse
|
31
|
Ghembaza A, Boleto G, Bommelaer M, Karras A, Javaugue V, Bridoux F, Alyanakian MA, Molinier Frenkel V, Ghillani-Dalbin P, Musset L, Barete S, Roosweil D, Choquet S, Le Joncour A, Mirouse A, Lipsker D, Faguer S, Vieira M, Cacoub P, Biard L, Saadoun D. Prognosis and long-term outcomes in type I cryoglobulinemia: A multicenter study of 168 patients. Am J Hematol 2023. [PMID: 37139676 DOI: 10.1002/ajh.26944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/05/2023]
Abstract
Type I cryoglobulinemia (CG) accounts for 10%-15% of all cryoglobulinemias and are exclusively seen in clonal proliferative hematologic conditions. In this multicenter nationwide cohort study, we analyzed the prognosis and long-term outcomes of 168 patients with type I CG (93 (55.4%) IgM and 75 [44.6%] IgG). Five- and 10-year event-free survivals (EFS) were 26.5% (95% CI 18.2%-38.4%) and 20.8% (95% CI 13.1%-33.1%), respectively. In multivariable analysis, factors associated with poorer EFS were renal involvement (HR: 2.42, 95% CI 1.41-4.17, p = .001) and IgG type I CG (HR: 1.96, 95% CI 1.13-3.33, p = 0.016), regardless of underlying hematological disorders. IgG type I CG patients had higher cumulative incidence of relapse (94.6% [95% CI 57.8%-99.4%] vs. 56.6% [95% CI 36.6%-72.4%], p = .0002) and death at 10 years (35.8% [19.8%-64.6%] vs. 71.3% [54.0%-94.2%], p = .01) as compared to IgM CG, respectively. Overall, complete response of type I CG at 6 months was 38.7%, with no significant difference between Igs isotypes. In conclusion, renal involvement and IgG CG were identified as independent poor prognostic factors of type I CG.
Collapse
Affiliation(s)
- Amine Ghembaza
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Gonçalo Boleto
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Instituto Português de Reumatologia, Lisbon, Portugal
| | - Marin Bommelaer
- Service de Biostatistique et Information Médicale, AP-HP Hôpital Saint-Louis - INSERM, UMR1153, Paris, France
| | - Alexandre Karras
- Département de néphrologie, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Vincent Javaugue
- Service de néphrologie et Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France
| | - Frank Bridoux
- Service de néphrologie et Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France
| | - Marie-Alexandra Alyanakian
- Laboratoire d'immunologie, Hôpital Necker-Enfants Malades, AP-HP et Institut Necker-Enfants malades (INEM), Paris, France
| | | | | | - Lucile Musset
- Laboratoire d'immunochimie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Stéphane Barete
- Unité fonctionnelle de dermatologie, service de médecine interne, Hôpital Pitié-Salpêtrière, Paris, France
| | - Damien Roosweil
- Service d'hématologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sylvain Choquet
- Service d'hématologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexandre Le Joncour
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Adrien Mirouse
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Dan Lipsker
- Clinique dermatologique, Université de Strasbourg, Strasbourg, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Hôpital Rangueil, Institut National de la Santé et de la Recherche Médicale, UMR 1297, Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Matheus Vieira
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Patrice Cacoub
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Lucie Biard
- Service de Biostatistique et Information Médicale, AP-HP Hôpital Saint-Louis - INSERM, UMR1153, Paris, France
| | - David Saadoun
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| |
Collapse
|
32
|
Yang X, Jiao C, Liu X, Zhang Y, Zhou H, Wang Y. Coexistence of cryoglobulinemia and ANCA-associated vasculitis in a chronic brucellosis patient -a case report and literature review. BMC Infect Dis 2023; 23:272. [PMID: 37131122 PMCID: PMC10152744 DOI: 10.1186/s12879-023-08232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/06/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND The renal involvement of brucellosis is not common. Here we reported a rare case of chronic brucellosis accompanied by nephritic syndrome, acute kidney injury, the coexistence of cryoglobulinemia and antineutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) superimposed on iliac aortic stent implantation. The diagnosis and treatment of the case are instructive. CASE PRESENTATION A 49-year-old man with hypertension and iliac aortic stent implantation was admitted for unexplained renal failure with signs of nephritic syndrome, congestive heart failure, moderate anemia and livedoid change in the left sole with pain. His past history included chronic brucellosis and he just underwent the recurrence and completed the 6 weeks of antibiotics treatment. He demonstrated positive cytoplasmic/proteinase 3 ANCA, mixed type cryoglobulinemia and decreased C3. The kidney biopsy revealed endocapillary proliferative glomerulonephritis with a small amount of crescent formation. Immunofluorescence staining revealed only C3-positive staining. In accordance with clinical and laboratory findings, post-infective acute glomerulonephritis superimposed with AAV was diagnosed. The patient was treated with corticosteroids and antibiotics and sustained alleviation of renal function and brucellosis was achieved during the course of a 3-month follow-up. CONCLUSIONS Here we describe the diagnostic and treatment challenge in a patient with chronic brucellosis related glomerulonephritis accompanied by the coexistence of AAV and cryoglobulinemia. Renal biopsy confirmed the diagnosis of postinfectious acute glomerulonephritis overlapping with ANCA related crescentic glomerulonephritis, which was not ever reported in the literature. The patient showed a good response to steroid treatment which indicated the immunity-induced kidney injury. Meanwhile, it is essential to recognize and actively treat the coexisting brucellosis even when there are no clinical signs of the active stage of infection. This is the critical point for a salutary patient outcome for brucellosis associated renal complications.
