Cutaneous lesions and finger clubbing uncovering hypocomplementemic\nurticarial vasculitis and hepatitis C with mixed cryoglobulinemia
A 49-year-old woman presented with a 1-year history of highly pruritic generalized\ncutaneous lesions. She denied systemic symptoms. She was otherwise healthy and was on no\nregular medication. Physical examination revealed localized urticarial wheals and\npurpuric macules on the forearms, wrists, thighs, legs and dorsum of the feet; according\nto the patient, the lesions lasted longer than 24 hours and resolved with\nhyperpigmentation (-). Finger clubbing was also evident (). There were no other findings on physical examination.\nHistopathologic examination of a cutaneous lesion showed a perivascular inflammatory\ninfiltrate in the superficial and mid dermis, composed mainly of polymorphonuclear\nneutrophils and rare eosinophils, associated with fibrinoid necrosis of the vascular\nwall and leukocytoclasia (). These\nfeatures were consistent with a leukocytoclastic vasculitis. Laboratory tests disclosed\nincreased liver enzymes (ALT 90 U/L, normal 10-30, AST 96 U/L, normal 1036), positive\nanti-hepatitis C virus (HCV) antibodies with high titres of serum HCV RNA (720000 UI/L),\nlow complement levels (C1q 3.0 mg/dL, normal 12.220.8; C4 < 2 mg/dL, normal 12-42)\nand type II mixed cryoglobulinemia (cryoglobulins 187 mcg/mL, mixed type II\nIgG-IgM/Kappa). The remainder of the laboratory tests were negative or within the normal\nrange. Abdominal ultrasound showed diffuse hepatic steatosis and thorax x-ray was\nunremarkable. Altogether clinical, laboratory and histopathological findings allowed the\ndiagnosis of hypocomplementemic urticarial vasculitis and hepatitis C with myxed\ncryoglobulinemia. The patient started symptomatic treatment with hydroxyzine 25 mg PO\nbid, with partial control of the pruritus, and was referred to a gastroenterology\nconsultation for management of the hepatic condition. A liver biopsy was performed and\nshowed features of chronic hepatitis with scarce fibrosis. In the meantime, liver enzyme\nlevels returned to the normal range (ALT 22 U/L, normal 10-30, AST 28 U/L, normal\n10-36). This was accompanied by progressive clearance of cutaneous lesions and\nresolution of the pruritus; residual hypopigmentation persisted in the sites of previous\nscratching. Given the benign liver pathology and the lack of hepatitis C activity, it\nwas decided by the gastroenterology specialist not to start any kind of treatment but to\nkeep the patient under close surveillance instead. The cutaneous condition remains\nstable after one year of follow-up, similar to the hepatic disease course.