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Natali P, Debbia D, Cucinelli MR, Trenti T, Amati G, Spinella A, Giuggioli D, Mascia MT, Sandri G. Analysis of cryoproteins with a focus on cryofibrinogen: a study on 103 patients. Clin Chem Lab Med 2022; 60:1796-1803. [PMID: 36082756 DOI: 10.1515/cclm-2022-0423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/31/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Cryofibrinogen (CF) is an abnormal protein in plasma that precipitates at 4 °C and dissolves at 37 °C. Whilst serum cryoglobulins (CGs) analysis is common practice, CF investigation is rarely performed. This study aims to describe the testing methodology developed at our laboratory, potential pitfalls for all analytical phases, the distribution among hospital wards and clinical conditions underlying test requests and clinical conditions in which to order CF analysis is useful. METHODS Retrospective analysis of laboratory samples received between January 2019 and June 2021 with CF testing requests. RESULTS A complete protocol for CF pre-analytical, analytical and post-analytical phases are supplied. Most test requests were received from the rheumatology department for systemic sclerosis or liver transplant screening. Among the 103 in-patients included, CF+ was confirmed in 68 patients (66%). Of observed CF+ patients (n=68) most cases were CGs- (n=44, 67%). Isolated CF was found in 43% of the cases. Among CF- patients (n=35; 34%) only 2 patients had positive CGs (CGs+). Among rheumatology patients (n=66), isolated CF+ was observed in 45% (n=30/66), whilst among patients with systemic sclerosis with CF+ (n=19), isolated CF+ was detected in 79% (n=15/19). CONCLUSIONS Described analytical procedures may be used for the creation of harmonized recommendations and indications for CF analysis. Isolated CF positivity among hospitalized patients, predominantly rheumatology and systemic sclerosis patients, appears higher than rates previously reported in literature. We propose CF test recommendations should be included in investigation protocols for diseases where cryofibrinogenemia may occur.
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Affiliation(s)
- Patrizia Natali
- Department of Laboratory Medicine and Pathological Anatomy, Azienda Ospedaliero-Universitaria e Azienda USL di Modena, Modena, Italy
| | - Daria Debbia
- Department of Laboratory Medicine and Pathological Anatomy, Azienda Ospedaliero-Universitaria e Azienda USL di Modena, Modena, Italy
| | - Maria R Cucinelli
- Department of Laboratory Medicine and Pathological Anatomy, Azienda Ospedaliero-Universitaria e Azienda USL di Modena, Modena, Italy
| | - Tommaso Trenti
- Department of Laboratory Medicine and Pathological Anatomy, Azienda Ospedaliero-Universitaria e Azienda USL di Modena, Modena, Italy
| | - Gabriele Amati
- Chair of Rheumatology - Department of Maternal, Child and Adult Medical and Surgical Sciences, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Amelia Spinella
- Chair of Rheumatology - Department of Maternal, Child and Adult Medical and Surgical Sciences, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Dilia Giuggioli
- Chair of Rheumatology - Department of Maternal, Child and Adult Medical and Surgical Sciences, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Maria T Mascia
- Chair of Rheumatology - Department of Maternal, Child and Adult Medical and Surgical Sciences, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Gilda Sandri
- Chair of Rheumatology - Department of Maternal, Child and Adult Medical and Surgical Sciences, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
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Santiago MB, Melo BS. Cryofibrinogenemia: What Rheumatologists Should Know. Curr Rheumatol Rev 2022; 18:186-194. [PMID: 35339184 DOI: 10.2174/1573397118666220325110737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/13/2021] [Accepted: 01/31/2022] [Indexed: 11/22/2022]
Abstract
Cryofibrinogenemia refers to the presence of cryofibrinogen in plasma. This protein has the property of precipitating at lower temperatures. Cryofibrinogenemia is a rare disorder, clinically characterized by skin lesions, such as ulcers, necrosis, livedo reticularis, arthralgia, thrombosis, and limb ischemia. These features are most often observed in rheumatological practice and consist in the differential diagnoses of antiphospholipid syndrome, primary vasculitis, thrombotic thrombocytopenic purpura, and cryoglobulinemia. Classical histopathological findings include the presence of thrombi within the lumen of blood vessels of the skin without vasculitis. To date, there are no validated classification criteria. Management includes corticosteroids, immunosuppressive therapy, anticoagulants, and fibrinolytic agents. This narrative review aims to make physicians, particularly rheumatologists, aware of existence of this underdiagnosed condition. There are no epidemiological studies evaluating the prevalence of cryofibrinogenemia in different rheumatological disorders. Studies are also required to investigate if certain features of rheumatological diseases are related to the presence of cryofibrinogenemia.
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Affiliation(s)
- Mittermayer B Santiago
- Hospital Santa Izabel, Praça Almeida Couto 500, CEP: 40.000-000, Salvador, Bahia, Brazil.
- Serviços Especializados em Reumatologia da Bahia, Rua Conde Filho, 117, CEP: 40150-150, Salvador, Bahia, Brazil.
