Cryo and Mortality

Cryoglobulinemia and Mortality

This is a topic which I have been avoiding to keep from alarming those who have been newly diagnosed without good reason to do so.

After researching this , and thinking about it for some time, I decided that I should talk about this in a post on the forum.

Based on work done by Claudio Ferri (2004) it appears that the mortality rate for persons with cryoglobulinemia are about 42 percent, possibly as high as 50 percent in the first 6 years after diagnosis. Rossa et-al (2008) included the work of Ferri and others to arrive at similar results.

Rieu et-al (2002) examined outcomes for various comorbid conditions with cryoglobulinemia and determined that a more positive outcome was likely in patients who did not have liver, kidney or lung involvement with cryoglobulinemia.

Later work by Bryce et-al (2006) revisited mortality and observed that for all patients in their study, overall the mean 50 percent survival time was about seven years, and that for patients over the age of 57.6 years, the 50 percent survival time was a little better than 5 years.

In all three of these studies, researchers point out that the outcome is likely to be significantly better if there is no involvement of the kidneys, liver, or lungs. Surprisingly, in spite of the seriousness of potential involvement of these organs, the leading single cause of death in cryoglobulemia appears to be vasculitis.

With a cure for hepatitis C now available and with patients getting treated successfully, I would expect to see the 5 year survivor rates improve over the next few years as the number of people having liver involvement with cryoglobulinemia ought to decline markedly. Unless a breakthrough in treatment is achieved, I would expect to see vasculitis continue to be the leading cause of death in persons with cryoglobulinemia.

ADDENDUM: One thing that should be mentioned is that treatment of cryo has improved a lot in the last 2-3 decades. The expected survival of a person with severe cryoglobulinemia would be a matter of a few months, at most, without treatment.

I just added a citation for Rossa (2008). I had used his information but had not cited it.

If I Could Design Cryo Research

Cold Weather and the Cryo Patient’s Attempt to Control Temperature

I find it remarkable when doctors think that colder weather/climate is not a problem for people with cryoglobulinemia. Particularly when so .  . . so many people with cryo have a rather immediate response to cold. It is also known that individual responses to cold appear to be highly variable among people with cryoglobulinemia. There are also accounts of people moving to colder climates from warmer climates who suddenly display symptoms of cryoglobulinemia.

The debate over controls of precipitation temperature for cyoglobulins in the blood has neen a longstanding issue. In fact there is a lot more to it than just concentration and temperature, but the basic property of solubility is controlled by concentration and temperature as the saturation point will change with temperature. This is a fundamental physical property. The question does remain that the behavior of cryoglobulins in a petri dish is not guaranteed to be the same as in a living person, and the blood contains a lot more than just water and cryoglobulins, and the chemistry of it is rather dynamic… so technically it may well be correct to state that one can not clearly show that concentration and temperature are the big controls the precipitation of cryoglobulins.

At the same time common sense clearly suggests that given no other metric, one should seriously consider it from the standpoint of safety, especially since cryoglobulins DO precipitate/gel at temperatures below normal body temperature, and persons with cryogloblinemia DO experience adverse physical reactions to cold. Maybe some really bright grad student needs to get some funding and go after this rather fundamental question ?

Eating well and getting exercise is important and improving physical strength is helpful, always. It is particularly important when recovering from a long battle with a flare. It can take awhile to regain strength and wellness, so taking care of oneself is important.

As a normal emotional response  I do realize that it is easy to become fearful of cold when one has cryoglobulinemia, but realistically after a couple of bad experiences with cryo we have ample reasons to feel that way. It should not be surprising that some of us might be a little “over the top” with our cautions regarding cold. The reasons for that are quite sound. We don’t know for sure what the “safe” operational limits are.

Palpable Purpura


Palpable Purpura survival.

This is a distillation of what I experience with palpable purpura. Others in Alliance for Cryo Support groups have had the same experience and so I thought you might find this useful.

Palpable Purpura is a kind of skin lesion common to small and medium vessel vasculitis.  Palpable Purpura is blood-filled lesions which are raised, and resemble blood-filled blisters, typically from tiny up to about a centimeter (about the size of a dime) in diameter. You can push on one with you finger and it will flatten out, and will not blanch (will not turn white) if the cause is vasculitis.  These lesion form rapidly (in a few minutes), and when active they can hurt much like a bee sting. Sometimes one only gets a few lesions, but at other times they can be numerous and the pain can become quite severe. The lesions can grow in size daily, and lesions which are close together may merge to form bigger lesions. The big risk here is that a large area of skin can die quickly , leading to ulcers, and infection and a host of other problems. This can be very bad.