Collapse
Affiliation(s)
- Xu Yang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Congcong Jiao
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Xiaomei Liu
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Yongzhe Zhang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Hua Zhou
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Yanqiu Wang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China.
| |
Collapse
|
33
|
Wang HY, Robson DC, Kim SJ. Annular vasculitic lesions. Clin Dermatol 2023; 41:326-339. [PMID: 37423264 DOI: 10.1016/j.clindermatol.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Vasculitic skin findings may present with annular morphologies. This group of conditions consists of capillaritis, such as pigmented purpuric dermatoses, and vasculitis, which is often classified by the affected vessel size. Annular vasculitic lesions may be the presenting sign of systemic disease, thus requiring thorough exploration to reach an accurate diagnosis and guide proper disease management. Herein we review the clinical presentation, histopathology, and treatments for cutaneous vasculitic disease that may present with annular lesions.
Collapse
Affiliation(s)
| | | | - Soo Jung Kim
- Department of Dermatology, Baylor College of Medicine, Houston, Texas, USA.
| |
Collapse
|
34
|
Stoyanov A, Toong C, Kong Y, Chen R, Urriola N. Serum protein electrophoresis and rheumatoid factor analysis is an effective screening strategy for cryoglobulinaemia. Pathology 2023; 55:391-396. [PMID: 36494206 DOI: 10.1016/j.pathol.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/05/2022] [Accepted: 09/06/2022] [Indexed: 11/15/2022]
Abstract
Accurate serum cryoglobulin detection is important to allow prompt treatment but laboratory testing requires stringent pre-analytical conditions and has long turnaround times. Serum protein electrophoresis (EPG) for paraproteinaemia and rheumatoid factor (RF) analysis may offer an effective initial screening strategy for the presence of cryoglobulinaemia. We retrospectively assessed the sensitivity of ancillary EPG and RF testing for the presence of serum cryoglobulinaemia in 586 eligible cryoglobulin positive samples received at the Royal Prince Alfred and Liverpool Hospital immunopathology laboratories over an 11-year period. Ninety-one percent of all cryoglobulin positive samples had either a detectable paraprotein or RF activity, with greatest sensitivity for type I and type II cryoglobulins (97% and 98%, respectively). The sensitivity remained high irrespective of whether EPG and RF analysis was performed with the same, or different, pre-analytical collection conditions to the cryoglobulin collection (92% vs 90%, p=0.46). Only two patients with detected cryoglobulins and no associated paraprotein or RF activity had clinical features of cryoglobulinaemia and neither required treatment. This study demonstrates that serum EPG and RF analysis has high sensitivity for the detection of clinically relevant cryoglobulinaemia, even when not collected under ideal pre-analytical conditions, and potentially offers a prompt and effective screening strategy.
Collapse
Affiliation(s)
- Alex Stoyanov
- Central Sydney Immunopathology Laboratory, Pathology East, NSW Health Pathology, Sydney, NSW, Australia.
| | - Catherine Toong
- Department of Immunopathology, Liverpool Hospital, NSW Health Pathology, Sydney, NSW, Australia
| | - Yvonne Kong
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Renfen Chen
- Central Sydney Immunopathology Laboratory, Pathology East, NSW Health Pathology, Sydney, NSW, Australia
| | - Nicolás Urriola
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Sydney, Australia
| |
Collapse
|
35
|
Effectiveness of direct-acting antiviral (DAA) agents on hepatitis C virus-related mixed cryoglobulinemia syndrome: One-year follow-up. THE EGYPTIAN RHEUMATOLOGIST 2023. [DOI: 10.1016/j.ejr.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
36
|
McEneaney PA, Nicklas BJ, Kuba JL, Rundell JD. Cutaneous Pedal Manifestations in Patient With Hepatitis C Virus-Associated Cryoglobulinemia: Case Report and Review of Literature. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:126-129. [PMID: 33089718 DOI: 10.1177/1534734620961893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cryoglobulinemia is an uncommon blood dyscrasia that can manifest itself in the lower extremity. Due to the insidious nature of this disease, dermatological symptoms and ulcerations can easily be mistaken for more common entities. The authors present an overview of cryoglobulinemia and a case report of a patient with lower extremity manifestations of this disorder. This can provide specific guidance on the steps necessary to accurately establish the diagnosis of cryoglobulinemia or rule it out and pursue other etiologies causing lower extremity ulceration.
Collapse
Affiliation(s)
| | - Bonnie J Nicklas
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
| | - Jennifer L Kuba
- Department of Veterans Affair Medical Center, Cleveland, OH, USA
| | - Joseph D Rundell
- Northern Illinois Foot and Ankle Specialists, Crystal Lake, IL, USA
| |
Collapse
|
37
|
Kaur J, Valisekka SS, Hameed M, Bandi PS, Varma S, Onwughalu CJ, Ibrahim H, Mongia H. Monoclonal Gammopathy of Undetermined Significance: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e195-e212. [PMID: 36966041 DOI: 10.1016/j.clml.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant plasma cell dyscrasia with a predominate rise of the IgG immunoglobulin fraction without end-organ damage, often diagnosed incidentally. Despite its progression into various subsequent forms of hematological malignancies, MGUS remains underdiagnosed. A literature search was conducted using the Medline, Cochrane, Embase, and Google Scholar databases, including articles published until December 2022. Keywords used encompassed "Monoclonal Gammopathy of Undetermined Significance," "Plasma Cell dyscrasia," "Monoclonal gammopathy of renal significance," and "IgM Monoclonal gammopathy of Undetermined Significance," This study aimed to conduct a critical review to update knowledge regarding the pathophysiology, risk factors, clinical features, diagnostic protocols, complications, and current and novel treatments for MGUS. We recommend a multidisciplinary approach to manage MGUS due to the complexity of the illness's etiology, diagnosis, and therapy. This comprehensive review also highlights future prospects, such as developing screening protocols for at-risk populations, prevention of disease progression by early diagnosis through genome-wide association studies, and management using Daratumumab and NSAIDs.
