Cryoglobulinemia physical examination: Difference between revisions

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==Overview==
==Overview==
Physical examination of patients with cryoglobulinemia is usually remarkable for: purpura, arthralgia, and acrocyanosis.  Type I cryoglobulinemia predominantly affects the kidney, skin and bone marrow whereas mixed CG (types II and III) predominantly involves the skin and peripheral nervous system. The various signs that appear are most commonly due to underlying hyperviscosity and thrombosis.


==Physical Examination==
==Physical Examination==
 
Physical examination of patients with cryoglobulinemia is usually remarkable for: purpura, arthralgia, and acrocyanosis.  Type I cryoglobulinemia predominantly affects the kidney, skin and bone marrow whereas mixed CG (types II and III) predominantly involves the skin and peripheral nervous system.
*Physical examination of patients with [disease name] is usually remarkable for:purpura,arthralgia, and .
 


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with cryoglobulinemia usually appear normal. Clinical manifestations that appear vary according to the type of cryoglobulinemia. The various signs that appear are most commonly due to underlying hyperviscosity and thrombosis.
Patients with cryoglobulinemia usually appear normal. Clinical manifestations that appear vary according to the type of cryoglobulinemia. The various signs that appear are most commonly due to underlying hyperviscosity and thrombosis.


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
Vital signs in patients with cryoglobulinemia are normal.
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
The cutaneous manifestations associated with cryoglobulinemia are as follows:<ref name="pmid7704562">{{cite journal| author=Monti G, Galli M, Invernizzi F, Pioltelli P, Saccardo F, Monteverde A et al.| title=Cryoglobulinaemias: a multi-centre study of the early clinical and laboratory manifestations of primary and secondary disease. GISC. Italian Group for the Study of Cryoglobulinaemias. | journal=QJM | year= 1995 | volume= 88 | issue= 2 | pages= 115-26 | pmid=7704562 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7704562  }} </ref><ref name="pmid6996482">{{cite journal| author=Gorevic PD, Kassab HJ, Levo Y, Kohn R, Meltzer M, Prose P et al.| title=Mixed cryoglobulinemia: clinical aspects and long-term follow-up of 40 patients. | journal=Am J Med | year= 1980 | volume= 69 | issue= 2 | pages= 287-308 | pmid=6996482 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6996482  }} </ref><ref name="pmid1880249">{{cite journal| author=Cohen SJ, Pittelkow MR, Su WP| title=Cutaneous manifestations of cryoglobulinemia: clinical and histopathologic study of seventy-two patients. | journal=J Am Acad Dermatol | year= 1991 | volume= 25 | issue= 1 Pt 1 | pages= 21-7 | pmid=1880249 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1880249  }} </ref>
*[[Leukocytoclastic vasculitis|Leukocytoclastic]] vasculitis
*Raynauds phenomenon
*Raynauds phenomenon
*Livedo reticularis
*Livedo reticularis
*Palpable purpura
*Palpable purpura
*Digital ischemia
*Digital ischemia
 
*Acrocyanosis
<gallery widths="150px">
* Hyperkeratotic spicules in cold-exposed areas
 
*Cold induced urticaria
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* [[Nystagmus]]
OR
*Retinal hemorrhage
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]  
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
*[[Lymphadenopathy]]
OR
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
* Pulmonary examination of patients with cryopglobulinemia is postive for the following findings:<ref name="pmid443251">{{cite journal| author=Bombardieri S, Paoletti P, Ferri C, Di Munno O, Fornal E, Giuntini C| title=Lung involvement in essential mixed cryoglobulinemia. | journal=Am J Med | year= 1979 | volume= 66 | issue= 5 | pages= 748-56 | pmid=443251 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=443251  }} </ref><ref name="pmid2805608">{{cite journal| author=Viegi G, Fornai E, Ferri C, Di Munno O, Begliomini E, Vitali C et al.| title=Lung function in essential mixed cryoglobulinemia: a short-term follow-up. | journal=Clin Rheumatol | year= 1989 | volume= 8 | issue= 3 | pages= 331-8 | pmid=2805608 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2805608  }} </ref>
OR
**Shortness of breath
* Asymmetric chest expansion / Decreased chest expansion
**Cough
*Lungs are hypo/hyperresonant
** Reduction in forced expiratory flow rates
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
** Pleural effusion findings
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
* Cardiovascular examination of patients with cryoglobulinemia is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope


===Abdomen===
===Abdomen===
Abdominal examination of patients with [disease name] is usually normal.
*[[Hepatomegaly]]
 
*[[Splenomegaly]]
OR
*[[Abdominal distention]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with cryoglobulinemia is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
*[[Hematuria]] as a result of [[Membranoproliferative glomerulonephritis|membranoproliferative]] glomerulonephritis.<ref name="pmid4216269">{{cite journal| author=Brouet JC, Clauvel JP, Danon F, Klein M, Seligmann M| title=Biologic and clinical significance of cryoglobulins. A report of 86 cases. | journal=Am J Med | year= 1974 | volume= 57 | issue= 5 | pages= 775-88 | pmid=4216269 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4216269  }} </ref><ref name="pmid7723249">{{cite journal| author=Tarantino A, Campise M, Banfi G, Confalonieri R, Bucci A, Montoli A et al.| title=Long-term predictors of survival in essential mixed cryoglobulinemic glomerulonephritis. | journal=Kidney Int | year= 1995 | volume= 47 | issue= 2 | pages= 618-23 | pmid=7723249 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7723249  }} </ref>
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
*Headache
*[[Dizziness]]
*[[Ataxia]]
*[[Confusion]]
*[[Dementia]]
*[[Stroke]]
*Coma


===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
Extremities examination of patients with cryoglobulinemia usually have the following findings:<ref name="pmid3046019">{{cite journal| author=Montagnino G| title=Reappraisal of the clinical expression of mixed cryoglobulinemia. | journal=Springer Semin Immunopathol | year= 1988 | volume= 10 | issue= 1 | pages= 1-19 | pmid=3046019 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3046019  }} </ref>
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


===Skin===
*Digital [[ischemia]]/[[gangrene]]
* Palpable [[purpura]]
*[[Fasciculation|Fasciculations]] in the upper/lower extremity
*Joint involvement most commonly in knees, ankles, proximal interphalangeal joints.
*Peripheral [[neuropathy]]
{| class="wikitable"
! colspan="3" |Physical examination findings according to the type of cryoglobulinemia
|-
|'''Type 1'''
|'''Type 2'''
|'''Type 3'''
|-
|[[Gangrene]]
|Joint abnormalities
|[[Purpura]]
|-
|[[Acrocyanosis]]
|[[Membranoproliferative Glomerulonephritis|Membranoproliferative]] glomerulonephritis
|
|}


===Abdomen===
===Gallery===
* [[Hepatosplenomegaly]]
<gallery>
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Image:Atrophie Blanche05.jpg|Atrophie Blanche. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite
Image:Atrophie Blanche06.jpg|Atrophie Blanche. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite
Image:Atrophie Blanche07.jpg|Atrophie Blanche. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite
Image:Atrophie Blanche08.jpg|Atrophie Blanche. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite
</gallery>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Disease]]
[[Category:Disease]]

Latest revision as of 13:55, 30 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Physical examination of patients with cryoglobulinemia is usually remarkable for: purpura, arthralgia, and acrocyanosis. Type I cryoglobulinemia predominantly affects the kidney, skin and bone marrow whereas mixed CG (types II and III) predominantly involves the skin and peripheral nervous system. The various signs that appear are most commonly due to underlying hyperviscosity and thrombosis.