The lesions are typically more active at night and it is not unusual to wake in the morning and find that your feet are covered with new lesions which formed while you slept. In the daytime, they may be less active and will be less full in appearance.  These lesions will continue to form until the vascultis remits. Once they begin to heal, it often takes about a week to ten days for the blisters to drain, and form scabs over the lesions which will gradually heal over a period of weeks, or months.

Here are some things you can do to make things a little more bearable:

  1. Reduce pressure on your skin in your feet, buttocks, thighs and legs. Get comfortable, and rest. Wear loose, comfortable clothing. Your skin is more prone to forming new lesions right now, and any pressure or abrasion to the skin can encourage new lesions to form. So, kick your shoes off , prop your feet up and take it easy.
  2. I found that taking Advil really helped reduce inflammation quite a lot. But at the same time, the process that was causing the lesions did not stop until my vascultis was treated well enough to force it to remit.
  3. For years, some doctors have advised taking an antihistamine ,particularly in the evening as a treatment for Palpable Purpura. The fact is that there is no medical basis for doing so, and there is no medical evidence that it ever worked for anyone. I know that it never worked for me….
  4. Watch out for signs of infection. If you are on immunosuppression therapy, the last thing you want to have happen is to pick up an opportunistic infection. Keep the lesions clean and dry, and take a good look at them daily to be sure they are healing. If you see signs of infection, see your doctor right away.

Winter is here, so stay warm!

How I know do I know if a flare is coming?

How I know do I know if a flare is coming???

One common characteristic of cryoglobulinemia is that of periods of remission followed by periods of flaring.

Very often, if one can spot a flare coming early enough and treat it early, many if the damaging effects and a lot of suffering can be avoided by forcing it back into remission with medication (usually high dose prednisone) before the situation gets out of hand.  I am going to outline here what I have experienced with cryo in the hope that it will benefit others. Please bear in mind that each person is a bit different, and that not everyone experiences the same set of symptoms with cryo.

The very first symptoms that I usually get before a flare starts are malaise, myalgia, and fatigue.

Malaise is a general feeling of “not well”. It can be subtle , this feeling will usually persist for a couple of weeks before strong, overt symptoms appear.

Myalgia is muscle weakness. This is generally due to muscles deteriorating due to vasculitis. My blood work might show an elevated C reactive protein and an elevated erythrocyte sedimentation rate at this time. If the muscle loss is significant, I might begin to experience rapid weight loss. Achy muscles are sometimes a problem. I sometimes end up with a few splinter lesions under my fingernails as an early warning that I might flare soon.

Fatigue starts gradually. I feel tired. A little extra sleep is sometimes needed , and I tire easily.

After a couple of weeks of these rather subtle symptoms I begin experiencing mild arthralgia… Achy rheumatoid arthritis-like symptoms, particularly in the morning. Typically my knees and feet are affected first and I am generally a lot stiffer for the first couple of hours in the morning, and limber up a bit later in the day. The swelling and joint pain are always symmetrical, affecting the left and right joints more or less equally, and seems to start at the lower part of the body and works its way up as the situation worsens.

After a few days of mild arthralgia I suddenly find myself faced with a full blown flare and often have severe RA symptoms to the extent that I can not walk or stand without a cane. Sometimes my hands are so stiff and sore that I can’t use them for a while in the mornings. Swelling in my feet and legs can be so bad that my shoes no longer fit. I really need to begin treating my flare with high dose prednisone by this time, in order to avoid further damage to my body. At this point , I begin seeing a few petiachae on my feet, and sometimes my hands, I may develop palpable purpura , or necrotic lesions with dry gangrene. I sometimes experience raynauds’s phenomena, and on one occasion had a remarkably vivid display of levido reticularis. I sometimes develop skin ulcers which take months to heal. Neuropathy seems to be more intense at this time. Treating at this point is a little late, because a lot of damage has been done by the time remission can be reestablished. But treatment is still necessary because in my case the cryo has never remitted on its own. It just gets worse until it is treated.

