Cyroglobulinemia in Chronic Hepatitis B Infection with Undetectable Viral Load

Abstract

A 53 year old woman with history of chronic hepatitis B presents with palpable purpura of the lower extremities and recurrent hematuria. She was found to have elevated creatinine (1.4 mg/dl increased from her baseline of 0.8 mg/dl) and proteinuria (6.8 mg/dl). Renal biopsy revealed membranoproliferative glomerulonephritis and epidermal biopsy revealed leukocytoclastic vasculitis. Serum cryoglobulin precipitate was positive and Hepatitis B viral load was initially undetectable as the sample was allowed to cool to room temperature. A repeat sample was retested while keeping the serum above 37°C, this time the viral load was found to be elevated at 361 copies/ml. Both antiviral (entecavir) and immunosuppressive therapy (cyclophosphamide and prednisone) were initiated and the patient's skin and renal manifestations improved rapidly. Proper communication between the clinician and laboratory is essential to ensure an accurate diagnosis in the context of cryoglobulinemic vasculitis.