Collapse
Affiliation(s)
- Jasneet Kaur
- Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA..
| | | | - Maha Hameed
- Internal Medicine, Florida State University/Sarasota Memorial Hospital, Sarasota, Florida, USA.
| | | | | | | | - Hany Ibrahim
- Ain Shams University, Faculty of Medicine, Cairo, Egypt.
| | | |
Collapse
|
38
|
Mazzaro C, Bomben R, Visentini M, Gragnani L, Quartuccio L, Saccardo F, Sebastiani M, Filippini D, Lauletta G, Monti G, Gattei V. Hepatitis B virus-infection related cryoglobulinemic vasculitis. Clinical manifestations and the effect of antiviral therapy: A review of the literature. Front Oncol 2023; 13:1095780. [PMID: 36824142 PMCID: PMC9941626 DOI: 10.3389/fonc.2023.1095780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
Objective Hepatitis B virus (HBV) infection causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Furthermore, about 20% of the patients develop extrahepatic manifestations such as cryoglobulinemic vasculitis (CV), polyarteritis nodosa, non-rheumatoid arthritis, glomerulonephritis and non-Hodgkin lymphoma. This review analyzed literature data on clinical manifestations of HBV-related CV and the impact of antiviral therapy with analoques nucleotide. Methods A PubMed search was performed to select eligible studies in the literature, up to July 2022. Results Some studies have analyzed clinical manifestations in HBV-related CV and have investigated the role of antiviral therapy with nucleotides analogues (NAs). Clinical manifestations of CV vary from mild to moderate (purpura, asthenia and arthralgias) to severe (leg ulcers, peripheral neuropathy, glomerulonephritis, and non-Hodking lymphoma). NAs therapy leads to suppression of HBV-DNA; therefore, it is capable of producing clinical response in the majority of patients with mild to moderate symptoms. Conclusion Antiviral therapy with NAs is the first choice for HBV suppression and control of mild to moderate disease. In severe vasculitis (glomerulonephritis, progressive peripheral neuropathy and leg ulcers), rituximab alone or with plasma-exchange is always indicated in combination with antiviral therapy.
Collapse
Affiliation(s)
- Cesare Mazzaro
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy,*Correspondence: Cesare Mazzaro,
| | - Riccardo Bomben
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Gragnani
- Centro Manifestazioni Sistemiche da Virus Epatitici, University of Florence, Firenze, Italy
| | | | - Francesco Saccardo
- Department of Internal Medicine, Saronno General Hospital, Saronno, Italy
| | - Marco Sebastiani
- Rheumatology Unit, Department of Surgery, Medicine, Dentistry and Morphological Sciences with Transplant Surgery, Oncology and Regenerative Medicine Relevance, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Gianfranco Lauletta
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, Liver Unit, University of Bari Medical School, Bari, Italy
| | - Giuseppe Monti
- Department of Internal Medicine, Saronno General Hospital, Saronno, Italy
| | - Valter Gattei
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| |
Collapse
|
39
|
Luo J, Liu C, Lv QJ, He T, Qiang X, Li Y, Huang QM, He JL. Non-hepatitis-associated mixed cryoglobulinemia with polyclonal plasma cells disease and alcoholic cirrhosis: A rare case report. Front Med (Lausanne) 2023; 10:1014261. [PMID: 36760401 PMCID: PMC9905412 DOI: 10.3389/fmed.2023.1014261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/03/2023] [Indexed: 01/26/2023] Open
Abstract
Mixed cryoglobulinemia refers to the serum presence of a variety of cryoglobulins, which are defined as immunoglobulins that precipitate at temperatures of < 37°C. The most common cause of mixed cryoglobulinemia is hepatitis C virus (HCV), while other infections, including hepatitis B virus (HBV) and HIV infections, and lymphoproliferative and autoimmune disorders have also been associated with the disease. We reported a rare case of type II-III mixed cryoglobulinemia caused by alcoholic cirrhosis. We need to increase the awareness of and facilitate the early identification of mixed cryoglobulinemia in our clinical study when encountering a patient with liver cirrhosis combined with renal impairment so that treatment can begin early to improve the success rate of therapy and reduce the fatality rate in a potentially life-saving therapy.
Collapse
Affiliation(s)
- Jiao Luo
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Cheng Liu
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Qing-Jian Lv
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Ting He
- Department of Nephrology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xing Qiang
- Department of Hematology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yi Li
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Qi-Mi Huang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China,Qi-Mi Huang ✉
| | - Jia-Lin He
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China,*Correspondence: Jia-Lin He ✉
| |
Collapse
|
40
|
De La Flor Merino JC, Apaza J, Díaz F, Sandoval E, Valga F, Villa D, Marschall A, Abascal ML, Rivas A, Cieza M. An Unusual Case of Seronegative Cryoglobulinemic Glomerulonephritis with Dominant Organized IgA Deposits Associated with Staphylococcal Infection: Casual or Causal Relationship? GLOMERULAR DISEASES 2023; 3:140-147. [PMID: 37901697 PMCID: PMC10601932 DOI: 10.1159/000531737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/22/2023] [Indexed: 10/31/2023]
Abstract
Introduction Cryoglobulinemia refers to the presence of cryoglobulins (CGs) in the serum, encompassing a group of diseases caused by the type of circulating GC. Cryoglobulinemic glomerulonephritis (CryoGN) is the principal manifestation of renal involvement. The diagnosis may be challenging because the hallmark of cryoglobulinemia is the detection of CG in the serum. However, cases of CryoGN without serological evidence of CGs are not uncommon in clinical practice, often diagnosed by anatomopathological findings in the renal biopsy. Case Presentation We report the case of an 86-year-old male who developed renal impairment, nephritic syndrome, and nephrotic-range proteinuria, without serological evidence of CGs, associated with staphylococcal bacteremia without apparent focus. Renal biopsy and pathological examination showed a membranoproliferative glomerulonephritis pattern with CD61-negative pseudothrombi. Immunofluorescence microscopy showed atypical IgA-dominant deposits. Electron microscopy revealed amorphous subendothelial and mesangial deposits and organized electrodense deposits within capillary loops (pseudothrombi) with microtubular substructure measuring 20-40 nm in thickness. These findings were consistent with seronegative CryoGN and microtubular organized atypical IgA-dominant deposits. Discussion In this report, we discuss the clinical, analytical, and histopathological findings of a rare case of CryoGN without serological evidence of CGs. Regarding the etiology that triggered the glomerular disease in our patient, we conducted an exhaustive study in order to determine the underlying cause of CryoGN. At the time of biopsy, the patient had an active staphylococcal bacteremia. There are reports that postulate that staphylococcal antigens drive activation of immune system and in consequence, could cause this rare form of IgA-dominant glomerulonephritis with cryoglobulinemic features. After ruling out other causes of cryoglobulinemia, we discuss a plausible causal relationship of the staphylococcal infection in the pathogenesis of CryoGN in our patient.