The thing that is happening is that cryoglobulins are rapidly building up in my blood and the immune system breakdown products causing the vaculitis are increasing. If I wait too long to treat my flare, the cryoglobulin levels will have risen to the point that the vasculitis becomes a process that will continue until all the undesired “wreckage” of immune system components are cleared from my body…. this can take a while, even if I have already started on high dose prednisone to halt the flare. But, if I treat the flare early, I can reduce the amount of damage and misery by quite a lot.

NOTE: Not everyone with cryo experiences symptoms of rheumatoid arthritis, or lesions, skin ulcers, or even a rash. in some cases the sole presenting symptom is neuropathy, while other people only experience a mild rash. It all varies from one individual to the next, so become familiar with your cryo (I am sure you already are) so that you can spot these trends early and hopefully find medical help to halt the flare before it does much damage.

ADDENDUM: The problem with the “prodrome” that leads into a flare is that it is subtle, and unreliable. Sometimes I’ll feel a little tired and achy for a few days, and it just goes away.. no flare happens. I have also had no real prodrome, but have gone straight into a big flare, with little to no warning.
Usually I do have early warning symptoms, and I need to stay alert and aware of my condition so that I can treat the flare as soon as it escalates into a full blown flare… When it does start to flare “big” it is sudden, and it frequently escalates within an hour. A common scenario is that I might be sitting in a chair working at the computer for a while, then discover (when I try to get up), that I am flaring. This frequently happens in the evening for whatever reason… and when it does, I keep my phone and my cane next to the bed in case I discover that I am very ill when I wake up on the morning. More than once I have discovered that I could not stand or walk without my cane when getting up in the morning. Fortunately, I usually loosen up a bit after a couple of hours.

Cold Soaked? Seven Ways to Warm Up.

When it comes to cold weather, if you have cryoglobulinemia, less exposure to cold is best. For many people with type I cryo, their reaction to cold can be immediate and very strong, so great care must be taken to minimize cold exposure. For those of us with type II and type III cryoglobulins it often takes a little longer for us to react to cold, but we still do.. and it often does not matter which type you have when you can eventually reach a point where it seems that any temperature is equally “bad”.

For me, my first clue that I have overexposed myself to cold is usually a mild petichial rash, or raynauds, or levido reticularis on my extremities… usually on my hands or feet. Another clue is that I might suddenly find myself experiencing symptoms of rheumatoid arthritis, particularly stiff and sore knees. At this point ,I know I have done myself harm, and that I need to act right away to recover.

Everyone is a little different.. you are going to have to try some of these ideas to decide what works for you.

This is how I cope with it;

1) GET INDOORS AND WARM UP RIGHT AWAY! For me, I usually do not react to cold instantly, and reacting to cold seems to be the result of the total dose of cold over time. So I need to avoid getting deeply chilled and to warm up fast when I do.

2) sometimes it is a good idea to lay down , and get horizontal , to keep cryoglobulins from pooling in your legs and buttocks after long periods of sitting or standing. Sometimes an hour or so of getting horizontal with my feet elevated a little is helpful for me and will reduce pain and swelling in my feet/legs a bit..

3) If you are sitting, elevate your feet, and use a heated foot pad. This often makes me feel a lot more comfortable, reduces pain in stiff and sore feet and ankles, reduces swelling in my feet and lower legs a bit, and seems to help reduce skin damage from lesions and ulcers a little.
If you have sensorimotor neuropathy, your sense of pain might not be all too accurate, so be careful when using a heat pad to keep your feet warm.

4) If you can, get up and move around once in a while. If you just sit or stay in bed, and you are of the type who has rheumatoid arthritis , or symptoms like RA, staying immobile can be a bad idea. If you feel up to it, get up and move around once in a while to keep your joints limber… usually arthralgia will improve once you start moving around a bit in the morning. It is almost always worse in the AM, but often improves in an hour or two. Sometimes in the evening things can suddenly turn worse. You sort of need to learn when it is a good idea to stop and rest and when it is a good idea to push ahead against all odds.

5) If you are the type who develops palpable purpura or necrotic skin lesions rather easily, you might find it helpful to avoid clothing that puts pressure on your skin, such as tight-fitting socks and pants. I have learned the hard way that sometimes I am better off with no socks on my feet and fewer lesions than with socks and more lesions… I also found that at these times I can easily develop lesions on my skin by simply abrading the skin or by just bumping into things… so be careful and adjust your clothing and your behavior to your needs.

