CASE REPORT
Cryofibrinogenemia Triggered by a Monoclonal Paraprotein Successfully Treated With Cyclophosphamide Manuela Moraru, MD,* Miguel Yebra-Bango, MD, PhD,Þ Elisa Cisneros, BS,* Susana Mellor, MD, PhD,Þ Pablo Tutor, MD, PhD,Þ and Fernando Dı´az-Espada, PhD*
Abstract: Cryofibrinogenemia is a rare clinical finding with a yet unknown physiopathogenic mechanism. We describe the case of a woman with cold-induced extensive necrotic lesions that responded poorly to initial corticosteroid and anticoagulant therapies. Serum cryoglobulin determinations were persistently negative. After several years of evolution, she developed severe cold-related skin lesions that required left-leg amputation. Further analysis disclosed the presence of cryofibrinogen and an apparently insignificant serum monoclonal immunoglobulin GJ peak. We additionally demonstrate that the cold precipitation of fibrinogen was directly related to the monoclonal paraprotein presence. The lesions responded dramatically to a B cellYtargeted therapy with intravenous cyclophosphamide and dexamethasone.
serum; plasma sample analysis is required for its identification. Cryofibrinogen precipitates at low temperatures and redissolves at 37-C. Smaller amounts of various plasma proteins involved in the clotting process may also be present in the cryoprecipitate.2 Diverse molecular processes might account for its production. Although inhibitors of plasma fibrinolysis such as >1-antitripsin or >2-macroglobulin could have a triggering effect in CF formation,6 other proteins found in the CF complex might also have a role in its pathogenesis. Here, we report a patient with severe vasculitic lesions and cryofibrinogenemia triggered by the presence of a monoclonal paraprotein. Extensive necrosis affecting the lower leg resolved entirely after treatment with a combination of cyclophosphamide and dexamethasone.
Key Words: cryoproteins, cryofibrinogen, vasculitis, cyclophosphamide
CASE REPORT
(J Clin Rheumatol 2014;20: 34Y37)
C
ryofibrinogenemia is defined by the presence of an abnormal cold-precipitable fibrinogen complex in plasma.1,2 It fundamentally associates with episodes of thrombotic ischemia induced by cold environment. The presence of cryofibrinogen (CF) can be asymptomatic, or it can course with clinical manifestations ranging from self-limited skin involvement to severe, chronic disease that eventually evolves into ischemic necrosis. Sudden unexplained skin changes and CF presence in plasma are required for diagnosis. In addition, occlusion of medium and small vessels evidenced on angiogram and/or skin biopsy showing either leukocytoclastic vasculitis or CF clogging vessels represents supportive evidence for diagnosis.3 Cryofibrinogenemia can present independently or secondary to various inflammatory disorders, malignancy, or infections,4 with no clearly defined treatment of choice. Immunosuppressive, fibrinolytic, and antiplatelet agents as well as plasmapheresis and corticosteroidal antiinflammatory therapies have been attempted with contradictory results.4,5 The definition of a CF production mechanism in any particular case would be of help in choosing a better treatment option. Cryofibrinogen describes a cold-precipitable complex of fibrinogen and other proteins, including in rare cases immunoglobulins. Unlike cryoglobulins, CF cannot be detected in
From the Departments of *Immunology and †Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain. No financial support was received for this study. The authors declare no conflict of interest. Correspondence: Fernando Dı´az-Espada, PhD, Hospital Universitario Puerta de Hierro, Department of Immunology, Joaquin Rodrigo 2, 28222, Majadahonda, Madrid. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 1076-1608/14/2001Y0034 DOI: 10.1097/RHU.0000000000000058
34
www.jclinrheum.com