Collapse
Affiliation(s)
| | | | - Francisco Díaz
- Department of Anatomic Pathology, Hospital Gregorio Marañón, Madrid, Spain
| | - Edna Sandoval
- Department of Hematology, Hospital Central Defense Gomez Ulla, Madrid, Spain
| | - Francisco Valga
- Department of Nephrology, Hospital Universitario Doctor Negrin de Gran Canarias, Las Palmas de Gran Canaria, Spain
| | - Daniel Villa
- Department of Nephrology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Alexander Marschall
- Department of Cardiology, Hospital Central Defense Gomez Ulla, Madrid, Spain
| | | | - Andrea Rivas
- Department of Nephrology, Hospital Nacional Cayetano Heredia, Lima, Peru
| | - Michael Cieza
- Chief of the Teaching Coordination Unit Universidad Peruana Cayetano Heredia, Lima, Peru
| |
Collapse
|
41
|
Kronbichler A, Bajema I, Geetha D, Säemann M. Novel aspects in the pathophysiology and diagnosis of glomerular diseases. Ann Rheum Dis 2022; 82:585-593. [PMID: 36535746 DOI: 10.1136/ard-2022-222495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Immune deposits/complexes are detected in a multitude of tissues in autoimmune disorders, but no organ has attracted as much attention as the kidney. Several kidney diseases are characterised by the presence of specific configurations of such deposits, and many of them are under a 'shared care' between rheumatologists and nephrologists. This review focuses on five different diseases commonly encountered in rheumatological and nephrological practice, namely IgA vasculitis, lupus nephritis, cryoglobulinaemia, anti-glomerular basement membrane disease and anti-neutrophil cytoplasm-antibody glomerulonephritis. They differ in disease aetiopathogenesis, but also the potential speed of kidney function decline, the responsiveness to immunosuppression/immunomodulation and the deposition of immune deposits/complexes. To date, it remains unclear if deposits are causing a specific disease or aim to abrogate inflammatory cascades responsible for tissue damage, such as neutrophil extracellular traps or the complement system. In principle, immunosuppressive therapies have not been developed to tackle immune deposits/complexes, and repeated kidney biopsy studies found persistence of deposits despite reduction of active inflammation, again highlighting the uncertainty about their involvement in tissue damage. In these studies, a progression of active lesions to chronic changes such as glomerulosclerosis was frequently reported. Novel therapeutic approaches aim to mitigate these changes more efficiently and rapidly. Several new agents, such as avacopan, an oral C5aR1 inhibitor, or imlifidase, that dissolves IgG within minutes, are more specifically reducing inflammatory cascades in the kidney and repeat tissue sampling might help to understand their impact on immune cell deposition and finally kidney function recovery and potential impact of immune complexes/deposits.
Collapse
Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK .,Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden and Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| |
Collapse
|
42
|
Faisatjatham S, Uaprasert N, Iampenkhae K, Udomkarnjananun S. Detectable serum IgM monoclonal gammopathy in non-hepatitis-associated mixed cryoglobulinemic glomerulonephritis: A case report and literature review. SAGE Open Med Case Rep 2022; 10:2050313X221140648. [PMID: 36507058 PMCID: PMC9726840 DOI: 10.1177/2050313x221140648] [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: 05/12/2022] [Accepted: 11/02/2022] [Indexed: 12/12/2022] Open
Abstract
Cryoglobulinemia is the presence of circulating cryoglobulin which can cause systemic vasculitis and glomerulonephritis. Monoclonal gammopathy of renal significance is strongly associated with type I cryoglobulinemia, but the role of detectable serum monoclonal gammopathy in mixed (type II) cryoglobulinemia is not clearly established. We report a case of a 71-year-old woman who presented with skin rash, leg edema, and azotemia. Investigations showed a positive result for rheumatoid factor, low complement C4 level, positive result for serum cryoglobulin, and positive M-spike on serum protein electrophoresis and IgM kappa monoclonal gammopathy on serum immunofixation. Kidney biopsy revealed membranoproliferative glomerulonephritis, polytypic IgM-dominant deposits in an immunofluorescence study, and microtubular substructures in an electron microscopic study. After an extensive workup, no evidence of myeloma or lymphoma was found. A diagnosis of monoclonal gammopathy of renal significance-associated mixed cryoglobulinemic glomerulonephritis was made. Due to the detectable IgM kappa monoclonal gammopathy in the patient's serum, clonal-directed therapy was administered. The patient had been in clinical remission after treatment with clone-directed therapy with cyclophosphamide and steroids. The literature review for cases of type II cryoglobulinemic glomerulonephritis that have detectable serum monoclonal gammopathy are summarized in this study.