6) if you suddenly find yourself headed into a major flare you might need to call your doctor. For some of us a flare is mostly just discomfort, and for others of us it can be life threatening, so be alert to your condition and act on it early.

7) and lastly, STAY WARM!, dress in layers, use a heat pad to keep your feet warm! Keep your core body temperature up to reduce the possibility of cryoglobulins affecting internal organs.

Three Core Cryo Symptoms: Meltzer’s Triad

Meltzer’s Triad

In 1956 Meltzer and Franklin described arthralgia, purpura and weakness as the three core symptoms of essential cryoglobulinemia. These are generally seen in people who have type II and type III cryoglobulinemia. It is seen in 25-30% of patients with cryo. I just thought I’d share this.

Cryo Symptoms: Points to Consider

Symptoms of Cryo: Points to Consider

Sometimes cryoglobulinemia will present with very few symptoms externally, before you have a full-blown flare. I have listed of a few of the more subtle things, and some of the weird things that have happened to me as symptoms some sort of serve as a warning that I am in the early stages of a flare, others only happen when the flare is a big one.

You also need to be aware that cryoglobulinemia can affect any organ, and any system in the body. Cryo can affect so many parts of the body, but below are what I believe to be the most common aspects of cryoglobulinemia. Keep these 14 points in mind when tracking your own symptoms.

  • Malaise.
    • I sometimes get a general feeling of “not well”, but “not sick” days or weeks before a flare.  Malaise is a general felling of “not well”.
    • Plus after a week or so of a full-on flare it is very hard to remember what normal is, and everything becomes a struggle.
    • It is hard to be happy when you are as sick as a dog, with no end in sight, and not really knowing what bizarre life-threatening medical event might or might not strike you at any time. You sort of go into survival mode.
  • Muscle weakness.
    • Don’t confuse this with feeling tired. You might not be tired at all but your muscles are actually weak.
    • This is because people with cryo often experience muscle degeneration, or myopathy in the early stages of a flare and this means weak, sometimes sore muscles.
    • This takes months to heal after cryo is driven into remission. A good combination of rest and exercise helps a bit.
    • Don’t try to push weak injured muscles hard during a flare or you will just pull a muscle and have more pain. Take it easy.
  • Aches and Pains.
    • General aches and pains, mostly sore muscles…. just kind of achy and nondescript pain for a while before a flare.
  • Fatigue.
    • You simply feel tired. Your body is burning a lot of energy on an runaway immune system You can expect to feel tired.
  • Rapid Weight Loss.
    • Rapid weight loss. You will lose a lot of weight as the flare progresses. Some of it is due to muscle loss, some is just weight loss in general.
  • Splinter lesions.
    • Splinter Lesions under the fingernails are tiny blood-filled lesions under the nail that appear suddenly. They are tiny, long, and thin.
    • They form instantly and it takes months for the nail to grow out enough for them to go away.
    • Splinter.Lesionsplinter.lesions.2
  • Fever
    • Fever of unknown origin: You wind up running a fever with no apparent cause.
  • Janeway Lesions
    • I have had janeway lesions that form right at the corner where the end of the nail meets the skin. These seem to start as a tiny spot that forms suddenly. I generally feel a small, but sharp pain the moment they form due the blood vessels rupturing. Look at the picture above (the white arrow). In my case they usually grow and turn into necrotic lesions as the flare progresses. This results in dry gangrene which takes anywhere from 3-6 months to heal. I have lost the tips of two fingers to these. They start out really tiny… smaller than the head of a pin.
  • Arthralgia
    • Arthralgia is arthritis like symptoms. In some cases people with cryo have rheumatoid arthritis as the primary condition, others have symptoms that seem to mimic rheumatoid arthritis, but without the rapid damage to tissues in the joints. Some never experience this.
  • Raynaud’s Phenomena
    • Raynaud’s phenomena, the patriotic symptom: Sudden changes in blood circulation in the hands and/or feet.  Sometimes the circulation in my fingers is compromised by the cryo.  My fingers may turn white, or blue, and eventually will turn red when the circulation returns. Sometimes the palms of my hands will be a very bright red.
  • Achy Joints
    • Stiff/Achy joints: The RA-like swelling in the joints can cause stiffness and pain.
  • Swelling
    • The RA-like symptoms will cause swelling in the joints. Most notably in the ankles, knees , wrist and hands/fingers.
    • Usually the swelling, stiffness, and pain from RA is symmetrical…. that is if the knees are affected, it is typically both knees, not just one, etc. Another interesting thing is that when the joints in the fingers swell , the very last joint toward the end of the finger is always unaffected… no swelling there.
    • Beyond the swelling caused by RA, you have edema, mostly in the lower legs, feet and ankles. This is caused by poor circulation. It can be to the extent that your shoes no longer fit. It does not feel good, and for me, my feet feel rather awful, I am aware of every bone in my feet at this point, and walking is uncomfortable.
    • Massaging the lower legs helps a little, elevating the feet helps a bit. I like to use a heating pad under my feet to keep them warm in an attempt to force cryoglobulins back into solution. it all helps a bit, but the real cure is to get the cryo back into remission.
    • You also need to know that many medications can cause edema in the feet and ankles. Steroids are known for this and it tends to compound the problem.
  • Skin: skin rash, lesions, necrosis, and other things

