title: Heat-insoluble cryoglobulin in a patient with essential type II cryoglobulinemia and cryoglobulin-occlusive membranoproliferative glomerulonephritis: case report and literature review.
abstract: BACKGROUND
  A type of heat-insoluble cryoglobulin has been rarely reported and poorly understood. We report the case of a 79 y-old female who was admitted to hospital due to edema and renal failure.
  
  
  METHODS
  Serial biochemical, immunological, and histological investigations were conducted.
  
  
  RESULTS
  This patient had elevated serum urea and creatinine with positive rheumatoid factor and low serum C3 and C4. Her serum was positive for cryoglobulin at 4 degrees C. The precipitate did not dissolve at 37 degrees C until it was heated to 56 degrees C. Electrophoresis of the cryoglobulin demonstrated a monoclonal spike in the gamma region characterized as IgG-kappa and polyclonal IgM by immunofixation. Bone marrow aspiration showed presence of 5% plasma cells. Histological examination of renal biopsy revealed a diffuse increase in mesangial matrix, cellularity and endocapillary proliferation. Numerous monocyte/macrophages were present within mesangium and capillary lumina. Focal double contouring of glomerular basement membrane with subendothelial deposits and "hyaline thrombi" were noted. Accordingly, a type II heat-insoluble cryoglobulinemia associated with membranoproliferative glomerulonephritis and monoclonal gammopathy of undetermined significance was made.
  
  
  CONCLUSIONS
  The unusual heat-insoluble cryoglobulins may indicate severe clinical consequence. Proper laboratory procedure and careful examination of cryoglobulin will assure early recognition and detection of heat-insoluble cryoglobulins.
authors.affiliation: Department of Pathology and Laboratory Medicine, Royal University Hospital, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, Canada S7N 0W8. qing.meng@usask.ca
authors.forename: Qing H
authors.initials: QH
authors.lastname: Meng
authors.forename: Rajni
authors.initials: R
authors.lastname: Chibbar
authors.forename: Derek
authors.initials: D
authors.lastname: Pearson
authors.forename: Joanne
authors.initials: J
authors.lastname: Kappel
authors.forename: John
authors.initials: J
authors.lastname: Krahn
mesh_terms: D000368:Aged; D003449:Cryoglobulinemia / Q000097:blood / Q000150:complications* / Q000378:metabolism* / Q000473:pathology; D003450:Cryoglobulins / Q000737:chemistry* / Q000378:metabolism*; D005260:Female; D015432:Glomerulonephritis, Membranoproliferative / Q000097:blood / Q000150:complications* / Q000378:metabolism* / Q000473:pathology; D006358:Hot Temperature; D006801:Humans; D012995:Solubility
chemical_list: D003450:Cryoglobulins