Collapse
Affiliation(s)
- Surasak Faisatjatham
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand,Department of Medicine, Khon Kaen Hospital, Khon Kaen, Thailand
| | - Noppacharn Uaprasert
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kroonpong Iampenkhae
- Department of Pathology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand,Suwasin Udomkarnjananun, Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873, Rama 4 Road, Pathumwan, Bangkok 10330, Thailand.
| |
Collapse
|
43
|
Oganesyan A, Gregory A, Malard F, Ghahramanyan N, Mohty M, Kazandjian D, Mekinian A, Hakobyan Y. Monoclonal gammopathies of clinical significance (MGCS): In pursuit of optimal treatment. Front Immunol 2022; 13:1045002. [PMID: 36505449 PMCID: PMC9728929 DOI: 10.3389/fimmu.2022.1045002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of clinical significance (MGCS) represents a new clinical entity referring to a myriad of pathological conditions associated with the monoclonal gammopathy of undetermined significance (MGUS). The establishment of MGCS expands our current understanding of the pathophysiology of a range of diseases, in which the M protein is often found. Aside from the kidney, the three main organ systems most affected by monoclonal gammopathy include the peripheral nervous system, skin, and eye. The optimal management of these MGUS-related conditions is not known yet due to the paucity of clinical data, the rarity of some syndromes, and limited awareness among healthcare professionals. Currently, two main treatment approaches exist. The first one resembles the now-established therapeutic strategy for monoclonal gammopathy of renal significance (MGRS), in which chemotherapy with anti-myeloma agents is used to target clonal lesion that is thought to be the culprit of the complex clinical presentation. The second approach includes various systemic immunomodulatory or immunosuppressive options, including intravenous immunoglobulins, corticosteroids, or biological agents. Although some conditions of the MGCS spectrum can be effectively managed with therapies aiming at the etiology or pathogenesis of the disease, evidence regarding other pathologies is severely limited to individual patient data from case reports or series. Future research should pursue filling the gap in knowledge and finding the optimal treatment for this novel clinical category.
Collapse
Affiliation(s)
- Artem Oganesyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia,*Correspondence: Artem Oganesyan,
| | - Andrew Gregory
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Nerses Ghahramanyan
- Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Arsène Mekinian
- Department of Internal Medicine (DMU i3), Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France,French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| |
Collapse
|
44
|
Mazzaro C, Adinolfi LE, Pozzato G, Nevola R, Zanier A, Serraino D, Andreone P, Fenoglio R, Sciascia S, Gattei V, Roccatello D. Extrahepatic Manifestations of Chronic HBV Infection and the Role of Antiviral Therapy. J Clin Med 2022; 11:6247. [PMID: 36362478 PMCID: PMC9657147 DOI: 10.3390/jcm11216247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/27/2022] [Accepted: 10/12/2022] [Indexed: 08/30/2023] Open
Abstract
The hepatitis B virus (HBV) infection leads to chronic hepatitis, cirrhosis, and hepatocarcinoma. However, about 20% of patients experience extrahepatic manifestations such as polyarteritis nodosa, non-rheumatoid arthritis, non-Hodgkin lymphoma, cryoglobulinemic vasculitis, and glomerulonephritis. These influence the patient's morbidity, quality of life and mortality. The treatment of an HBV infection is based on nucleotide analogues (NAs) which are safe and effective for the suppression of HBV-DNA in almost 100% of cases. A few studies have shown that NAs induce a viral response and an improvement of extrahepatic diseases. There is a lack of a thorough analysis of the available treatments for extrahepatic HBV manifestations. In 90% to 100% of cases, the NAs stop the HBV replication, and they produce a clinical response in the majority of patients with mild to moderate extrahepatic signs/symptoms. Arthritis can definitely disappear after the HBV elimination and, in some cases, the HBV eradication following NAs therapy appears to improve the renal function in HBV-related nephropathies. Plasma exchange can be used in subjects who are suffering from the most aggressive forms of cryoglobulinemic vasculitis and glomerulonephritis, progressive peripheral neuropathy, and life-threatening cases, and this can be combined with glucocorticosteroids and antiviral agents. In selected refractory patients, the use of rituximab in conjunction with NAs therapy can be considered. The review provides an update on extrahepatic conditions that are linked to HBV and the impact of treating HBV with NAs.
Collapse
Affiliation(s)
- Cesare Mazzaro
- Clinical of Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Luigi Elio Adinolfi
- Unit Internal Medicine, Department of Advanced Medical and Surgery Sciences, Luigi Vanvitelli University of Campania, 80138 Naples, Italy
| | - Gabriele Pozzato
- Department of Clinical and Surgical Sciences, Maggiore Hospital University of Trieste, 34149 Trieste, Italy
| | - Riccardo Nevola
- Unit Internal Medicine, Department of Advanced Medical and Surgery Sciences, Luigi Vanvitelli University of Campania, 80138 Naples, Italy
| | - Ada Zanier
- Department of Internal Medicine, Pordenone General Hospital, 33170 Pordenone, Italy
| | - Diego Serraino
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, 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
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy
| | - Valter Gattei
- Clinical of Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy
| |
Collapse
|
45
|
Mazzaro C, Bomben R, Gragnani L, Visentini M, Pozzato G, Pozzo F, Zucchetto A, Gattei V. Hepatitis C virus-associated B-cell lymphomas: The importance of the new direct antiviral agent therapy. Semin Hematol 2022; 59:177-182. [PMID: 36805885 DOI: 10.1053/j.seminhematol.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/23/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
Hepatitis C virus (HCV) is a hepatotropic and lymphotropic virus, responsible for both chronic hepatitis and extra-hepatic manifestations. Multiple epidemiologic, clinical, biological, and molecular studies have suggested that HCV plays a causal role also in the development of several lymphoproliferative disorders, either benign, such as mixed cryoglobulinemia, or malignant, such as B-cell non-Hodgkin lymphomas (NHL). Chronic viral antigenic stimulation of B-lymphocytes plays a fundamental basic role from the onset of lymphoma to its final steps. In the past, several studies demonstrated that the association of pegylated interferon plus ribavirin was able to eradicate HCV, with subsequent regression of indolent B-cell low-grade NHL. Other studies have demonstrated that direct antiviral agents (DAAs) therapy have some efficacy in HCV-associated NHL, particularly in patients with low-grade NHL or marginal zone-lymphoma, but these results need to be confirmed in larger studies with longer follow-up. The response rate of antiviral therapy seems favorable also in high grade NHL when DAAs therapy is administered in combination with chemotherapy and therefore antiviral therapy should be considered as a first-line approach in HCV-related NHL.