- Serviço de Reumatologia do Hospital Universitário Professor Edgard Santos, Rua Augusto Viana, CEP: 40110-060, Salvador, Bahia, Brazil.
- Escola Bahiana de Medicina e Saúde Pública, Av. Dom João VI, 275, CEP: 40290-000, Salvador, Bahia, Brazil
| | - Bartira Souza Melo
- Hospital Santa Izabel, Praça Almeida Couto 500, CEP: 40.000-000, Salvador, Bahia, Brazil
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Sudo M, Sakamaki Y, Hosojima M, Yamamoto S, Ito Y, Imai N, Kaneko Y, Goto S, Li CP, Shimizu A, Narita I. Cryofibrinogen-associated glomerulonephritis diagnosed by mass spectrometry and immunoelectron microscopy. HUMAN PATHOLOGY: CASE REPORTS 2019. [DOI: 10.1016/j.ehpc.2018.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rodrigues F, Bachmeyer C. Comment on: Cryofibrinogenaemia—a neglected disease. Rheumatology (Oxford) 2018; 57:767-768. [DOI: 10.1093/rheumatology/kex472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/31/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Claude Bachmeyer
- Department of Internal Medicine, Tenon Hospital (AP-HP), Paris, France
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5
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Moiseev S, Luqmani R, Novikov P, Shevtsova T. Cryofibrinogenaemia-a neglected disease. Rheumatology (Oxford) 2017; 56:1445-1451. [PMID: 27789759 DOI: 10.1093/rheumatology/kew379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Indexed: 11/14/2022] Open
Abstract
Cryofibrinogen is an abnormal protein that forms precipitate only in plasma. Cryofibrinogenaemia (CF) can be detected both in healthy persons and patients with autoimmune diseases, cancer and infections. Essential CF is frequently asymptomatic, although in a proportion of patients it is associated with skin lesions and systemic manifestations and can lead to refractory skin ulcers and gangrene or thrombotic events. Identification of CF in plasma is simple, but establishing a definite diagnosis may be a challenge due to a lack of accepted diagnostic criteria. Several treatment options have been suggested for patients with symptomatic CF, although their efficacy has been shown only in uncontrolled series or case reports. A variety of possible approaches to drug treatment poses additional problems for the physician. Treatment for secondary CF usually relies on effective management of the underlying disease. The clinical significance of CF and its true prevalence are apparently underestimated and should be further studied.
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Affiliation(s)
- Sergey Moiseev
- Clinic of Nephrology, Internal and Occupational Diseases, Sechenov First Moscow State Medical University.,Department of Internal Medicine, Faculty of Medicine, Lomonosov Moscow State Medical University, Moscow, Russia
| | - Raashid Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - Pavel Novikov
- Clinic of Nephrology, Internal and Occupational Diseases, Sechenov First Moscow State Medical University
| | - Tatiana Shevtsova
- Department of Internal Medicine, Faculty of Medicine, Lomonosov Moscow State Medical University, Moscow, Russia
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6
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Abstract
Chronic skin ulcers are frequently encountered in clinical practice and are often due to very heterogeneous etiologies. Cryofibrinogenemia is an unusual cause of non-healing skin ulcers. It is a small-vessel occlusive vascular disorder that results from the precipitation of cryofibrinogens in plasma. The lack of definitive diagnostic criteria means cryofibrinogenemia remains an under-diagnosed entity that causes significant morbidity. One of the most common manifestations of cryofibrinogenemia is skin ulceration. The presence of non-healing ulcers in otherwise healthy patients with no evidence of large-vessel disease should raise the suspicion of essential cryofibrinogenemia. An important clinical feature is the presence of microlivedo, which represents short hyperpigmented linear streaks around the ulcer or even distally about the foot. Histopathologic findings are microthrombi in the dermis and not confined exclusively to the ulcerated area. Cryofibrinogenemia can be secondary to an underlying disorder, so careful investigation to exclude other etiologies is always necessary.
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Sethi S, Yachoui R, Murray DL, Radhakrishnan J, Alexander MP. Cryofibrinogen-Associated Glomerulonephritis. Am J Kidney Dis 2017; 69:302-308. [DOI: 10.1053/j.ajkd.2016.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/17/2016] [Indexed: 11/11/2022]
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Cryofibrinogénémie : étude monocentrique au CHU de Toulouse. Rev Med Interne 2015; 36:237-42. [DOI: 10.1016/j.revmed.2014.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 07/24/2014] [Accepted: 09/17/2014] [Indexed: 11/23/2022]
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Bendjama K, Guionaud S, Aras G, Arber N, Badimon L, Bamberger U, Bratfalean D, Brott D, David M, Doessegger L, Firat H, Gallas JF, Gautier JC, Hoffmann P, Kraus S, Padro T, Saadoun D, Szczesny P, Thomann P, Vilahur G, Lawton M, Cacoub P. Translation Strategy for the Qualification of Drug-induced Vascular Injury Biomarkers. Toxicol Pathol 2014; 42:658-71. [DOI: 10.1177/0192623314527644] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Drug-induced vascular injury (DIVI) is a common preclinical toxicity usually characterized by hemorrhage, vascular endothelial and smooth muscle damage, and inflammation. DIVI findings can cause delays or termination of drug candidates due to low safety margins. The situation is complicated by the absence of sensitive, noninvasive biomarkers for monitoring vascular injury and the uncertain relevance to humans. The Safer And Faster Evidence-based Translation (SAFE-T) consortium is a public–private partnership funded within the European Commission’s Innovative Medicines Initiative (IMI) aiming to accelerate drug development by qualifying biomarkers for drug-induced organ injuries, including DIVI. The group is using patients with vascular diseases that have key histomorphologic features (endothelial damage, smooth muscle damage, and inflammation) in common with those observed in DIVI, and has selected candidate biomarkers associated with these features. Studied populations include healthy volunteers, patients with spontaneous vasculitides and other vascular disorders. Initial results from studies with healthy volunteers and patients with vasculitides show that a panel of biomarkers can successfully discriminate the population groups. The SAFE-T group plans to seek endorsement from health authorities (European Medicines Agency and Food and Drug Administration) to qualify the biomarkers for use in regulatory decision-making processes.
