Digital ischemic necrosis with cryoglobulinemia associated with hepatitis B infection

(1)

Letter

to

the

Editor

Digital

ischemic

necrosis

with

cryoglobulinemia

associated

with

hepatitis

B

infection

A77-year-oldmalepatientpresentedwithaoneweekhistory

of general worsening condition, with mental status and

respiratory insufﬁciency. He was thereforeadmitted tothe

IntensiveCareUnit.Hispastmedicalhistorywas

unremark-ableexcept for hypertension.He hadcyanosis of the nose,

handsandfeetwithpurpletoblackdiscoloration(Fig.1).Initial

laboratorystudyresultswerenotableforleukocytes:24,000/

mm3_,_neutrophils:_85%,_hemoglobin:_8.6_g/dL, _{thrombocytes:}

120,000/mm3_,_erythrocyte_{sedimentation}_rate_(ESR):₁₁₀_mm/

h,C-reactiveprotein(CRP):64mg/L,aspartate

aminotransfer-ase:83U/L,alanineaminotransferase:125U/L,BUN:110mg/

dL,creatinine:3.4mg/dL.Inthedifferentialdiagnosis,sepsis

withmultiorganfailureandcoronaryarterydiseasewithacute

heartfailurewereconsidered.

Myeloproliferative diseases, autoimmune diseases, and

HCV infection were ruled out by awide clinico-serological

work-up.ANA,P-ANCA,C-ANCA,anti-dsDNA,anti-Sm,

anti-RNP, and rheumatoid factor were found to be negative.

journalof orthopaedics13(2016)448–449

Fig.1–Clinicalappearanceofacrocyanosisonnoseandhandswithpurpletoblackdiscoloration.

Keywords:

Digitalischemicnecrosis

Cryoglobulinemia

HepatitisB

Available

online

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ScienceDirect

(2)

HepatitisBsurfaceantigen(HBsAg)waspositive,andHepatitis

B‘‘e’’antigen(HBeAg)wasnegative.ThehepatitisBviralload

waspositiveat3300IU/ml.

Cryoglobulinswerepositiveinserum,whichwerethought

tobethecauseoftheclinicalpictureandacuterenalfailure.

Thecryoprecipitatewascharacterizedby

immunoelectropho-resis, whichshowedthat theproteins containedpolyclonal

immunoglobulinIgG,whiletherewasnomonoclonalprotein.

Theﬁnaldiagnosiswasmadeasmixedtypecryoglobulinemia

withacrocyanosisandacutedigitalischemicnecrosis

associ-ated with hepatitis-B. Despite aggressive, supportive

anti-microbials and lamivudine treatment, the patient's clinical

course deteriorated, and the patient died of a myocardial

infarctiononhospitaldaythree.

Theacuteonsetofacrocyanosisalongwithabnormalvital

signsisaredﬂagsymptomofanunderlying,potentially

life-threatening disease such as an embolic phenomenon or

vasculitis.

Mixed cryoglobulinemia (MC), type II and type III, are

deﬁnedas the presence of circulating cryoprecipitable

im-munecomplexesintheserum.1,2_Rarely_encountered_in_the

clinicalsetting,itspresentationischaracterizedbyaclassical

clinicaltriadofpurpura,weakness,andarthralgias.1_Its_true

prevalence remains unknown, however MC is noted for

variableorganinvolvement,includingskinlesions(orthostatic

purpura, ulcers), chronic hepatitis, membranoproliferative,

glomerulonephritis,peripheralneuropathy,diffusevasculitis,

Raynaud'sphenomenon,andlessfrequently,interstitiallung

involvementand endocrine disorders.1–3 High cryocrit level

maycauseischemiccardiacorcerebrovasculardisease.4

AlthoughchronicHCVinfectionisknowntobethemost

signiﬁcantinfectionrelatedtotypeIImixedcryoglobulinemia,

a few reported cases have shown the signiﬁcance of HBV

infectioninthiscondition.1,2Inpatientswithcomorbidities

such as renal disease, liver failure, lymphoproliferative

disease,andmalignancies,overallprognosisisusuallyworse.

Thepresentcaseunderlinestheimportanceofrecognizing

cryoglobulinemia. In patients with hepatitis B infection,

cryoglobulinemiaisararebutcrucialextrahepatic

manifesta-tionthatmayberelatedtohighmorbidityandmortality.

Conﬂicts

of

interest

Theauthorshavenonetodeclare.

r

e

f

e

r

e

n

c

e

s

1. FerriC.Mixedcryoglobulinemia.OrphanetJRareDis.2008;3:25.

2. YamazakiT,AkimotoT,OkudaK,etal.Purpurawith ulcerativeskinlesionsandmixedcryoglobulinemiaina quiescenthepatitisBviruscarrier.InternMed.2014;53: 115–119.

3. GrigorescuI,DumitrascuDL.Spontaneousand antiviral-inducedcutaneouslesionsinchronichepatitisBvirus infection.WorldJGastroenterol.2014;20:15860–15866.

4. BrownPJ,ZirwasMJ,English3rdJC.Thepurpledigit:an algorithmicapproachtodiagnosis.AmJClinDermatol. 2010;11:103–116.

FerhatArslan

DepartmentofInfectiousDiseasesandClinicalMicrobiology,

IstanbulMedipolUniversityHospital,Istanbul,Turkey

ErgenekonKaragöz*

GATAHaydarpasaTrainingHospital,Istanbul,Turkey

AliMert

IstanbulMedipolUniversityHospital,Istanbul,Turkey

*Correspondingauthor.

E-mailaddress:ergenekonkaragoz@hotmail.com(E.Karagöz)

Received20April2015

Availableonline20October2015

http://dx.doi.org/10.1016/j.jor.2015.09.008

0972-978X/

#2015Prof.PKSurendranMemorialEducationFoundation.

PublishedbyElsevier,adivisionofReedElsevierIndia,Pvt.Ltd.

Allrightsreserved.