In 1992, a 56-year-old woman was seen at our hospital for cold-related livedo reticularis, cutaneous macular lesions, and subsequent development of skin ulcerations on her lower limbs. Previous findings had included multinodular goiter with subsequent hypothyroidism treated with levothyroxine and no previous infectious, malignant, or systemic pathologies. Laboratory tests showed unaltered hematologic, serum, and urine biochemical patterns. Evaluation of inflammatory markers revealed normal levels of >1antitripsin, C-reactive protein, erythrocyte sedimentation rate, and complement factors C3 and C4. Rheumatoid factor and antinuclear, antiphospholipid, antithyroid, and antineutrophil cytoplasm antibodies were persistently negative, as were Coombs tests and serum cryoglobulins and cold agglutinin determination. Coagulation tests showed no alterations, and lupus anticoagulant determination and fibrinogen levels were normal. Microbiologic tests excluded acute and chronic infections with human immunodeficiency or hepatitis B and C viruses. Bone marrow biopsy and computed tomography did not reveal any signs of malignancy or hematologic disease. Biopsy of skin lesions showed leukocytoclastic vasculitis (Figure, A). The patient was sequentially treated with oral corticosteroids, dapsone, colchicine, azathioprine, oral cyclophosphamide, and mycophenolate mofetil with incomplete response. After 10 years of indolent evolution with occasional flares of mild cutaneous purpuric lesions, she developed severe cold related skin lesions in both upper and lower extremities. A lower-limb arteriography disclosed small vessel obstruction compatible with distal vasculitis. At that time, the histopathologic examination of a new skin biopsy revealed small vessel thrombotic obstruction (Figure, B). Serial blood examinations performed periodically did not find other relevant alterations. Subsequent oral anticoagulant therapy associated with low-dose oral corticosteroids initially controlled the extension of necrotic lesions; however, after several years of treatment, the patient developed extensive necrotic lesions and required left-leg amputation. The necrotic lesions further expanded to the right leg and upper limbs and were poorly controlled with the therapy regimens used.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Cryofibrinogenemia and Cyclophosphamide
FIGURE. A, Initial studies on a skin biopsy specimen showing substantial inflammatory blood vessel infiltrates (leukocytoclastic vasculitis), with red cell extravasation and fibrinoid necrosis of vessel walls. Small thrombus could be identified in the lumen of some blood vessels (arrow). B, A skin biopsy specimen obtained at the time of cryofibrinogenemia diagnosis showing vascular occlusion with eosinophilic, thrombotic deposits and a moderate inflammatory infiltrate. There was also evidence of epidermal necrosis (periodic acidYSchiff, original magnification 200). Resolution of extensive ulcerated necrotic lesions (C) after cyclophosphamide plus dexamethasone treatment (D). Inset, Washed cryoprecipitates of patient’s plasma (PP) or a mixture of patient’s serum and control plasma (SP+PN) were electrophoresed on an agarose IFE gel (Sebia). Individual lanes were immunofixed with an antifibrinogen (>F) or anti-IgG (>G) antiserum. Lane T was treated with an acidic protein fixative. Nonprecipitated proteins were washed out with saline solution, and then the gel was stained with Coomassie blue. Color figure available online at www.jclinrheum.com.
Exhaustive evaluation after the last radical surgery showed unaltered biochemical, hematologic, and coagulation patterns. The laboratory results at this time point revealed low levels of immunoglobulins: IgG 680 mg/dL (reference interval, 600Y1600 mg/dL), IgM 84 mg/dL (40Y250 mg/dL), and IgA 125 mg/dL (70Y400 mg/dL). Serum protein electrophoresis followed by immunofixation revealed the presence of a faint band corresponding to a monoclonal IgGJ paraprotein. Densitometric scanning of agarose gels quantified the monoclonal peak as 180 mg/dL. Serum free light chains levels were as follows: J 111.4 mg/L (reference interval, 3.30Y19.40 mg/L), L 2.30 mg/L (5.70Y26.30 mg/L). Urine analysis disclosed a Bence-Jones J protein. A subsequent biopsy showed normal bone marrow. In the absence of hematologic disease, the paraprotein detected * 2013 Lippincott Williams & Wilkins
