Clinical vignette: Warm weather and plasmapheresis in the management of Hepatitis C cryoglobulinemia

A 51-year-old male with untreated chronic HCV presented to a rural hospital with a worsening bilateral lower extremity rash. He had recently been diagnosed with MPGN, severe anemia, and congestive heart failure. Cryoglobulinemic vasculitis was suspected, and the patient was referred to a larger regional hospital for further evaluation and plasmapheresis. On admission, the patient had pancytopenia and worsening renal function. Physical examination was consistent with painful palpable purpura involving both lower extremities. Initial testing showed Hep C viral load of 3.8 million, and serologic testing confirmed the presence of cryoglobulins. After a blood transfusion, plasmapheresis was initiated daily for 3 days then the frequency was decreased to every other day. After 6 rounds of plasmapheresis, renal function and the lower extremity rash had improved significantly. Hep C therapy was considered but was not possible due to the patients multiple contraindications including severe anemia, renal failure, CHF, and poor adherence to previous medication prescriptions. The patient was discharged and readmitted several times due to recurrence of painful lower extremity rash and fatigue. After each discharge, the patient would return to his hometown at a higher altitude and with a colder climate, likely exacerbating his CG. The patient was advised to move to a warmer climate and to continue plasmapheresis until he was a candidate for HCV therapy. He underwent a total of 30 sessions of plasmapheresis by the time of his last discharge. This case provides an example of the relative success of long term plasmapheresis for symptom management in patients with HCV-induced CG who are not candidates for HCV treatment.\u2