Mixed Cryo

Today, Dr. Fine presented an interesting case of an elderly gentleman with a history of PVD s/p recent fem-fem and fem-pop bypass who presented with subacute progressive BLE ulcerations, found to have mixed cryoglobulinemia in the setting of HCV. Additionally, he was diagnosed with splenic marginal zone lymphoma (another extraheptic manifestation of hepatitis C) and was treated for his underlying hep C.

Learning Points:

We reviewed the differential diagnosis of lower extremity ulcers including common and uncommon causes. See our previous blog post for more information about characterizing ulcers by history, pain, morphology, and physical exam findings.

 Table from Muchtar's article entitled "How I treat cryoglobulinemia" published in January 2017 edition of Blood (link below). 

Table from Muchtar's article entitled "How I treat cryoglobulinemia" published in January 2017 edition of Blood (link below). 

Most HCV associated cryo cases are mixed cryoglobulinemia (type II or type III).

Thank you to Dr. Shatzel, one of our awesome hem/onc fellows, for pointing out an article published in Blood 2017 regarding treatment of cryoglobulinemia. This article is an excellent resource with case based discussion of treatment of type I cryoglobulinemia, noninfectious mixed cryoglobulinemia, relapsed cryoglobulinemia, HCV-associated (infectious) mixed cryoglobulinemia and asymptomatic cryoglobulinemia. See the figures below with management algorithms.

 Figure from Muchtar's article entitled "How I treat cryoglobulinemia" published in January 2017 edition of Blood (link above). 

Figure from Muchtar's article entitled "How I treat cryoglobulinemia" published in January 2017 edition of Blood (link above). 

 Figure from Muchtar's article entitled "How I treat cryoglobulinemia" published in January 2017 edition of Blood (link above). 

Figure from Muchtar's article entitled "How I treat cryoglobulinemia" published in January 2017 edition of Blood (link above).