Urticarial Vasculitis with Papular Lesions in a Patient with Type C Hepatitis and Cryoglobulinemia

Abstract

We describe a case of urticarial vasculitis accompanied by erythematous wheals, palpable pupura, and subsequent necrotic ulcerated papular lesions in a patient with type C chronic hepatitis and type II cryoglobulinemia (IgM-kappa and polyclonal IgG). A 56-year-old man developed recurrent urticarial lesions on his lower extremities and trunk. The histology revealed leukocytoclastic vasculitis with perivascular immunoglobulin deposits. Subsequently, multiple reddish papular lesions with necrotic ulcerations appeared on the extensor aspect of his extremities and buttocks. Histology of these lesions showed cryoglobulinemic vasculitis with prominent fibrinoid necrosis of the vascular walls and cryoprecipitate within the vasculature as well as increased hyalinized collagen bundles. These papular lesions have not previously been described as cutaneous necrotizing venulitis to the best of our knowledge. It is suggested that the immune response to hepatitis C virus infection and cryoglobulins may be responsible for severe necrotizing venulitis, resulting in unusual cutaneous lesions.

Hepatitis-C-Virus-assoziierte Dermatosen

“…auch hämorrhagische Blasen und Beinulzera [25,38,50]. Beschrieben wurde ferner das Auftreten von Urtikaria-Vaskulitis [36,39] und Pyoderma gangraenosum [56] bei HCV-assoziierter Kryoglobulinämie.…”

Chronic Urticaria Is Not Significantly Associated With Hepatitis C or Hepatitis G Infection

“…This study by Kanazawa et al 12 is the only published work suggesting a possible link between HCV and chronic urticaria, whereas all other studies, including the present one, showed nonsignificant results. Few patients in the world literature have both urticaria and HCV infection (Table 2), 7,[11][12][13][14][15][29][30][31] except those with mixed cryoglobulinemia, who have urticarial vasculitis rather than true urticaria. On the other hand, in a previous study 8 of a systematic cutaneous examination of 100 HCV-infected patients, none of the patients had present or past urticaria.…”

Urticarial venulitis

“…Single case reports include colon carcinoma (42), polycythemia vera (43), Muckle–Wells syndrome (44), and Cogan's syndrome (45). Urticarial venulitis has been noted in patients with hepatitis B (46,47) and C (30,48) virus infections, infectious mononucleosis (49), Lyme borreliosis (50), and in the shunt nephritis syndrome with bacteremia, mixed cryoglobulinemia, and glomerulonephritis (51). The relation of urticarial venulitis to other conditions in these anecdotal reports needs to be confirmed.…”