in the patient’s serum could be classed as a gammapathy of undetermined significance. Cryoglobulin determinations were, again, negative. However, as a high suspicion of cold-related pathology persisted, we searched for the presence of CF. Citrated blood samples were incubated at 4-C for 72 hours, and an important amount of precipitate was formed (plasma cryocrit, 14%). Protein electrophoresis of the washed cryoprecipitate showed 2 bands, one of similar electrophoretic mobility to the paraprotein identified in the serum and the other coincident with the expected A2 migration pattern of fibrinogen. This was further confirmed by immunofixation tests with specific antibodies to IgG and fibrinogen (Figure, inset). We hypothesized that the formation of the cryoprecipitate was directly related to the presence of the monoclonal paraprotein. To address this, we incubated www.jclinrheum.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
35
JCR: Journal of Clinical Rheumatology
Moraru et al
patient serum with plasma from a normal individual at 4-C and observed a cryoprecipitate comparable to that formed in the patient plasma alone. Immunofixation of the cryoprecipitate revealed the presence of fibrinogen (normal sample) and the IgG paraprotein (patient serum) (Figure, inset). We assumed that the vasculitic lesions were initiated by the reaction of the monoclonal IgG component and the patient’s fibrinogen. At that time, necrotic lesions persisted in the patient’s lower limb (Figure, C), and after local debridement, we decided to start a treatment aimed at reducing the monoclonal component. Limited response to initial cycles of plasmapheresis led us to start a more specific treatment for B cellYderived malignancies. Subsequent monthly intravenous administration of a combination of cyclophosphamide and dexamethasone achieved satisfactory clinical improvement (Figure, D). Laboratory follow-up showed minimal (G3%), maintained plasma cryocrit levels. Quantification of serum proteins over a 1-year period after treatment revealed decreased levels of immunoglobulins (IgG 416Y650 mg/dL) as well as those of the monoclonal IgG peak (100Y130 mg/dL) and free J chains (73.1 mg/L). The patient is now receiving bimonthly cyclophosphamide and dexamethasone, and the skin lesions have not appeared in a 4-year follow-up period.
DISCUSSION Cryoglobulins are the trigger for most cold-related pathologies. As fibrinogen is consumed during the coagulation process, it is not present in serum, and its identification in cryoprecipitates requires the analysis of plasma samples. Blain et al4 analyzed a series of 220 patients referred to their laboratory because of cryoproteinemia suspicion, and they found that more than 10% of these patients had both cryoglobulins and CF. In this context, the cryoglobulin identification might limit further plasma analysis, and as a consequence, CF presence might be underestimated. When cryoglobulin determination is negative, but a high suspicion of cold-related pathology exists, plasma screening for CF should also be performed. Cold-related vasculitis is usually associated with deposition of immunoglobulins (cryoglobulins). The resulting precipitate leads to the development of leukocyte infiltrates in the blood vessels usually described as leukocytoclastic vasculitis on histopathologic examination.7 In some cases, particularly in monoclonal type 1 cryoglobulinemia,8 this inflammatory process can result in disruption of the endothelial layer, leading to further activation of the coagulation cascade and vascular occlusion by thrombosis. On the other hand, cold-induced thrombotic cutaneous events are the hallmark of cryofibrinogenemia.3 Histopathologic descriptions in skin biopsies of patients with this condition usually indicate the presence of occlusive cylinders composed of fibrin,9,10 more akin to abnormalities observed in livedoid vasculopathies.11 Furthermore, leukocytoclastic vasculitis has also been described in some cases of cryofibrinogenemia associated with monoclonal gammmapathy.12 The normal histological distinction between those 2 types of cold-related vasculitis may be blurred when both thrombogenic and inflammatory events are induced by cryoprecipitates composed of fibrinogen and a monoclonal paraprotein. The exact mechanism that leads to CF formation remains unknown in most cases. In a minor number of patients with cryofibrinogenemia, an associated monoclonal paraprotein was found. In some of these cases, the monoclonal component was observed in serum but not in the cryoprecipitate,13,14 whereas in others it was appreciated only after cryoprecipitation.9,10,12 In all of these patients, the monoclonal component was an IgGJ immunoglobulin, and a causative effect of the paraprotein on the
