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Abstract: FR-PO715

Mixed Cryoglobulinemic Glomerulonephritis Triggered by Influenza Vaccination

Session Information

Category: Glomerular Diseases

  • 1401 Glomerular Diseases: From Inflammation to Fibrosis

Authors

  • Wirtshafter, Stephanie, University of Pennsylvania, Philadephia, Pennsylvania, United States
  • Hanna, Gamil, University of Pennsylvania, Philadephia, Pennsylvania, United States
  • Blum, Marissa, University of Pennsylvania, Philadephia, Pennsylvania, United States
  • Geara, Abdallah Sassine, University of Pennsylvania, Philadephia, Pennsylvania, United States
Introduction

Mixed cryoglobulinemia is associated with viral infections such as hepatitis B or C virus, lymphoproliferative and autoimmune disorders. Influenza vaccine-induced cryoglobulinemia has been rarely reported. We present a rare case of cryoglobulinemic vasculitis following influenza vaccination with new onset renal involvement.

Case Description

A 68-year-old male with history of atrial fibrillation and chorioretinopathy presented in fall 2022 for a rash and edema of the lower extremities and thrombocytopenia after influenza vaccination. Prior, in both 2020 and 2021, he had similar presentation of rash and edema following annual influenza vaccine. His illness was self-limited, but evaluation had shown mixed cryoglobulins. A bone marrow biopsy was unremarkable and viral etiologies were negative. He was diagnosed with idiopathic mixed cryoglobulinemic vasculitis. For recent presentation, in addition to the edema and rash, he had thrombocytopenia and a positive rheumatoid factor (RF). Patient received intravenous immunoglobulin (IVIG) with improvement of rash and platelet count, but his edema persisted. Soon after, he was readmitted and found to have acute kidney injury (AKI) (creatinine of 2.89 mg/dL; baseline 1.2 mg/dL), hematuria, proteinuria, and labs showing RF elevation and low complements. An evaluation for paraprotein revealed IgM kappa and IgA lambda paraproteins, with cryoglobulin elevation in polyclonal fashion including IgG, IgA, but predominately IgM. He received IVIG and creatinine improved. A kidney biopsy showed endocapillary proliferative glomerulonephritis with organized deposits, consistent with mixed-type cryoglobulinemic glomerulonephritis treated with rituximab infusions, resulting in improvement in cryoglobulins and complement levels and renal function, with creatinine at 1.46 mg/dL in May 2023. Of note, plasmapheresis was given for rash from IVIG.

Discussion

Our patient had a favorable outcome after rituximab, IVIG, and plasmapheresis for diagnosis of mixed cryoglobulinema triggered by the influenza vaccine, noting a reduction of cryoglobulins, improved renal function, and resolution of rash. Cryoglobulins can form as an immune response to infections though it is unclear why cryoglobulins are produced as a response to a vaccination. Understanding this novel association and interaction is important for prompt diagnosis and management.