HCV Infection with Palpable Purpura - Patient Case of the Week
Try this case and test your knowledge of HCV infection.
A 40-year-old woman with a history of illicit intravenous drug abuse and hepatitis C virus (HCV) infection presents with a skin rash and arthritis affecting her hands and elbows. She also complains of severe weakness and fatigue. She has had long-term elevated transaminase levels, but she has declined treatment for fear of potential adverse events.
Physical examination reveals palpable purpura over her extremities (see Figure), swollen and tender joints in the elbows and hands, and a diminished sensation with a "stocking and glove" distribution in her extremities.
Which of the following tests will confirm the diagnosis?
The correct answer is:
serum cryoglobulin testing
Examine the link between hepatitis C virus infection and cryoglobulinemic vasculitis.
HCV infection is associated with a mixed cryoglobulinemic syndrome, which should be suspected among infected patients who present with palpable purpura, arthralgias, and renal insufficiency.
Patients with long-term HCV infection are at risk for developing mixed cryoglobulinemia syndrome. Cryoglobulinemic vasculitis may present with a single manifestation or a combination of palpable purpura, Raynaud phenomenon, arthralgias or arthritis, kidney disease, and peripheral neuropathy. Patients with cryoglobulinemia have hypocomplementemia, typically with very low C4 levels, and positive rheumatoid factor.
Testing for serum cryoglobulins is diagnostic. Importantly, cryoglobulins are tested by drawing blood in tubes that have been prewarmed to 37°C (98.6°F) without anticoagulants; false-negative results are possible without this preparatory step.
A kidney biopsy and electromyography will show glomerulonephritis and peripheral neuropathy, but neither will confirm the diagnosis. A liver biopsy would only confirm HCV infection.
Arntfield RT, Hicks CM. Systemic lupus erythematosus and the vasculitides (Chapter 108). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1402-1417.
Himoto T, Masaki T. Extrahepatic manifestations and autoantibodies in patients with hepatitis C virus infection. Clin Dev Immunol. 2012;2012:871401.
Lauletta G, Russi S, Conteduca V, Sansonno L. Hepatitis C virus infection and mixed cryoglobulinemia. Clin Dev Immunol. 2012;2012:502156.
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