36
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&
Volume 20, Number 1, January 2014
CF precipitation was not established. In our patient, we found an IgGJ paraprotein in both the serum and the cryoprecipitate. Moreover, a triggering effect of the monoclonal component on CF deposition was demonstrated after incubation of a patient’s serum sample and a control plasma. All these findings suggest that immunoglobulins that react with fibrinogen in specific conditions could stand as an alternative mechanism for CF formation. Such an alternative mechanism might be responsible for the generation of at least some cases of cryofibrinogenemia. Collectively, the available evidence suggests that the association of CF and a monoclonal paraprotein is not a rare finding in patients with cryofibrinogenemia, but rather, an underdiagnosed one. Hence, it seems recommendable to screen for monoclonal paraproteins in the serum of patients with CF. In addition, when a triggering effect of a paraprotein on cryoprecipitate formation is established, treatments aimed at reducing the monoclonal paraprotein levels might be more efficacious than other therapies currently used for cryofibrinogenemia. In our patient, the lesions responded dramatically to monthly intravenous administration of a combination of cyclophosphamide and dexamethasone (see Figure, C and D). Cyclophosphamide is an alkylating agent that interferes with cell division by cross-linking cell DNA. Memory B cells are particularly susceptible to the cytotoxic activity of cyclophosphamide.15 This specific feature makes it far more efficient in clearing antigen-specific immunoglobulins than plasmapheresis alone, and it therefore explains the better longterm response to this treatment regimen compared with plasmapheresis cycles. The case we present in this report supports the usefulness of early detection of monoclonal gammopathies in patients with cryofibrinogenemia and the efficacy of B cellYdirected therapies in those cases where a triggering effect of the monoclonal immunoglobulin on CF cryoprecipitation could be established.
ACKNOWLEDGMENTS The authors thank Dr Maria Dolores Suarez Massa for providing histological analysis, follow-up, and advice and Maria Victoria Perez Morente and Palmira Martı´n Villarubia for their excellent technical work.
REFERENCES 1. Korst DR, Kratochvil CH. Cryofibrinogen in a case of lung neoplasm associated with thrombophlebitis migrans. Blood. 1955;10:945Y953. 2. Michaud M, Pourrat J. Cryofibrinogenemia. J Clin Rheumatol. 2013;19:142Y148. 3. Amdo TD, Welker JA. An approach to the diagnosis and treatment of cryofibrinogenemia. Am J Med. 2004;116:332Y337. 4. Blain H, Cacoub P, Musset L, et al. Cryofibrinogenaemia: a study of 49 patients. Clin Exp Immunol. 2000;120:253Y260. 5. Browning CE, Callen JP. Warfarin therapy for liveloid vasculopathy associated with cryofibrinogenemia and hyperhomocysteinemia. Arch Dermatol. 2006;142:75Y78. 6. Saadoun D, Elalamy I, Ghillani-Dalbin P, et al. Cryofibrinogenemia: new insight into clinical and pathogenic features. Am J Med. 2009;122:1128Y1135. 7. Shihabi ZK. Cryoglobulins: an important but neglected clinical test. Ann Clin Lab Sci. 2006;36:395Y408.
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Cryofibrinogenemia and Cyclophosphamide
8. Cohen SJ, Pittelkow MR, Su WP. Cutaneous manifestations of cryoglobulinemia: clinical and histopathological study of seventy-two patients. J Am Acad Dermatol. 1991;25:21Y27.
12. Euler HH, Zeuner RA, Beress R, et al. Monoclonal cryo-antifibrinogenemia. Arthritis Rheum. 1996;39: 1066Y1069.
9. Nash JW, Ross P, Crowson N, et al. The histopathologic spectrum of cryofibrinogenemia in four anatomic sites. Am J Clin Pathol. 2003;119:114Y122.
13. Martin S. Cryofibrinogenemia, monoclonal gammopathy and purpura. Arch Dermatol. 1979;115:208Y211.
10. Bair JS, Wu YC, Lu YC. Cryofibrinogenemia: report of a case. J Formos Med Assoc. 1991;90:99Y104.
14. Rachmilewitz EA, Sacks MI, Path MC, et al. Essential cryofibrinogenemia: clinical, pathological and immunological studies. Israel J Med Sci. 1970;6:32Y43.
11. Tran MD, Be`cherel PA, Cordel N, et al. Atrophie blanche idiopathique. Ann Dermatol Venereol. 2001;128:1003Y1007.
15. Colvin OM. An overview of cyclophosphamide development and clinical applications. Curr Pharmacol Des. 1999;5:555Y560.
