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Arai S, Matsui R, Ono W, Asakawa S, Yamazaki O, Tamura Y, Terasaki M, Hagiwara K, Nakagawa T, Ohashi R, Shimizu A, Shibata S, Fujigaki Y. Discontinuing Hemodialysis through Corticosteroid Treatment in a Patient with Cryofibrinogen-associated Glomerulonephritis. Intern Med 2024; 63:1899-1905. [PMID: 37926528 PMCID: PMC11272508 DOI: 10.2169/internalmedicine.2897-23] [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: 09/10/2023] [Accepted: 09/24/2023] [Indexed: 11/07/2023] Open
Abstract
Cryofibrinogen-associated glomerulonephritis (CryoFiGN) is rare, and its diagnosis is difficult while treatment is not established. We herein report an elderly woman with CryoFiGN who experienced recurrent purpura and nephritic features that subsequently progressed to nephrotic syndrome and required hemodialysis during the 18-month clinical course. The patient was treated with corticosteroids, which led to the discontinuation of hemodialysis. The diagnosis of CryoFiGN was based on the clinical presentation, characteristic glomerular deposits, and results of laser microdissection and liquid chromatography-tandem mass spectrometry of the glomeruli. This case highlights the potential utility of corticosteroids as a treatment option for patients with CryoFiGN, even after hemodialysis.
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Affiliation(s)
- Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Rena Matsui
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Wataru Ono
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Mika Terasaki
- Department of Analytical Human Pathology, Nippon Medical School, Japan
| | - Kanade Hagiwara
- Department of Urology, Teikyo University School of Medicine, Japan
| | - Tohru Nakagawa
- Department of Urology, Teikyo University School of Medicine, Japan
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Japan
| | - Akira Shimizu
- Department of Analytical Human Pathology, Nippon Medical School, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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Gant CM, Koelman CA, Nguyen TQ, Abrahams AC, Wetzels JFM, Duineveld C, Jak M, Minnema MC, Klein SK, Jacobs JFM, Bosma RJ. Cryoglobulinemic Vasculitis in Disguise: Cryofibrinogenemia as Variant of Monoclonal Gammopathy of Renal Significance. Am J Kidney Dis 2024; 83:415-419. [PMID: 37734685 DOI: 10.1053/j.ajkd.2023.07.017] [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: 11/15/2022] [Revised: 07/13/2023] [Accepted: 07/22/2023] [Indexed: 09/23/2023]
Abstract
Monoclonal gammopathy with cryoactivity (ie, cryoglobulins) that causes glomerulonephritis is considered within the spectrum of monoclonal gammopathy of renal significance. Cryofibrinogenemia (cryoactivity of coagulation factors) is very rarely associated with glomerulonephritis. We present a 39-year-old woman with a relapsing nephrotic syndrome. Laboratory investigation detected cryofibrinogen; the precipitate consisted of fibrinogen and a monoclonal immunoglobulin (M-protein; IgG-λ), and the latter was also detected in serum (4g/L). Initial conventional immunosuppressive therapy resulted in temporary renal remission. In view of the M-protein, subsequent therapy consisted of bortezomib/dexamethasone and high-dose melphalan followed by autologous hematopoietic stem cell transplantation, and resulted in a very good partial hematological response and temporary renal remission. However, after hematological and renal relapse, we performed unique experiments to clarify the role of the M-protein. Mixing patient serum with donor plasma resulted in cryoactivity, composed of M-protein+fibrinogen. Patient plasma deprived of M-protein did not have cryoactivity. Therefore, cryoactivity was dependent on the M-protein. We started lenalidomide, which resulted in very good partial hematological and renal remission. Thus, cryofibrinogenemia can be the consequence of an M-protein, which we suggest should be defined as monoclonal gammopathy of renal significance.
