Abstract
SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Cryoglobulins are defined as immunoglobulins that precipitate in the cold and dissolve upon rewarming. Mixed cryoglobulinemia is a condition characterized by the presence of cryoglobulins in the serum that have both IgG and IgM components. Although typically associated with hepatitis C, this disease can also be due to an infectious etiology. Cryoglobulins can occasionally deposit in small blood vessels throughout the body, leading to a mixed cryoglobulinemic vasculitis. CASE PRESENTATION: A 66-year-old male presented with an extensive purpuric lower extremity rash and shortness of breath. Lab work initially was remarkable for acute renal failure and a normocytic, normochromic anemia. The patient was found to be bacteremic with Streptococcus mutans and started on a four-week course of penicillin. Transesophageal echocardiogram showed aortic valve thickening without frank vegetations, leading to a diagnosis of presumed endocarditis. Five days into his hospital stay, the patient developed hemoptysis and acute hypoxic respiratory failure. He was subsequently intubated and transferred to intensive care. Bronchoscopy revealed diffuse alveolar hemorrhage (DAH). Rheumatologic work up was positive for C3 hypocomplementemia and cryoglobulinemia; however, the patient was negative for hepatitis C. Extensive autoimmune workup was unremarkable. Renal biopsy ultimately revealed focal necrotizing and crescentric glomerulonephritis (GN) with mesangial C3 staining, most consistent with endocarditis-associated GN. The patient had improvement in symptoms with antimicrobial therapy alone and demonstrated no benefit from corticosteroids or plasma exchange. He was ultimately extubated and discharged home. DISCUSSION: Mixed cryoglobulinemic vasculitis typically presents with palpable purpura and arthralgias. One atypical sequela is pulmonary capillaritis, leading to diffuse alveolar hemorrhage. While there is no clear association with endocarditis-associated GN and mixed cryoglobulinemia, they are both immune-mediated conditions that result in the deposition of immune complexes. The standard treatments of those diagnosed with mixed cryoglobulinemic vasculitis are immunosuppressive therapy and plasma exchange. However, initiating immunosuppressive therapy without antimicrobial therapy in patients with disease secondary to infection could lead to increased mortality and recurrence rates. CONCLUSIONS: This was a patient who not only presented with S. mutans bacteremia but also developed multiple potentially fatal sequelae that are not typically seen. He was fortunate to have recovered following antimicrobial therapy. Therefore, although mixed cryoglobulinemic vasculitis is typically secondary to hepatitis C infection, less common etiologies must remain on the differential in order to ensure prompt and appropriate treatment. Reference #1: Cryoglobulinemia. Background, Pathophysiology, Epidemiology. https://emedicine.medscape.com/article/329255-overview. Published February 3, 2019. Accessed March 14, 2019. Reference #2: Belizna CC, Hamidou MA, Levesque H, Guillevin L, Shoenfeld Y. Infection and vasculitis. Rheumatology (Oxford, England). https://www.ncbi.nlm.nih.gov/pubmed?term=19258377. Published May 2009. Accessed March 14, 2019. DISCLOSURES: No relevant relationships by Soorya Aggarwal, source=Web Response No relevant relationships by Nathan Brewster, source=Web Response No relevant relationships by Breanna Goldner, source=Web Response no disclosure on file for Jennifer Rovella
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