* 2013 Lippincott Williams & Wilkins
www.jclinrheum.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
37
Cryofibrinogenemia Triggered by a Monoclonal Paraprotein Successfully Treated With Cyclophosphamide Manuela Moraru, MD,* Miguel Yebra-Bango, MD, PhD,Þ Elisa Cisneros, BS,* Susana Mellor, MD, PhD,Þ Pablo Tutor, MD, PhD,Þ and Fernando Dı´az-Espada, PhD*
Abstract: Cryofibrinogenemia is a rare clinical finding with a yet unknown physiopathogenic mechanism. We describe the case of a woman with cold-induced extensive necrotic lesions that responded poorly to initial corticosteroid and anticoagulant therapies. Serum cryoglobulin determinations were persistently negative. After several years of evolution, she developed severe cold-related skin lesions that required left-leg amputation. Further analysis disclosed the presence of cryofibrinogen and an apparently insignificant serum monoclonal immunoglobulin GJ peak. We additionally demonstrate that the cold precipitation of fibrinogen was directly related to the monoclonal paraprotein presence. The lesions responded dramatically to a B cellYtargeted therapy with intravenous cyclophosphamide and dexamethasone.
serum; plasma sample analysis is required for its identification. Cryofibrinogen precipitates at low temperatures and redissolves at 37-C. Smaller amounts of various plasma proteins involved in the clotting process may also be present in the cryoprecipitate.2 Diverse molecular processes might account for its production. Although inhibitors of plasma fibrinolysis such as >1-antitripsin or >2-macroglobulin could have a triggering effect in CF formation,6 other proteins found in the CF complex might also have a role in its pathogenesis. Here, we report a patient with severe vasculitic lesions and cryofibrinogenemia triggered by the presence of a monoclonal paraprotein. Extensive necrosis affecting the lower leg resolved entirely after treatment with a combination of cyclophosphamide and dexamethasone.
Key Words: cryoproteins, cryofibrinogen, vasculitis, cyclophosphamide
CASE REPORT
(J Clin Rheumatol 2014;20: 34Y37)
C
ryofibrinogenemia is defined by the presence of an abnormal cold-precipitable fibrinogen complex in plasma.1,2 It fundamentally associates with episodes of thrombotic ischemia induced by cold environment. The presence of cryofibrinogen (CF) can be asymptomatic, or it can course with clinical manifestations ranging from self-limited skin involvement to severe, chronic disease that eventually evolves into ischemic necrosis. Sudden unexplained skin changes and CF presence in plasma are required for diagnosis. In addition, occlusion of medium and small vessels evidenced on angiogram and/or skin biopsy showing either leukocytoclastic vasculitis or CF clogging vessels represents supportive evidence for diagnosis.3 Cryofibrinogenemia can present independently or secondary to various inflammatory disorders, malignancy, or infections,4 with no clearly defined treatment of choice. Immunosuppressive, fibrinolytic, and antiplatelet agents as well as plasmapheresis and corticosteroidal antiinflammatory therapies have been attempted with contradictory results.4,5 The definition of a CF production mechanism in any particular case would be of help in choosing a better treatment option. Cryofibrinogen describes a cold-precipitable complex of fibrinogen and other proteins, including in rare cases immunoglobulins. Unlike cryoglobulins, CF cannot be detected in
From the Departments of *Immunology and †Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain. No financial support was received for this study. The authors declare no conflict of interest. Correspondence: Fernando Dı´az-Espada, PhD, Hospital Universitario Puerta de Hierro, Department of Immunology, Joaquin Rodrigo 2, 28222, Majadahonda, Madrid. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 1076-1608/14/2001Y0034 DOI: 10.1097/RHU.0000000000000058
34
www.jclinrheum.com
