An Aggressive Case of Cryoglobulinemia and Membranoproliferative Glomerulonephritis: A Case Report

TL;DR

A 66-year-old woman with a rare and aggressive form of cryoglobulinemia and kidney disease had severe lung complications and a poor outcome despite treatment.

Contribution

This case highlights the rare and aggressive pulmonary manifestations of HCV-associated mixed cryoglobulinemia.

Findings

The patient had Type II mixed cryoglobulinemia with positive IgM kappa and polyclonal IgG.

Pulmonary involvement occurred without evidence of diffuse alveolar hemorrhage but led to a complicated disease course.

Treatment with steroids and rituximab failed to improve the patient's condition.

Abstract

This case report describes a 66-year-old female with membranoproliferative glomerulonephritis (MPGN) with pulmonary involvement presumed secondary to Hepatitis C virus (HCV)-associated with mixed cryoglobulinemia. In this condition, pulmonary involvement is uncommon, and aggressive lung involvement can be associated with poor outcomes. Within eight weeks, the patient was hospitalized twice with acute pulmonary presentations and presented at a third hospitalization with dyspnea, chest pain, abdominal pain, and edema. Imaging revealed persistent and historically evolving lung consolidation, as well as a renal biopsy showing MPGN associated with mixed cryoglobulinemia. A lung biopsy revealed inflammation. Bronchoalveolar lavage did not show hemosiderin-laden macrophages and did not grow infectious agents. Serology revealed negative ANCAs and rheumatoid factor positive at 476 IU/ml (upper limit normal 14 IU/ml). Qualitative cryoglobulins were positive at 2 %ppt (reference range: negative %ppt) and Type II mixed cryoglobulinemia with IgM kappa plus polyclonal IgG. The treatment involved steroids and rituximab. The patient’s clinical status deteriorated, and she elected to change her resuscitation status to comfort care measures. This case emphasizes that cryoglobulinemia can present with aggressive manifestations on a wide spectrum. Pulmonary manifestations are rare and were evident in this case (although without clear evidence of diffuse alveolar hemorrhage) and led to a complicated disease course and an unfavorable outcome. Overall, this case underscores the complexity of mixed cryoglobulinemia presentations and the challenges of managing severe cases with multi-organ involvement.

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