Chemisty Case Study: Heat-Insoluble Cryoglobulin

Case History

A 50 year old female was admitted for acute renal failure on CKD stage IV, present with gross hematuria, anemia (due to blood loss) and hypertension. The patient has a significant history of unresolved cryoglobulinemic vasculitis initially diagnosed in 2016 and has been treated by several rounds of rituximab. Other medical histories include Sjogren’s syndrome, MGUS with monoclonal IgM Kappa, coagulopathy (protein S deficiency, on anticoagulant), hyperviscosity, myalgia, deep vein thrombosis, leg edema with superficial ulcer, pulmonary embolus and membranoproliferative glomerulonephritis (MPGN). Kidney biopsy revealed intraglomerular hyaline thrombi consistent with cryoglobulinemic glomerulopathy, interstitial fibrosis tubular atrophy, arterial sclerosis, suggestive thrombotic microangiopathy. Immunohistochemistry was positive for C3, IgM, Kappa, Lambda and CD68. Bone marrow biopsy shown dyserythropoesis without malignancy. Blood testing shown negative hepatitis panel and undetectable C4.

We observed unusual cryoprecipitate test results from this patient: gelatinous appearance precipitate which accounts for more than 40% of volume was observed in both plasma and serum and cannot be cleared at 37C° after several hours of incubation. Further testing shown incubation at 56°C for 30min cleared up the serum but not the plasma. After checking the test history, we found that there was a similar situation for the patient’s cryoprecipitate test a few months back earlier in 2018, and was reported negative for cryoglobulins due to the heat-insoluble nature of the precipitate. Patient was transfused for anemia. No plasmapheresis was done. Due to the patient’s incomplete response to rituximab, Cytoxan was also added to help improve the symptoms.

Cryoprecipitate

• Definition: Cryoprecipitates (or cryoproteins) are blood proteins that form precipitates or gels at temperatures lower than 37°C and typically re-dissolve after warming up to 37°C. There are two types:
• Cryoglobulin (CG): precipitate from both serum and plasma; either immunoglobulins or a mixture of immunoglobulins and complement components
• Cryofibrinogen (CF): precipitate from plasma only; typically composed of a mixture of fibrinogen, fibrin, fibronectin, and fibrin split products
• Lab Testing done in our hospital:
  1. Blood are collected in two pre-warmed tubes (one serum, one EDTA plasma) and kept in warm water (37°C) until the serum tube clots.
  2. The plasma and serum are extracted at room temperature, and then stored in refrigerator for 72 hours.

• If cryoprotein is present, a precipitate or gel will be seen. An aliquot of the serum is rewarmed at 37°C to verify the cryo-nature.

1. The precipitate as a percentage of the original serum volume is measured in an ESR tube to determine the cryocrit.
2. Immunofixation is ordered per pathologist to identify the immunoglobulin compositions of the cryoglobulin.

Cryoglobulinemia

• Classification

Strictly speaking, cryoglobulinemia refers to the presence of cryoglobulin (CG) in a patient’s serum, which could be either asymptomatic or present with apparent clinic syndromes (i.e. cryoglobulinemic vasculitis). Cryoglobulinemia can be classified into three types (see table below [1]), with mixed cryoglobulinemia (type II and type III) representing 80% of the cases.

• Clinical Manifestations

Type I cryoglobulinemia is frequently asymptomatic, while mixed cryoglobulinemia manifests clinically by a classical triad of purpura, weakness and arthralgias, as well as some other conditions including MPGN, chronic hepatitis, peripheral neuropathy, lymphoma, Raynaud’s, Sjogren’s syndrome, etc.

The presence of heat-insoluble cryoglobulins is rare, and its pathogenesis is poorly understood. On the other side, it may indicate sever clinical consequence as seen in our case and some others as mentioned above.

Reference

1. Mixed Cryoglobulinemia, Ferri, C; Orphanet Journal of Rare Diseases 2008, 3:25

 Further reading

1. Essential type II cryoglobulinemia with cryoglobulin-occlusive MPGN and MGUS (Clin Chim Acta. 2009 Aug;406(1-2):170-3):79 y.o. female admitted due to edema and renal failure, cryoglobulin re-dissolved at 56°C, composed of monoclonal IgG-Kappa and polyclonal IgM.

2. HCV associated thrombotic microangiopathy and cryoglobulin-occlusive MPGN (Am J Med Sci. 2013 Oct;346(4):345-8):57 y.o. female, cryoglobulin re-dissolved at 47°C, composed of monoclonal IgM-Kappa and polyclonal IgG. Symptoms only partially resolved upon treatment of plasmapheresis, corticosteroids and antiviral therapy of peginterferon plus ribavirin.

3. Essential type I cryoglobulinemia with massive cryoglobulin-occlusive glomerulonephritis (Am J Kidney Dis. 1995 Oct;26(4):654-7):54 y.o. male progressed to ESRD prior to the detection of cryoglobulin. Cryoglobulin with white gelatinous appearance re-dissolved at 54°C, composed of monoclonal IgG-Kappa.

4. Primary Sjogren’s syndrome with type II cryoglobulinemia and mesangiocapillary glomerulonephritis (Nephrol Dial Transplant. 2000 Jun;15(6):917-8):82 y.o. patient with IgM-MGUS, negative BM, deposition of IgG, IgM and C3 on kidney biopsy, decreased complement levels, negative HCVAb, HBsAb, HBsAg. cryoglobulin re-dissolved at 47°C, composed of monoclonal IgM-Kappa and polyclonal IgG-Kappa.

 

-Rongrong Huang, PhD is a first year clinical chemistry fellow at Houston Methodist Hospital. Her interests include general clinical chemistry, genetic biochemistry and applications of mass spectrometry in clinical laboratories.

-Xin Yi, PhD, DABCC, FACB, is a board-certified clinical chemist, currently serving as the Co-director of Clinical Chemistry at Houston Methodist Hospital in Houston, TX and an Assistant Professor of Clinical Pathology and Laboratory Medicine at Weill Cornell Medical College.