    • petechiae
      • A rash caused by tiny blood vessels rupturing and bleeding in the skin causing tiny ( < 2mm) papules to form. These can come and go rather quickly.
    • purpura
      • This is also caused by bleeding in the skin. It is a close cousin to petetchiae , only the papules are larger… from 2 mm up to about 10 mm (dime sized).  See the purpura survival guide in the blog for more info on this. These can be painful and may take weeks to heal.
    • skin necrosis
      • Basically, patches of skin turn black and die. This is “dry gangrene”. It is surprisingly fast, It can be extensive, and can result in very bad things. Small necrotic lesions are sometime misdiagnosed as spider bites.
    • Skin ulcers
      • Open sores that won’t heal. The skin dies and breaks down, leaving an open wound. This often requires the services of a wound clinic. Often on the extremities, usually on the feet, between toes, or on the lower legs, but can appear anywhere. Also lesions in the mouth or in the nasal cavity. They can be quite painful; and take a long time to heal, even with proper treatment.
    • Livedo Reticularis
      • This is a really scary looking event when it happens.  Basically the veins just under the skin will dilate (usually in response to a change in temperature) .  The end result is a sometimes-vivid  spider-webbish pattern of purplish veins in the skin.  It generally appears on arms, hands, feet, and legs but can sometimes completely cover the torso.  It looks really scary, but in terms of cyoglobulinemia, is basically harmless… but is also an indicator that something is going on (namely, cryo). It can come and go in seconds.  Sometimes a nice hot shower will make it go away.
  • Neuropathy.
    • Mostly in the form of paresthesias (unusual sensations) caused by damage to the nerves in the hands, feet , arms, and lower legs.
    • In some cases the only presenting symptom of cryoglobulinemia is neuropathy.
    • In some cases sufficient damage is done to nerves in the lower legs that people experience “foot drop” (loss of motor control) in one, or both feet.
    • I have had a bout of paralysis and numbness in my right foot ‘that has partially healed, but my neurologist observed that I often drop the toe in my right foot, apparently due to a bit of a foot drop. It sometimes makes me stumble when I walk.

B Cell and Cryo

It has been speculated that B cells are living too long due to apoptosis failing, as they age past their pre-programmed expiration date they start producing cryoglobulins. It is very likely more complex than this, but failed apoptosis (programmed cell death) is one cause for B cell proliferation. However it is unclear if the failure is in the message sent to the B cells to die or if they are ignoring it. One clue is that in the case for HEPC patients is that cryoglobulins will frequently contain fragments of HEPC RNA. Cryoglobulins do appear to function as an immune system component, but they basically trap targeted antigens by snaring then in their spider-web-ish structure and ripping them apart under electrostatic tension. It is sort of like the Borg in Star Trek. They tear things apart and incorporate them into their molecular structure. The down side is that cryoglobulins behave a bit like both antigens and antibodies which results in a runaway immune system when the immune system basically attacks itself. I tend to interpret the cryoglobulins as the immune systems last desperate effort to rid itself on a source of long standing inflammation. This is not entirely true but it helps me to visualize it. Also, one thing that I suspect may be true is that in cases of non-HEPC cryo, one may benefit from keeping the immune system suppressed long enough, and deep enough to sometimes be effectively “cured”, or at least permanently in remission. This is also speculative, but the fact that stem cell transplants often “cure” cryo strongly suggests that something along this line is going on.