Collapse
Affiliation(s)
- Cesare Mazzaro
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Pordenone, Italy.
| | - Riccardo Bomben
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Pordenone, Italy
| | - Laura Gragnani
- MASVE Interdepartmental Center, Department of Experimental and Clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, Firenze, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Gabriele Pozzato
- Clinical and Surgical Sciences, University of Trieste, Trieste, Italy
| | - Federico Pozzo
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Pordenone, Italy
| | - Antonella Zucchetto
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Pordenone, Italy
| | - Valter Gattei
- Clinical and Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Pordenone, Italy
| |
Collapse
|
46
|
Gragnani L, Lorini S, Marri S, Rattotti S, Madia F, Zibellini S, Monti M, Basile U, Di Stasio E, Libra M, Arcaini L, Zignego AL. B-cell activating factor (BAFF), BAFF promoter and BAFF receptor allelic variants in hepatitis C virus related Cryoglobulinemic Vasculitis and Non-Hodgkin's Lymphoma. Hematol Oncol 2022; 40:658-666. [PMID: 35460540 PMCID: PMC9790294 DOI: 10.1002/hon.3008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/16/2022] [Accepted: 04/18/2022] [Indexed: 12/30/2022]
Abstract
Cryoglobulinemic Vasculitis (CV) is an autoimmune/lymphoproliferative disorder associated with HCV infection that in 5%-10% of cases evolves into a B cell Non-Hodgkin's Lymphoma (NHL). B-cell activating factor (BAFF) is a key regulator in B-cell development and survival. Particular genetic variants are responsible for BAFF signaling impairment in autoimmune and neoplastic diseases. We evaluated BAFF and BAFF-receptor (BAFF-R) polymorphisms in order to determine if they predispose to HCV-related CV and NHL. The analysis was performed on 416 HCV-chronically infected patients: 136 HCV without signs/symptoms of lymphoproliferations/autoimmunity (HCV), 166 HCV with CV (HCV-CV) and 114 HCV with NHL (HCV-NHL). Rs9514828 SNP on BAFF promoter, rs61756766 on BAFF-R and rs12428930 on the BAFF gene were evaluated by Real-Time PCR. Concerning rs9514828, the frequency of C/T genotype was significantly higher in HCV-CV than in HCV. The difference in the distribution of the T/T mutant genotype in HCV-CV compared to HCV was significant as well as the distribution of C/T and T/T genotype in HCV-NHL versus HCV. T minor allele was more frequent in HCV-NHL and HCV-CV than in HCV. The distribution of C/T + T/T (for the dominant model of penetrance C/T + T/T vs. C/C) was significantly higher in HCV-CV and HCV-NHL than in HCV. Genotyping of rs61756766 on BAFF-R coding gene, revealed C/T heterozygosis at a frequency of 11% in HCV-NHL versus 3% in HCV. The T minor allele frequency was higher in HCV-NHL than in HCV. No differences emerged by genotyping rs12428930 SNP on BAFF coding gene. Our results reinforce the hypothesis that BAFF/BAFF-R genetic pattern has a role in the pathogenesis of HCV-related lymphoproliferations. BAFF/BAFF-R variants could identify a risk haplotype for HCV related CV and NHL and a BAFF/BAFF-R genetic profile assessment could potentially contribute to tailoring anti-BAFF therapy by identifying patients with BAFF alterations in which the treatment could be more beneficial.
Collapse
Affiliation(s)
- Laura Gragnani
- MASVE Interdepartmental Hepatology CenterDepartment of Experimental and Clinical MedicineUniversity of FlorenceCenter for Research and Innovation CRIA‐MASVEFirenzeItaly
| | - Serena Lorini
- MASVE Interdepartmental Hepatology CenterDepartment of Experimental and Clinical MedicineUniversity of FlorenceCenter for Research and Innovation CRIA‐MASVEFirenzeItaly
| | - Silvia Marri
- MASVE Interdepartmental Hepatology CenterDepartment of Experimental and Clinical MedicineUniversity of FlorenceCenter for Research and Innovation CRIA‐MASVEFirenzeItaly
| | - Sara Rattotti
- Division of HematologyFondazione IRCCS Policlinico San MatteoPaviaItaly
| | - Francesco Madia
- MASVE Interdepartmental Hepatology CenterDepartment of Experimental and Clinical MedicineUniversity of FlorenceCenter for Research and Innovation CRIA‐MASVEFirenzeItaly
| | - Silvia Zibellini
- Division of HematologyFondazione IRCCS Policlinico San MatteoPaviaItaly
| | - Monica Monti
- MASVE Interdepartmental Hepatology CenterDepartment of Experimental and Clinical MedicineUniversity of FlorenceCenter for Research and Innovation CRIA‐MASVEFirenzeItaly
| | - Umberto Basile
- Area Diagnostica di LaboratorioFondazione Policlinico Universitario "A. Gemelli", I.R.C.C.SRomeItaly
| | - Enrico Di Stasio
- Area Diagnostica di LaboratorioFondazione Policlinico Universitario "A. Gemelli", I.R.C.C.SRomeItaly,Dipartimento di Scienze biotecnologiche di base, cliniche intensivologiche e perioperatorieUniversità Cattolica del Sacro CuoreRomeItaly
| | - Massimo Libra
- Department of Biomedical and Biotechnological SciencesUniversity of CataniaCataniaItaly
| | - Luca Arcaini
- Division of HematologyFondazione IRCCS Policlinico San MatteoPaviaItaly,Department of Molecular MedicineUniversity of PaviaPaviaItaly