In 1992, a 56-year-old woman was seen at our hospital for cold-related livedo reticularis, cutaneous macular lesions, and subsequent development of skin ulcerations on her lower limbs. Previous findings had included multinodular goiter with subsequent hypothyroidism treated with levothyroxine and no previous infectious, malignant, or systemic pathologies. Laboratory tests showed unaltered hematologic, serum, and urine biochemical patterns. Evaluation of inflammatory markers revealed normal levels of >1antitripsin, C-reactive protein, erythrocyte sedimentation rate, and complement factors C3 and C4. Rheumatoid factor and antinuclear, antiphospholipid, antithyroid, and antineutrophil cytoplasm antibodies were persistently negative, as were Coombs tests and serum cryoglobulins and cold agglutinin determination. Coagulation tests showed no alterations, and lupus anticoagulant determination and fibrinogen levels were normal. Microbiologic tests excluded acute and chronic infections with human immunodeficiency or hepatitis B and C viruses. Bone marrow biopsy and computed tomography did not reveal any signs of malignancy or hematologic disease. Biopsy of skin lesions showed leukocytoclastic vasculitis (Figure, A). The patient was sequentially treated with oral corticosteroids, dapsone, colchicine, azathioprine, oral cyclophosphamide, and mycophenolate mofetil with incomplete response. After 10 years of indolent evolution with occasional flares of mild cutaneous purpuric lesions, she developed severe cold related skin lesions in both upper and lower extremities. A lower-limb arteriography disclosed small vessel obstruction compatible with distal vasculitis. At that time, the histopathologic examination of a new skin biopsy revealed small vessel thrombotic obstruction (Figure, B). Serial blood examinations performed periodically did not find other relevant alterations. Subsequent oral anticoagulant therapy associated with low-dose oral corticosteroids initially controlled the extension of necrotic lesions; however, after several years of treatment, the patient developed extensive necrotic lesions and required left-leg amputation. The necrotic lesions further expanded to the right leg and upper limbs and were poorly controlled with the therapy regimens used.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Cryofibrinogenemia and Cyclophosphamide
FIGURE. A, Initial studies on a skin biopsy specimen showing substantial inflammatory blood vessel infiltrates (leukocytoclastic vasculitis), with red cell extravasation and fibrinoid necrosis of vessel walls. Small thrombus could be identified in the lumen of some blood vessels (arrow). B, A skin biopsy specimen obtained at the time of cryofibrinogenemia diagnosis showing vascular occlusion with eosinophilic, thrombotic deposits and a moderate inflammatory infiltrate. There was also evidence of epidermal necrosis (periodic acidYSchiff, original magnification 200). Resolution of extensive ulcerated necrotic lesions (C) after cyclophosphamide plus dexamethasone treatment (D). Inset, Washed cryoprecipitates of patient’s plasma (PP) or a mixture of patient’s serum and control plasma (SP+PN) were electrophoresed on an agarose IFE gel (Sebia). Individual lanes were immunofixed with an antifibrinogen (>F) or anti-IgG (>G) antiserum. Lane T was treated with an acidic protein fixative. Nonprecipitated proteins were washed out with saline solution, and then the gel was stained with Coomassie blue. Color figure available online at www.jclinrheum.com.
Exhaustive evaluation after the last radical surgery showed unaltered biochemical, hematologic, and coagulation patterns. The laboratory results at this time point revealed low levels of immunoglobulins: IgG 680 mg/dL (reference interval, 600Y1600 mg/dL), IgM 84 mg/dL (40Y250 mg/dL), and IgA 125 mg/dL (70Y400 mg/dL). Serum protein electrophoresis followed by immunofixation revealed the presence of a faint band corresponding to a monoclonal IgGJ paraprotein. Densitometric scanning of agarose gels quantified the monoclonal peak as 180 mg/dL. Serum free light chains levels were as follows: J 111.4 mg/L (reference interval, 3.30Y19.40 mg/L), L 2.30 mg/L (5.70Y26.30 mg/L). Urine analysis disclosed a Bence-Jones J protein. A subsequent biopsy showed normal bone marrow. In the absence of hematologic disease, the paraprotein detected * 2013 Lippincott Williams & Wilkins
