21/08/2026
Differential Diagnosis (DD):
Diagnosis Supporting Features
1. Cryoglobulinemic GN HCV history + renal involvement + low C3/C4 + skin findings + pancytopenia → highly suggestiv
2. Hepatorenal Syndrome (HRS) Cirrhosis + renal dysfunction, less likely
3. Lupus nephritis Pancytopenia + low C3/C4 + renal involvement,
لكن تحاليل ANA وdsDNA سالبة
4. MM/Amyloidosis Proteinuria + renal disease, لكن لا يوجد M-spike ولا أعراض واضحة
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✅ Final Diagnosis:
> Cryoglobulinemia secondary to HCV with cryoglobulinemic glomerulonephritis.
الحالة دي تعتبر من المضاعفات خارج الكبد لفيروس سي، وبتظهر بصورة اعتلال كلوي مناعي.
🔎 How to confirm diagnosis?
إزاي نأكد التشخيص؟
1. Cryoglobulin test:
Draw blood in warm tube and refrigerate → نلاحظ تكون ترسيب بعد 24–72 ساعة.
ده التحليل الأساسي.
2. Cryocrit level: لو متاح، نقيس نسبة الترسيب.
3. Renal biopsy:
MPGN picture (مع ترسيبات IgM, IgG, C3).
ظهور شكل "tram-track" في الجلوميرولي دليل قوي على النوع ده.
4. Check type:
Type II: Monoclonal IgM + polyclonal IgG.
Type III: Polyclonal IgM and IgG.
5. Optional: Skin biopsy لو في purpura →
ممكن توري leukocytoclastic vasculitis.
Case Presentation
A 63-year-old male, not diabetic, not hypertensive.
Presenting Complaint:
The patient presented with progressive lower limb edema and abdominal distension.
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📜 History of Present Illness:
Known case of liver cirrhosis post HCV infection.
Over the past month:
Developed progressive bilateral LL edema
Increasing ascites
Complains of foamy urine and occasional hematuria
Reported no history of NSAIDs, diabetes, or autoimmune symptoms.
No fever, no rash, no joint pain, and no photosensitivity..l
🔍 Clinical Examination:
General: Pale with ecchymotic patches over limb
Chest: BEAE, no crepitations
Abdomen: Moderately distended with shifting dullness
Extremities: Bilateral pitting LL edema.
Conscious level: Intact.
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🧪 Investigations:
CBC: Pancytopenia
Creatinine: 3.5 ↑
Urine analysis:
Heavy proteinuria, hematuria, granular casts
Urine ACR: 3888 mg/g
Complement: Low C3 & C4
Autoimmune markers:
ANA, Anti-dsDNA, Anti-phospholipid: All negative
APS.
Protein electrophoresis:
Decrease in α2 and β1 globulin
Ultrasound:
Cirrhotic liver, moderate ascites, Grade I hydronephrosis
Blood film: Pancytopenia confirmed.
What's your differential diagnosis ❓
