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Mixed glioma — Clinical Guidelines

Overview

Mixed cryoglobulinaemia is a systemic vasculitis characterized by the presence of circulating immune complexes (cryoglobulins) primarily involving lymphatic system, skin, kidney, and peripheral nervous system, often associated with hepatitis C virus (HCV) infection 1 3 7.

Diagnosis

Presence of mixed cryoglobulins (IgM and IgG) in serum 7

Clinical manifestations including purpura, arthralgia, renal failure, and neurological symptoms 8

Detection of rheumatoid factor activity and HCV antibodies 7

Elevated CXCL10 serum levels, indicative of active vasculitis 3

Immunofluorescence showing vascular deposits of immunoglobulins in lesional skin 9

Management

First-line treatments: Corticosteroids for acute flares and severe manifestations such as cerebral involvement 8

Adjunctive therapies: Apheresis (plasma exchange or double cascade filtration) for severe renal or neurological complications 6

Specific drug classes: No specific doses mentioned, but plasmapheresis is noted as effective 6

Special Populations

Comorbidities: Patients with chronic glucocorticoids or rituximab treatment may have lower vaccination rates due to fear of side effects 1

No specific data: Limited information on management in pregnancy, pediatrics, or elderly populations based on provided abstracts

Key Recommendations

Corticosteroids are recommended for managing acute flares and severe manifestations such as cerebral involvement in mixed cryoglobulinaemia (Evidence: Moderate 8)

Apheresis should be considered for patients with severe renal or neurological complications due to improved haemorheology (Evidence: Moderate 6)

Monitor CXCL10 levels to assess disease activity and potential need for intensified treatment (Evidence: Moderate 3)

Evaluate HCV infection status and consider antiviral therapy in HCV-positive patients (Evidence: Moderate 7)

Address vaccine hesitancy in patients on chronic immunosuppressive therapy through education and support (Evidence: Expert opinion 1)

References

1 Vacchi C, Testoni S, Visentini M, Zani R, Lauletta G, Gragnani L et al.. COVID-19 vaccination rate and safety profile in a multicentre Italian population affected by mixed cryoglobulinaemic vasculitis. Clinical and experimental rheumatology 2023. link 2 Krysiak R, Okrzesik J, Szkrobka W, Okopień B. The effect of fenofibrate on cardiometabolic risk factors in bromocriptine-treated women with mixed dyslipidemia: A pilot study. Pharmacological reports : PR 2016. link 3 Antonelli A, Ferri C, Fallahi P, Ferrari SM, Frascerra S, Franzoni F et al.. CXCL10 and CCL2 serum levels in patients with mixed cryoglobulinaemia and hepatitis C. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2009. link 4 Fornasieri A, Bernasconi P, Ribero ML, Sinico RA, Fasola M, Zhou J et al.. Hepatitis C virus (HCV) in lymphocyte subsets and in B lymphocytes expressing rheumatoid factor cross-reacting idiotype in type II mixed cryoglobulinaemia. Clinical and experimental immunology 2000. link 5 Crovatto M, Mazzaro C, Mishiro S, Santini G, Baracetti S, Zorat F et al.. GBV-C/HGV and HCV infection in mixed cryoglobulinaemia. British journal of haematology 1999. link 6 Russo GE, Caramiello MS, Vitaliano E, De Marco CM, Pennacchia M, Giusti S et al.. Haemorheological changes in mixed cryoglobulinaemia during apheresis treatment. Transfusion science 1996. link 7 L'Abbate A, Cutrupi S, Rognetta M, Fabiano C, Craxi A. IgM and IgG antibodies to hepatitis C virus in patients with mixed cryoglobulinaemia. Clinical and experimental immunology 1993. link 8 Pines A, Kaplinsky N, Goldhammer E, Frankl O. Cerebral involvement in primary mixed cryoglobulinaemia. Postgraduate medical journal 1982. link 9 Giannetti A, Serri F, Bernasconi C. Immunofluorescent studies of the skin in mixed cryoglobulinaemia and Schönlein-Henoch purpura. Acta dermato-venereologica 1976. link

Mixed glioma