Cryoglobulinemic Vasculitis Stemming from Delayed Recognition of Rheumatoid Arthritis

Vasculite Crioglobulinémica como Apresentação Inicial de Artrite Reumatoide

Resumo

Cryoglobulinemic vasculitis (CV) is an immunocomplex-
-mediated condition with multi-organ involvement and a heterogeneous clinical presentation. CV has been documented in patients with rheumatoid arthritis (RA) but its incidence is nowadays rare due to the early diagnosis and proper therapeutic management of RA, including the emergence of biologic disease-modifying antirheumatic drug therapy.

We report a case of a 61-year-old woman who presented
with a 5-day history of violaceous macular lesions on both
lower limbs, decreased left lower limb sensitivity and inability to walk. She also reported a 17-year history of chronic symmetrical additive polyarthralgia of metacarpophalangeal joints, which was accompanied by synovitis and deformities of these joints.

Blood analysis showed normocytic anemia, elevated
acute phase reactants, elevated rheumatoid factor and anti-
-cyclic citrullinated peptide antibody, reduced complement
component 4 and elevated cryoglobulins with type III mixed
cryoglobulinemia pattern. Skin biopsy revealed cutaneous
necrotizing vasculitis / neutrophilic venulitis. Systemic corticosteroid therapy and rituximab were started with clinical and analytical improvement.

This long-standing untreated case of seropositive RA
presenting with CV demonstrates that, despite being a rare
complication of RA, CV can be its initial presentation. A high
index of clinical suspicion is the key to an early diagnosis,
and prompt treatment institution is crucial to minimize morbidity and mortality.