| | - Anna Linda Zignego
- MASVE Interdepartmental Hepatology CenterDepartment of Experimental and Clinical MedicineUniversity of FlorenceCenter for Research and Innovation CRIA‐MASVEFirenzeItaly
| |
Collapse
|
47
|
Seitz L, Seitz P, Pop R, Lötscher F. Spectrum of Large and Medium Vessel Vasculitis in Adults: Primary Vasculitides, Arthritides, Connective Tissue, and Fibroinflammatory Diseases. Curr Rheumatol Rep 2022; 24:352-370. [PMID: 36166150 PMCID: PMC9513304 DOI: 10.1007/s11926-022-01086-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/24/2022]
Abstract
Purpose of Review To provide a comprehensive overview of the spectrum of large and medium vessel vasculitis in adults with primary vasculitides, arthritides, connective tissue, and fibroinflammatory diseases as well as vasculitis mimics, for an efficient differential diagnosis and initial diagnostic approach. Recent Findings Imaging has had a tremendous impact on the diagnosis of medium to large vessel vasculitis, now often replacing histopathologic confirmation and identifying new disease manifestations (e.g., intracranial disease in giant cell arteritis; vascular manifestations of IgG4-related disease). Novel diseases or syndromes involving blood vessels have been described (e.g., VEXAS-Syndrome with polychondritis). The use of the terms “medium” or “large” vessel varies considerably between medical specialties. Summary The differential diagnosis of large and medium vessel vasculitis is becoming increasingly complex as new entities or disease manifestations of known inflammatory rheumatic diseases are regularly identified. A more precise and widely recognized definition of the vessel sizes would make future research more comparable.
Collapse
Affiliation(s)
- Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland. .,Immunodeficiency Laboratory, Department of Biomedicine, University Hospital and University of Basel, Basel, Switzerland.
| | - Pascal Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland
| | - Roxana Pop
- Department of Infectious Diseases and Hospital Hygiene, University Hospital, University of Zurich, Zurich, Switzerland
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital, University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland
| |
Collapse
|
48
|
Roccatello D, Sciascia S, Naretto C, Barreca A, Solfietti L, Battaglia L, Viziello L, Fenoglio R, Rossi D. Recognizing the new disorder "idiopathic hypocryoglobulinaemia" in patients with previously unidentified clinical conditions. Sci Rep 2022; 12:14904. [PMID: 36050335 PMCID: PMC9437023 DOI: 10.1038/s41598-022-18427-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
A considerable number of patients with high clinical suspicion for cryoglobulinaemic vasculitis either show negative results for the detection of cryoglobulins or show only trace amounts which cannot be characterized for composition. We aimed at establishing whether the failure to detect or the detection of trace amounts of cryoglobulin with conventional methods either identifies a peculiar subset of low level cryoglobulinaemia (from now on hypocryoglobulinaemia) or represents a separate entity. Using a modified precipitation technique in hypo-ionic medium, we prospectively identified between 2008 and 2021 237 patients (median age 60.8 years [22-97], 137 females) having < 0.5% cryocrit and clinical suspicion of autoimmune disorder. Of these 237 patients, only 54 (22.7%) had a history of HCV infection. One hundred and sixty-nine out of 237 patients (71%) had an established underlying disease, while 68 patients (28.6%) (median age 62.9 years [29-93], 35 females) did not show either laboratory markers or clinical symptoms consonant with an underlying aetiology. These 68 cases with only trace amounts of cryoglobulins were defined as having a putatively idiopathic hypocryoglobulinaemia. Nineteen of these 68 patients (27.9%) had a history of HCV infection. Twenty-four patients out of 68 (35.3%) were positive for rheumatoid factor (RF), while 25 (36.7%) patients had signs of complement consumption (i.e., C4 < 15 mg/dl and/or C3 < 80 mg/dl ), and 36 (52.9%) had increased inflammatory indexes. Seven patients only had arthralgia and constitutional symptoms while 61 out of 68 (89.7%) presented with at least one of the three cardinal signs of cryoglobulinaemic vasculitis including skin lesions, peripheral nerve involvement, and glomerulonephritis. Seventy-five percent of the subjects had type III hypocryoglobulins. In patients with hypocryoglobulinaemia the histologic features of glomerulonephritis (also examined by electron microscopy) resembled those of mixed cryoglobulinaemia-associated glomerulonephritis. In conclusion, hypocryoglobulins are often polyclonal and are mainly unrelated to HCV infection. Patients who present high clinical suspicion for vasculitis, especially glomerulonephritis and yet test negative for cryoglobulinaemia detected by standard techniques, could require deeper investigation even in the absence of HCV infection, RF activity or signs of complement consumption.
