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Hepatitis C Associated Cryoglobulinemia and Membranoproliferative Glomerulonephritis Presenting as Diffuse Alveolar Hemorrhage

Aswin Nukala, MD; Aravindan Jeyarjasingam, MD; Andres Serrano, MD
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Mount Sinai Medical Center - Chicago, Chicago, IL


Chest. 2015;148(4_MeetingAbstracts):868A. doi:10.1378/chest.2214912
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Abstract

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Student/Resident Case Report Posters I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Cryoglobulinemia (CG) is a condition in which immunoglobulin and complement complexes precipitate in the blood at temperatures colder than 37 degrees Celsius. The formation of these immune complexes leads to deposition in capillaries and small arterioles resulting in a systemic vasculitis. Deposition in the pulmonary vasculature is an extremely unusual entity and can result in alveolar hemorrhage. In this case, the authors describe a rare presentation of hepatitis C associated mixed CG and membranoproliferative glomerulonephritis (MPGN) resulting in diffuse alveolar hemorrhage.

CASE PRESENTATION: A 63 year old male with a history of IV heroin abuse, hepatitis C associated mixed cryoglobulinemia (Type 2) and MPGN presented to the emergency room with complaints of worsening dyspnea and hemoptysis with streaks of blood for the past 2 weeks. He denied recent weight loss or travel history. A BMP revealed that the patient had an acute on chronic kidney injury with an elevated creatinine of 2.9, which was above his baseline of 1.9. A chest X ray revealed diffuse alveolar infiltrates. A CT of his chest demonstrated diffuse groundglass opacities and reticulonodular interstitial markings in the lung apices suspicious for hemorrhage. Cryoglobulin and hepatitis C antibody were also positive. Complement levels were decreased and rheumatoid factor was elevated. ANCA related vasculitis was ruled out. The patient underwent bronchoscopy, which revealed an erythematous airway and grossly bloody fluid. Analysis of the BAL revealed greater than 31,000 RBC’s confirming the suspected diagnosis of alveolar hemorrhage. Because of the renal and pulmonary involvement of the underlying CG, the patient was treated with plasmapheresis, corticosteroids and rituximab and improved clinically.

DISCUSSION: Pulmonary renal syndrome in patients with cryoglobulinemia can present as MPGN and diffuse alveolar hemorrhage. The pathophysiology involves immune complex deposition in the small capillaries of the airway. Clinicians should have a high degree of suspicion in patients with underlying hepatitis C and renal failure who present with hemoptysis. Early diagnosis with laboratory and radiographic testing is important in determining whether the patient will benefit from plasmapheresis, corticosteroids, and/or immunosuppressive therapy.

CONCLUSIONS: Alveolar vasculitis and hemorrhage have been very rarely described as a presentation of cryoglobulinemia in a handful of cases. Even with successful treatment of acute flare-ups, pulmonary involvement in these patients portends a very poor overall prognosis.

Reference #1: Tariq Abdulkarim, Mohammad Saklayen, Jayson Yap. “Cryoglobulinemia due to Hepatitis C with Pulmonary Renal Syndrome.” Hindawi Publishing Corporation. April 2013.

Reference #2: Khurram Abbass, Jack M. Bernstein, Ali Ajam. “A rare presentation of pulmonary hemorrhage with hepatitis C-associated cryoglobulinemia and membranoproliferative glomerulonephritis.” Clinical Kidney Journal. September 2010.

DISCLOSURE: The following authors have nothing to disclose: Aswin Nukala, Aravindan Jeyarjasingam, Andres Serrano

No Product/Research Disclosure Information


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