P-PN021. A case series of cryoglobulinemia with different clinical presentations and different nerve conduction studies (NCS) findings

Abstract

Introduction . Neuropathy in cryoglobulinemia can be due to hyperviscosity (type I) or non obstructive immune complex mediated inflammatory vasculitis (type II and III). Methods . Case series: Our first patient was a 72-year-old gentleman with 5-month duration of severe asymmetrical neuropathic pain and rapidly progressive weakness in right peroneal and bilateral ulnar distribution associated with significant weight loss and pain, but no sphincter and autonomic dysfunction. He denied fever, arthritis, Raynaud’s phenomenon, rash and edema. His NCS revealed bilateral ulnar and right peroneal neuropathy. Left sural nerve biopsy revealed vasculitis, and cryoglobulin was found to be positive. Myeloma panel was suggestive of Kappa monoclonal gammopathy with normal flow cytometry and bone marrow. We concluded it as cryoglobulinemic vasculitis with Kappa light chain MGUS presenting with mononeuritis multiplex. Second patient was a 56-year-old man, HCV treated one year ago with undetectable viral load currently, and had generalized Myasthenia Gravis, presented with burning sensation of bilateral feet and erythematous macules, blanching papules on ankles, arms with normal power and reflexes. Nerve conduction study was normal and supported the clinical diagnosis of small fiber neuropathy due to cryoglobulinemia with treated HCV. Third case, a 70-year-old lady, presented with tingling sensation of both lower limbs with impaired sensation of up to ankles, distal toes weakness (3/5) and absent ankle reflexes for 2 months. Her NCS showed distal sensorimotor axonal polyneuropathy. She was found to be anti-HCV positive and cryoglobulinemia with viral load of 1 × 10 6 IU/ml. All our patients had no history of exposure to heavy metals, metabolic, infection screening and ENA, ANCA, anti-CCP were negative and cryoglobulin was positive. Conclusion . Nerve conduction study can add to the clinical for diagnosis of various types of polyneuropathy (mononeuritis multiplex, large fiber peripheral neuropathy, small fiber neuropathy) as depicted in our cases.