Collapse
Affiliation(s)
- Dario Roccatello
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
| | - Savino Sciascia
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Carla Naretto
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Antonella Barreca
- Pathology Division, Città della Salute e Della Scienza, Torino, Italy
| | - Laura Solfietti
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Laura Battaglia
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Lucia Viziello
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Daniela Rossi
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| |
Collapse
|
49
|
Kondili LA, Monti M, Quaranta MG, Gragnani L, Panetta V, Brancaccio G, Mazzaro C, Persico M, Masarone M, Gentile I, Andreone P, Madonia S, Biliotti E, Filomia R, Puoti M, Fracanzani AL, Laccabue D, Ieluzzi D, Coppola C, Rumi MG, Benedetti A, Verucchi G, Coco B, Chemello L, Iannone A, Ciancio A, Russo FP, Barbaro F, Morisco F, Chessa L, Massari M, Blanc P, Zignego AL. A prospective study of direct-acting antiviral effectiveness and relapse risk in HCV cryoglobulinemic vasculitis by the Italian PITER cohort. Hepatology 2022; 76:220-232. [PMID: 34919289 PMCID: PMC9305531 DOI: 10.1002/hep.32281] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/27/2021] [Accepted: 12/08/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Mixed cryoglobulinemia is the most common HCV extrahepatic manifestation. We aimed to prospectively evaluate the cryoglobulinemic vasculitis (CV) clinical profile after a sustained virologic response (SVR) over a medium-term to long-term period. APPROACH AND RESULTS Direct-acting antiviral-treated cryoglobulinemic patients, consecutively enrolled in the multicentric Italian Platform for the Study of Viral Hepatitis Therapy cohort, were prospectively evaluated. Cumulative incidence Kaplan-Meier curves were reported for response, clinical deterioration, relapse and relapse-free survival rates. Cox regression analysis evaluated factors associated with different outcomes. A clinical response was reported in at least one follow-up point for 373 of 423 (88%) patients with CV who achieved SVR. Clinical response increased over time with a 76% improvement rate at month 12 after the end of treatment. A full complete response (FCR) was reached by 164 (38.8%) patients in at least one follow-up point. CV clinical response fluctuated, with some deterioration of the initial response in 49.6% of patients (median time of deterioration, 19 months). In patients who achieved FCR and had an available follow-up (137 patients) a relapse was observed in 13% and it was transient in 66.7% of patients. The rate of patients without any deterioration was 58% and 41% at 12 and 24 months, respectively. After achieving SVR, a clinical nonresponse was associated with older age and renal involvement; a clinical deterioration/relapse was associated with high pretreatment rheumatoid factor values, and FCR was inversely associated with age, neuropathy, and high cryocrit levels. CONCLUSION In patients with CV, HCV eradication may not correspond to a persistent clinical improvement, and clinical response may fluctuate. This implies an attentive approach to post-SVR evaluation through prognostic factors and tailored treatment.
Collapse
Affiliation(s)
| | - Monica Monti
- Center for Systemic Manifestations of Hepatitis VirusesDepartment of Experimental and Clinical MedicineUniversity of FlorenceFlorenceItaly
| | | | - Laura Gragnani
- Center for Systemic Manifestations of Hepatitis VirusesDepartment of Experimental and Clinical MedicineUniversity of FlorenceFlorenceItaly
| | - Valentina Panetta
- L'altrastatistica srlConsultancy & Training, Biostatistics officeRomeItaly
| | | | - Cesare Mazzaro
- Clinical and Experimental Onco‐Haematology UnitIRCCS Centro di Riferimento OncologicoAviano, PordenoneItaly
| | - Marcello Persico
- Internal Medicine and Hepatology UnitSalerno UniversitySalernoItaly
| | - Mario Masarone
- Internal Medicine and Hepatology UnitSalerno UniversitySalernoItaly
| | - Ivan Gentile
- Department of Clinical Medicine and SurgeryUniversity of Naples Federico IINaplesItaly
| | - Pietro Andreone
- Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Salvatore Madonia
- Department of Internal MedicineVilla Sofia‐Cervello HospitalPalermoItaly
| | - Elisa Biliotti
- Infectious and Tropical Diseases UnitUmberto I Hospital‐“Sapienza” UniversityRomeItaly
| | - Roberto Filomia
- Department of Internal MedicineUniversity Hospital of MessinaMessinaItaly
| | | | - Anna Ludovica Fracanzani
- General Medicine and Metabolic DiseasesFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoUniversità degli Studi di MilanoMilanItaly
| | - Diletta Laccabue
- Laboratory of Viral Immunopathology, Unit of Infectious Diseases and HepatologyAzienda Ospedaliero‐Universitaria di ParmaUniversity of ParmaParmaItaly
| | | | - Carmine Coppola
- Department of HepatologyGragnano HospitalGragnano, NaplesItaly
| | | | - Antonio Benedetti
- Clinic of Gastroenterology and HepatologyUniversità Politecnica delle MarcheAnconaItaly
| | - Gabriella Verucchi
- Clinic of Infectious Diseases and Microbiology UnitAlma Mater Studiorum Bologna UniversityBolognaItaly
| | - Barbara Coco
- Hepatology and Liver Physiopathology Laboratory and Internal MedicineDepartment of Clinical and Experimental MedicineUniversity Hospital of PisaPisaItaly
| | - Liliana Chemello
- Unit of Internal Medicine and Hepatology–Clinica Medica 5Department of Medicine‐DIMEDUniversity of PaduaPaduaItaly
| | | | - Alessia Ciancio
- Gastroenterology UnitCittà della Salute e della Scienza of TurinUniversity HospitalTurinItaly
| | - Francesco Paolo Russo
- Gastroenterology UnitDepartment of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | | | | | | | - Marco Massari
- Infectious Diseases UnitAzienda Unità Sanitaria Locale–IRCCS di Reggio EmiliaReggio EmiliaItaly
| | - Pierluigi Blanc
- Infectious Disease UnitSanta Maria Annunziata HospitalFlorenceItaly
| | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis VirusesDepartment of Experimental and Clinical MedicineUniversity of FlorenceFlorenceItaly
| |
Collapse
|
50
|
André F, Böckle BC. Sjögren-Syndrom. J Dtsch Dermatol Ges 2022; 20:980-1003. [PMID: 35881105 DOI: 10.1111/ddg.14823_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Fiona André
- Universitätsklinik für Dermatologie, Venerologie und Allergologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Barbara C Böckle
- Universitätsklinik für Dermatologie, Venerologie und Allergologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| |
Collapse
|