in the patient’s serum could be classed as a gammapathy of undetermined significance. Cryoglobulin determinations were, again, negative. However, as a high suspicion of cold-related pathology persisted, we searched for the presence of CF. Citrated blood samples were incubated at 4-C for 72 hours, and an important amount of precipitate was formed (plasma cryocrit, 14%). Protein electrophoresis of the washed cryoprecipitate showed 2 bands, one of similar electrophoretic mobility to the paraprotein identified in the serum and the other coincident with the expected A2 migration pattern of fibrinogen. This was further confirmed by immunofixation tests with specific antibodies to IgG and fibrinogen (Figure, inset). We hypothesized that the formation of the cryoprecipitate was directly related to the presence of the monoclonal paraprotein. To address this, we incubated www.jclinrheum.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
35
JCR: Journal of Clinical Rheumatology
Moraru et al
patient serum with plasma from a normal individual at 4-C and observed a cryoprecipitate comparable to that formed in the patient plasma alone. Immunofixation of the cryoprecipitate revealed the presence of fibrinogen (normal sample) and the IgG paraprotein (patient serum) (Figure, inset). We assumed that the vasculitic lesions were initiated by the reaction of the monoclonal IgG component and the patient’s fibrinogen. At that time, necrotic lesions persisted in the patient’s lower limb (Figure, C), and after local debridement, we decided to start a treatment aimed at reducing the monoclonal component. Limited response to initial cycles of plasmapheresis led us to start a more specific treatment for B cellYderived malignancies. Subsequent monthly intravenous administration of a combination of cyclophosphamide and dexamethasone achieved satisfactory clinical improvement (Figure, D). Laboratory follow-up showed minimal (G3%), maintained plasma cryocrit levels. Quantification of serum proteins over a 1-year period after treatment revealed decreased levels of immunoglobulins (IgG 416Y650 mg/dL) as well as those of the monoclonal IgG peak (100Y130 mg/dL) and free J chains (73.1 mg/L). The patient is now receiving bimonthly cyclophosphamide and dexamethasone, and the skin lesions have not appeared in a 4-year follow-up period.
DISCUSSION Cryoglobulins are the trigger for most cold-related pathologies. As fibrinogen is consumed during the coagulation process, it is not present in serum, and its identification in cryoprecipitates requires the analysis of plasma samples. Blain et al4 analyzed a series of 220 patients referred to their laboratory because of cryoproteinemia suspicion, and they found that more than 10% of these patients had both cryoglobulins and CF. In this context, the cryoglobulin identification might limit further plasma analysis, and as a consequence, CF presence might be underestimated. When cryoglobulin determination is negative, but a high suspicion of cold-related pathology exists, plasma screening for CF should also be performed. Cold-related vasculitis is usually associated with deposition of immunoglobulins (cryoglobulins). The resulting precipitate leads to the development of leukocyte infiltrates in the blood vessels usually described as leukocytoclastic vasculitis on histopathologic examination.7 In some cases, particularly in monoclonal type 1 cryoglobulinemia,8 this inflammatory process can result in disruption of the endothelial layer, leading to further activation of the coagulation cascade and vascular occlusion by thrombosis. On the other hand, cold-induced thrombotic cutaneous events are the hallmark of cryofibrinogenemia.3 Histopathologic descriptions in skin biopsies of patients with this condition usually indicate the presence of occlusive cylinders composed of fibrin,9,10 more akin to abnormalities observed in livedoid vasculopathies.11 Furthermore, leukocytoclastic vasculitis has also been described in some cases of cryofibrinogenemia associated with monoclonal gammmapathy.12 The normal histological distinction between those 2 types of cold-related vasculitis may be blurred when both thrombogenic and inflammatory events are induced by cryoprecipitates composed of fibrinogen and a monoclonal paraprotein. The exact mechanism that leads to CF formation remains unknown in most cases. In a minor number of patients with cryofibrinogenemia, an associated monoclonal paraprotein was found. In some of these cases, the monoclonal component was observed in serum but not in the cryoprecipitate,13,14 whereas in others it was appreciated only after cryoprecipitation.9,10,12 In all of these patients, the monoclonal component was an IgGJ immunoglobulin, and a causative effect of the paraprotein on the
