Cryoglobulins D89.1

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 14.04.2021

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Synonym(s)

cold agglutinin disease; cold agglutinin syndrome; Cryoglobulinemia; Cryoglobulins; Cryoglubulinemia

History
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Landsteiner, 1903; Lerner and Watson, 1947

Definition
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Occurrence of circulating serum proteins (cryoglobulins) that precipitate in cold conditions. These are immunoglobulins (mostly IgM) with the property of precipitating at 4ºC and re-solubilizing when rewarmed to 37ºC. About 80% of patients have an underlying haematological disease as cause, in most cases MGUS.

Classification
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There are three types:

  • Type I: Monoclonal cryoglobulins(paraproteins), mostly IgM, approx. 15%: Occurs mainly in multiple myeloma and Waldenström's disease.
  • Type II: Mono- and polyclonal mixed cryoglobulins with monoclonal IgM rheumatoid factor and polyclonal IgG (monoclonal IgG or IgA rheumatoid factors in the precipitate are rarer): this type accounts for about 60% of cases of cryoglobulinemia. Hepatitis C infection is considered the most common cause. It is also clinically present in systemic scleroderma, Sjögren's syndrome, systemic lupus erythematosus and (more rarely) in chronic polyarthritis. It has also been described to occur in long-term infectious diseases and in rare cases in Waldenström 's disease.
  • Type III: Exclusively polyclonal cryoglobulins (mostly circulating immune complexes in autoimmune diseases or infections): this type is present in about 25% of all cryoglobulin cases. Clinically occurring in systemic scleroderma, SLE, less frequently in chronic polyarthritis and chronic infectious diseases.

Etiopathogenesis
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Autoimmune diseases: systemic lupus erythematosus, Sjögren's syndrome, polyarteritis nodosa, rheumatoid arthritis, lymphocytic leukemia, malignant lymphogranulomatosis, sarcoidosis, ulcerative colitis.

Infections: e.g. hepatitis B, hepatitis C, infectious mononucleosis, toxoplasmosis, syphilis, Borrelia infections, cytomegalovirus infection, subacute bacterial endocarditis.

Other: Chronic liver disease, arthritis after intestinal bypass.

Clinical features
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  • Skin changes in the different types of cryoglobulins:
  • Extracutaneous manifestations: arthralgias, myalgias, nephropathies, neuropathies (IgM-associated polyneuropathy anti-MAG antibodies), anaemia (IgM-associated cold agglutinin disease is responsible for 15% of all haemolytic anaemias; pathophysiologically, anaemia is complement associated and occurs mainly extravascularly. The severity of anaemia depends on the thermal amplitude of the antibody = the ability of the antibody to bind to the erythrocytes at a certain temperature). Haemoglobinuria.

Laboratory
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BSG strongly accelerated at 37 °C, slowed down at 4 °C. Precipitation of cryoglobulins in serum at refrigerator temperatures (hours to days). Cryoglobulin concentration usually > 1 g/l (standard value < 100 mg/l). Frequently anaemia, haemoglobinuria, false-positive syphilisserology.

Diagnosis
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Immunoelectrophoretic cryoglobulin detection.

Therapy
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Treatment of the underlying disease, see there.
  • For essential mixed cryoglobulinemia (type II): cyclophosphamide (e.g. endoxane) 1-2 mg/kg bw/day in combination with prednisolone 0.25-0.5 mg/kg bw/day (Fauci scheme) leukocyte-adapted. Alternatively: Melphalan (e.g. Alkeran) and prednisolone shock therapy as in plasmocytoma or long-term therapy with chlorambucil (e.g. Leukeran, 2-5 mg/day p.o.).
  • In idiopathic cryoglobulinemia: Symptomatic therapy approaches, e.g. NSA such as ibuprofen (e.g. Ibuprofen Heumann) 400-600 mg/day p.o.; no immunosuppression.
  • In paraneoplastic forms, e.g. type I cryoglobulinemia and malignoma-associated cryofibrinogenemia: tumour search and treatment.
  • In autoimmune forms ( lupus erythematosus, systemic; Sjögren's syndrome; chronic polyarthritis (rheumatoid arthritis): treatment of the underlying disease, taking into account cryoglobulin-induced organ damage.
  • For chronic HBV and HCV infections: 3 times 5 million IU of interferon alfa-2a or interferon alfa-2b.

Note(s)
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Allow 5-10 ml whole blood to clot at 37 °C, centrifuge and send the serum.

Literature
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  1. Bonnet F et al (2003) Prevalence of cryoglobulinemia and serological markers of autoimmunity in human immunodeficiency virus infected individuals: a cross-sectional study of 97 patients. J Rheumatol 30: 2005-2010
  2. Cohen SJ et al (1991) Cutaneous manifestations of cryoglobulinemia: Clinical and histopathologic study of seventy-two patients. J Am Acad Dermatol 25: 21-27
  3. Grunenberg A et al. (2017) Monoclonal IgM gammopathy and Waldenström disease. Dtsch Ärztebl 114: 745-751
  4. Mazzaro C et al (2003) Interferon plus ribavirin in patients with hepatitis C virus positive mixed cryoglobulinemia resistant to interferon. J Rheumatol 30: 1775-1781
  5. Landsteiner K (1903) On relations between blood serum and somatic cells. Munch med weekday 50: 1812
  6. Lerner AB, Watson CJ (1947) Studies of cryoglobulins. I. Unusual purpura associated with the presence of a high concentration of cryoglobulin (cold precipitable serum globulin). Am J Med Sci 214: 410-415
  7. Peter HH et al (1995): Secondary vasculitides. In: Peter HH, Pichler WJ (Ed.) Clinical Immunology, Urban Schwarzenberg, S. 425-426
  8. Schwartzenberg S et al (2003) Generalized vasculitis, thrombocytopenia, and transient lymphoproliferative disorder caused by idiopathic mixed cryoglobulinemia. Am J Med Sci 326: 47-50

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Last updated on: 14.04.2021