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Affiliation(s)
| | | | | | - Nadir Arber
- Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Lina Badimon
- Cardiovascular Research Center, CSIC-ICCC, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Uwe Bamberger
- Boehringer Ingelheim Pharma GmbH & Co. KG Nonclinical Drug Safety Biberach/Riss, Germany
| | | | - David Brott
- AstraZeneca Pharmaceuticals, Translational Patient Safety and Enabling Sciences, Wilmington, Delaware, USA
| | - Maayan David
- Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | | | | | - Peter Hoffmann
- Novartis Pharmaceuticals Corporation, Preclinical safety, East Hanover, New Jersey, USA
| | - Sarah Kraus
- Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Teresa Padro
- Cardiovascular Research Center, CSIC-ICCC, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - David Saadoun
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France; Département Hospitalo-Universitaire I2B, UPMC Univ Paris 06, F-75005, Paris, France; INSERM UMR 7211, F-75005, Paris, France; INSERM, UMR_S 959, F-75013, Paris, France; CNRS, UMR 7211, F-75005, Paris, France
| | | | | | - Gemma Vilahur
- Cardiovascular Research Center, CSIC-ICCC, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Michael Lawton
- Pfizer Worldwide Research & Development, Drug Safety Research & Development, Groton, Connecticut, USA
| | - Patrice Cacoub
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France; Département Hospitalo-Universitaire I2B, UPMC Univ Paris 06, F-75005, Paris, France; INSERM UMR 7211, F-75005, Paris, France; INSERM, UMR_S 959, F-75013, Paris, France; CNRS, UMR 7211, F-75005, Paris, France
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Abstract
Cryofibrinogenemia is a cryoprotein that was first identified in 1955 by Korst and Kratochvil. Unlike cryoglobulin, the precipitate forms only in plasma and not in the serum. The presence of cryofibrinogen in plasma can be asymptomatic. Cryofibrinogenemia is considered a rare disorder: its prevalence varies from 0% to 7% in healthy subjects and from 8% to 13% in hospitalized patients. Nevertheless, cryofibrinogenemia, when a cryopathy is clinically suspected, has been reported in 12% to 51% of patients. Skin manifestations are usually the first signs and are usually moderate; in addition, cold intolerance, Raynaud phenomenon, purpura, or livedo reticularis often occurs. Skin necrosis, acral ulcers, and gangrene can lead to surgery and amputation. Systemic manifestations are common, and arterial or venous thrombotic events are frequent. Cryofibrinogenemia may be primary (essential) or secondary to other underlying disorders, such as carcinoma, infection, vasculitis, collagen disease, or associated with cryoglobulinemia. The histological features of cryofibrinogenemia can confirm the presence of cryofibrinogen within small and medium arteries, plus occlusive thrombotic diathesis composed of eosinophilic refractile deposits within vessel lumina. Cryofibrinogenemia is a treatable and potentially reversible disease.In moderate forms, it can be treated by simply avoiding cold temperatures. The use of corticosteroids in association with low-dose aspirin is the treatment of choice for moderate forms, although stanozolol is an alternative maintenance therapy. Immunosuppressive therapies, plasmapheresis, and/or intravenous fibrinolysis are useful at treating severe forms of cryofibrinogenemia. The use of anticoagulants is limited to the management of thrombotic events. Treatment of secondary cryofibrinogenemia involves the management of associated diseases. Regular follow-ups are needed because of the high risk of recurrence. Moreover, up to half of patients with cryofibrinogenemia considered as essential may develop lymphomas in the following years. Compared with cryoglobulinemia, less is known about cryofibrinogenemia. Its diagnosis should be considered when suggestive clinical manifestations are present and when there are specific biopsy findings. Although identification of cryofibrinogen in blood samples is simple and inexpensive, cryofibrinogenemia can be asymptomatic, and a lack of diagnosis criteria can make diagnosis difficult to confirm. This review describes the clinical manifestations and the biological and pathological features and discusses the criteria used to diagnose and manage cryofibrinogenemia.
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