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Affiliation(s)
- Christina M Gant
- Internal Medicine/Nephrology, Meander Medical Centre, Amersfoort, The Netherlands.
| | - Carin A Koelman
- Laboratory Medical Immunology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Tri Q Nguyen
- Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alferso C Abrahams
- Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jack F M Wetzels
- Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Margot Jak
- Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Monique C Minnema
- Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Saskia K Klein
- Hematology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Joannes F M Jacobs
- Laboratory Medical Immunology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Renate J Bosma
- Internal Medicine/Nephrology, Meander Medical Centre, Amersfoort, The Netherlands
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Feldman L, Dhamne M, Li Y. Neurologic manifestations associated with cryoglobulinemia: A single center experience. J Neurol Sci 2019; 398:121-127. [PMID: 30708209 DOI: 10.1016/j.jns.2019.01.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 01/17/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Limited information is available describing the spectrum of neurological complications of cryoglobulinemia. METHODS Single center retrospective review of patients with neurologic symptoms and elevated serum cryoglobulins, with their potential association being classified as definite, possible, or unlikely using defined criteria. RESULTS Among 492 patients, 131 (87 classified as definite and 44 as possible) had neurologic symptoms associated with cryoglobulinemia. Common comorbidities included hepatitis C (N = 43), monoclonal gammopathy of undetermined significance (N = 20), Sjogren's syndrome (N = 17), membranoproliferative glomerulonephritis (N = 17), and systemic lupus erythematosus (N = 10). Features supporting an association between cryoglobulinemia and neurological symptoms were the presence of purpura (p < .001), positive rheumatoid factor (p = .001) and low C4 (p = .002). Common peripheral neurological diagnoses were symmetric polyneuropathy (N = 84), small fiber neuropathy (N = 25), and mononeuritis multiplex (N = 16). Central neurological manifestations were infrequent and included seizures (N = 3), posterior reversible encephalopathy syndrome (N = 2), intracerebral hemorrhage (N = 1), vasculitis (N = 1), rapidly progressive dementia (N = 1), lymphoma (N = 1), and myelitis/meningitis (N = 1). Treatments utilized included corticosteroids (N = 74), rituximab (N = 42), cyclophosphamide (N = 27), methotrexate, azathioprine, or mycophenolate mofetil (N = 28), anti-viral therapy (N = 20), plasmapheresis (N = 16), and intravenous immunoglobulin (N = 20). Neurologic symptoms associated with cryoglobulinemia remained stable or improved in 86% of patients. CONCLUSION This study describes a wide spectrum of patients with neurologic symptoms attributed to cryoglobulinemia and provides a framework to approach this challenging diagnosis.
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Affiliation(s)
- Lauren Feldman
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Megha Dhamne
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Yuebing Li
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States.
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AlGain M, Damade R, Aucouturier F, Rivet J, Jachiet M, Malphettes M, Hickman G, Szalat R, Saussine A, de Masson A, Petit A, Rybojad M, Bagot M, Arnulf B, Bouaziz JD. Catastrophic cryofibrinogenaemia associated with chronic lymphocytic leukaemia and salvage therapy using plasmapheresis and cyclophosphamide. J Eur Acad Dermatol Venereol 2016; 31:e38-e39. [PMID: 27297832 DOI: 10.1111/jdv.13628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- M AlGain
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,King Abdulaziz University, Jeddah, Saudia Arabia
| | - R Damade
- Department of Internal Medicine, Hospital Louis Pasteur, Chartres, France
| | - F Aucouturier
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,Department of Biological Immunology, Saint-Louis Hospital, Paris, France
| | - J Rivet
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,Department of Pathology, Saint-Louis Hospital, Paris, France
| | - M Jachiet
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - M Malphettes
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,Department of Clinical Immunology, Saint-Louis Hospital, Paris, France.,Groupe d'Etude des Dermatoses associées à une Immunoglobuline Monoclonale, Paris, France
| | - G Hickman
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - R Szalat
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,Department of Clinical Immunology, Saint-Louis Hospital, Paris, France
| | - A Saussine
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - A de Masson
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - A Petit
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - M Rybojad
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,Groupe d'Etude des Dermatoses associées à une Immunoglobuline Monoclonale, Paris, France
| | - M Bagot
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - B Arnulf
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,Department of Clinical Immunology, Saint-Louis Hospital, Paris, France.,Groupe d'Etude des Dermatoses associées à une Immunoglobuline Monoclonale, Paris, France
| | - J D Bouaziz
- Department of Dermatology, Saint-Louis Hospital, Paris, France.,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.,Groupe d'Etude des Dermatoses associées à une Immunoglobuline Monoclonale, Paris, France
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