cryoglobulins are special serum immunoglobulin 's that usually precipitate at a temperature between 0c and 4c and dissolve when re - warmed to 37c . this in vitro phenomenon can be observed in a wide spectrum of infectious diseases , autoimmune disorders and with hematological malignancies . both type i and type ii are associated with lymphoproliferative disorders . during the winters in the north india temperature such cold weather is likely to produce cold - induced symptoms in patients with cryoglobulinemia . as very low temperature is unusual in indian subcontinent , cases of cryoglobulinemia are usually remains symptomless and hence undetected . we encountered an interesting case of cryoglobulinemia in a 68-year - old - male who presented with cryoglobulinemic manifestations for the last 18 months . a 68-year - old male patient who was chronic alcoholic presented with complain of headache on and off for the last 18 months before presenting to us in september 2011 . , there was hepatomegaly ( 3 cm below costal margin ) and splenomegaly ( 2 cm below costal margin ) however no palpable lymph nodes are noted . in the past history however , he was not able to get any report since his sample clotted soon after sampling . although , phlebotomist had taken the venous blood sample but it clots itself even in the presence of anticoagulants . following this , patient was called on the next day and sampling was done by maintaining the whole set up temperature at 37c and above . serological investigations for hepatitis b virus , hepatitis c virus , and human immunodeficiency virus infection were performed to exclude any viral infection and no associated infective etiology was found . serum sample for detection of antibodies ( rheumatoid factor , antinuclear antibodies , smooth muscle antibody , anti - mitochondrial antibody ) for any underlying autoimmune disorder was sent for however all the tests came negative . the hemogram showed bicytopenia with hemoglobin of 3.9/dl and total leucocyte count of 2.9  10/l . the marrow was cellular and clotted ; however showed the presence of homogenous pale pink background due to the presence of cryoglobulins [ figure 1b ] . differential nucleated cell count showed extensive increase in lymphocytes ( 73% ) along with plasma cells ( 8% ) [ figure 1c ] . the sinusoids were dilated and are filled with pale eosinophillic material ( cryoglobulins ) [ figure 1d ] . immunophenotying was performed on bone marrow sample and that showed expression of cd19 , cd79b along with heterogeneous expression of cd23 [ figure 2 ] . serum protein electrophoresis showed the presence of sharp m band in the gamma region , hence proving monoclonality of disease . on the basis of peripheral blood , bone marrow and flowcytometry findings a diagnosis of lymphoplasmacytic lymphoma was made . the patient was started on prednisolone 1 mg / kg / day and was asked to report weekly . the patient is now in follow - up and show improvement in their symptoms and easy sampling of blood . peripheral blood shows rouleaux formation ( mgg - giemsa , 400 ) ( a ) . bone marrow aspirate shows presence of pink homogenous material due to cryoglobulins ( mgg - giemsa , 200 ) ( b ) . high power view demonstrates increase in numbers of lymphocytes and plasma cells ( mgg - giemsa , 1000 ) ( c ) . dilated sinusoids filled with pale eosinophillic material are seen on trephine biopsy section ( h and e , 100 ) ( d ) panel of scatter plots showing the multicolor immunophenotyping of bone marrow aspirate sample by flow cytometry . the gating of cells in each tube has been done on side scatter - a ( ssc - a ) versus forward scatter - a ( fsc - a ) ( a ) . the cell is lymphoid region p1 were subsequently gated in ssc - a versus cd19 plot with the gated p2 population showing surface cd19 expression ( b ) . the gated cells show heterogeneous expression of cd23 along with homogeneous expression of cd79b ( c and d ) cryoglobulins are proteins that can precipitate at low temperatures ( < 4c ) and dissolve when re - warmed to 37c . the cryoglobulin can be defined on the basis of its composition : polyclonal or monoclonal immunoglobulins ; or the presence of rheumatoid activity ( ra ) . three types of cryoglobulinemia have been identified namely : type i includes monoclonal cryoglobulins ( igm , igg and iga ) without any ra ; type ii includes a monoclonal component ( usually igm with ra ) and a polyclonal component ( usually igm / igg ) ; type iii have several polyclonal components and a component with ra ( usually igg / igm ) . type ii and type iii are classically referred to as mixed cryoglobulinemia . in general , cryoglobulinemia regardless of their type are associated with skin manifestations , but may also cause rheumatologic symptoms that involve the kidneys , the peripheral nerves or central nervous system , the lungs , the myocardium and the gastrointestinal tract . interesting type i cryoglobulinemia is associated with low grade lymphoproliferative disorders such as multiple myeloma , waldenstrom macroglobulinemia , chronic lymphatic leukemia and account for 10 - 15% of all cases of cryoglobulinemia . type ii cryoglobulinemia is associated not only with lymphoproliferative diseases but also with autoimmune disorders and infective etiologies especially hepatitis . this case is also having lymphoplasmacytic lymphoma and hence can be categorized in to type i cryoglobulinemia . in tropical and subtropical countries like india where the winter is either nonexistent or very brief , most of the patient with cryoglobulinemia did not show any symptoms and remain undetected . in this case , difficulty in processing of sample raises the suspicion of disease which was confirmed by bone marrow examination and by exclusion of other autoimmune etiology along with infective pathology . the diagnosis of lymphoplasmacytic lymphoma on bone marrow aspiration solves the underlying pathogenesis of the cryoglobulinemia . we presented a case of cryoglobulinemia which is very rare in indian subcontinent and was suspected due to the problem in sampling and processing of the blood .