36
www.jclinrheum.com
&
Volume 20, Number 1, January 2014
CF precipitation was not established. In our patient, we found an IgGJ paraprotein in both the serum and the cryoprecipitate. Moreover, a triggering effect of the monoclonal component on CF deposition was demonstrated after incubation of a patient’s serum sample and a control plasma. All these findings suggest that immunoglobulins that react with fibrinogen in specific conditions could stand as an alternative mechanism for CF formation. Such an alternative mechanism might be responsible for the generation of at least some cases of cryofibrinogenemia. Collectively, the available evidence suggests that the association of CF and a monoclonal paraprotein is not a rare finding in patients with cryofibrinogenemia, but rather, an underdiagnosed one. Hence, it seems recommendable to screen for monoclonal paraproteins in the serum of patients with CF. In addition, when a triggering effect of a paraprotein on cryoprecipitate formation is established, treatments aimed at reducing the monoclonal paraprotein levels might be more efficacious than other therapies currently used for cryofibrinogenemia. In our patient, the lesions responded dramatically to monthly intravenous administration of a combination of cyclophosphamide and dexamethasone (see Figure, C and D). Cyclophosphamide is an alkylating agent that interferes with cell division by cross-linking cell DNA. Memory B cells are particularly susceptible to the cytotoxic activity of cyclophosphamide.15 This specific feature makes it far more efficient in clearing antigen-specific immunoglobulins than plasmapheresis alone, and it therefore explains the better longterm response to this treatment regimen compared with plasmapheresis cycles. The case we present in this report supports the usefulness of early detection of monoclonal gammopathies in patients with cryofibrinogenemia and the efficacy of B cellYdirected therapies in those cases where a triggering effect of the monoclonal immunoglobulin on CF cryoprecipitation could be established.
ACKNOWLEDGMENTS The authors thank Dr Maria Dolores Suarez Massa for providing histological analysis, follow-up, and advice and Maria Victoria Perez Morente and Palmira Martı´n Villarubia for their excellent technical work.
REFERENCES 1. Korst DR, Kratochvil CH. Cryofibrinogen in a case of lung neoplasm associated with thrombophlebitis migrans. Blood. 1955;10:945Y953. 2. Michaud M, Pourrat J. Cryofibrinogenemia. J Clin Rheumatol. 2013;19:142Y148. 3. Amdo TD, Welker JA. An approach to the diagnosis and treatment of cryofibrinogenemia. Am J Med. 2004;116:332Y337. 4. Blain H, Cacoub P, Musset L, et al. Cryofibrinogenaemia: a study of 49 patients. Clin Exp Immunol. 2000;120:253Y260. 5. Browning CE, Callen JP. Warfarin therapy for liveloid vasculopathy associated with cryofibrinogenemia and hyperhomocysteinemia. Arch Dermatol. 2006;142:75Y78. 6. Saadoun D, Elalamy I, Ghillani-Dalbin P, et al. Cryofibrinogenemia: new insight into clinical and pathogenic features. Am J Med. 2009;122:1128Y1135. 7. Shihabi ZK. Cryoglobulins: an important but neglected clinical test. Ann Clin Lab Sci. 2006;36:395Y408.
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Cryofibrinogenemia and Cyclophosphamide
8. Cohen SJ, Pittelkow MR, Su WP. Cutaneous manifestations of cryoglobulinemia: clinical and histopathological study of seventy-two patients. J Am Acad Dermatol. 1991;25:21Y27.
12. Euler HH, Zeuner RA, Beress R, et al. Monoclonal cryo-antifibrinogenemia. Arthritis Rheum. 1996;39: 1066Y1069.
9. Nash JW, Ross P, Crowson N, et al. The histopathologic spectrum of cryofibrinogenemia in four anatomic sites. Am J Clin Pathol. 2003;119:114Y122.
13. Martin S. Cryofibrinogenemia, monoclonal gammopathy and purpura. Arch Dermatol. 1979;115:208Y211.
10. Bair JS, Wu YC, Lu YC. Cryofibrinogenemia: report of a case. J Formos Med Assoc. 1991;90:99Y104.
14. Rachmilewitz EA, Sacks MI, Path MC, et al. Essential cryofibrinogenemia: clinical, pathological and immunological studies. Israel J Med Sci. 1970;6:32Y43.
11. Tran MD, Be`cherel PA, Cordel N, et al. Atrophie blanche idiopathique. Ann Dermatol Venereol. 2001;128:1003Y1007.
15. Colvin OM. An overview of cyclophosphamide development and clinical applications. Curr Pharmacol Des. 1999;5:555Y560.
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