Physical Examination

Physical examination of patients with cryoglobulinemia is usually remarkable for: purpura, arthralgia, and acrocyanosis. Type I cryoglobulinemia predominantly affects the kidney, skin and bone marrow whereas mixed CG (types II and III) predominantly involves the skin and peripheral nervous system.

Appearance of the Patient

Patients with cryoglobulinemia usually appear normal. Clinical manifestations that appear vary according to the type of cryoglobulinemia. The various signs that appear are most commonly due to underlying hyperviscosity and thrombosis.

Vital Signs

Vital signs in patients with cryoglobulinemia are normal.

Skin

The cutaneous manifestations associated with cryoglobulinemia are as follows:[1][2][3]

  • Leukocytoclastic vasculitis
  • Raynauds phenomenon
  • Livedo reticularis
  • Palpable purpura
  • Digital ischemia
  • Acrocyanosis
  • Hyperkeratotic spicules in cold-exposed areas
  • Cold induced urticaria

HEENT

Neck

Lungs

  • Pulmonary examination of patients with cryopglobulinemia is postive for the following findings:[4][5]
    • Shortness of breath
    • Cough
    • Reduction in forced expiratory flow rates
    • Pleural effusion findings

Heart

  • Cardiovascular examination of patients with cryoglobulinemia is usually normal.

Abdomen

Back

  • Back examination of patients with cryoglobulinemia is usually normal.

Genitourinary

Neuromuscular

Extremities

Extremities examination of patients with cryoglobulinemia usually have the following findings:[8]

Physical examination findings according to the type of cryoglobulinemia
Type 1 Type 2 Type 3
Gangrene Joint abnormalities Purpura
Acrocyanosis Membranoproliferative glomerulonephritis

Gallery

References

  1. ↑ Monti G, Galli M, Invernizzi F, Pioltelli P, Saccardo F, Monteverde A; et al. (1995). "Cryoglobulinaemias: a multi-centre study of the early clinical and laboratory manifestations of primary and secondary disease. GISC. Italian Group for the Study of Cryoglobulinaemias". QJM. 88 (2): 115–26. PMID 7704562.
  2. ↑ Gorevic PD, Kassab HJ, Levo Y, Kohn R, Meltzer M, Prose P; et al. (1980). "Mixed cryoglobulinemia: clinical aspects and long-term follow-up of 40 patients". Am J Med. 69 (2): 287–308. PMID 6996482.
  3. ↑ Cohen SJ, Pittelkow MR, Su WP (1991). "Cutaneous manifestations of cryoglobulinemia: clinical and histopathologic study of seventy-two patients". J Am Acad Dermatol. 25 (1 Pt 1): 21–7. PMID 1880249.
  4. ↑ Bombardieri S, Paoletti P, Ferri C, Di Munno O, Fornal E, Giuntini C (1979). "Lung involvement in essential mixed cryoglobulinemia". Am J Med. 66 (5): 748–56. PMID 443251.
  5. ↑ Viegi G, Fornai E, Ferri C, Di Munno O, Begliomini E, Vitali C; et al. (1989). "Lung function in essential mixed cryoglobulinemia: a short-term follow-up". Clin Rheumatol. 8 (3): 331–8. PMID 2805608.
  6. ↑ Brouet JC, Clauvel JP, Danon F, Klein M, Seligmann M (1974). "Biologic and clinical significance of cryoglobulins. A report of 86 cases". Am J Med. 57 (5): 775–88. PMID 4216269.
  7. ↑ Tarantino A, Campise M, Banfi G, Confalonieri R, Bucci A, Montoli A; et al. (1995). "Long-term predictors of survival in essential mixed cryoglobulinemic glomerulonephritis". Kidney Int. 47 (2): 618–23. PMID 7723249.
  8. ↑ Montagnino G (1988). "Reappraisal of the clinical expression of mixed cryoglobulinemia". Springer Semin Immunopathol. 10 (1): 1–19. PMID 3046019.


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