Case Report/Clinical Techniques

Vasculitis of Dental Pulp Associated with Cryoglobulinemia in Hepatitis C Virus Patients: Case Report
Mohammed El-Awady Grawish, PhD,* Ahmed Ragheb Zaher, PhD,* Heba M. Elsabaa, PhD,* and Doha Hegazy, PhD
Abstract
Introduction: This report presents a case of impacted lower third molar extracted for surgical reasons in patient with uncontrolled hepatitis C. After decalcication, dental pulp vasculature and its tissue quality were investigated. Methods: Serial sections of 4-mm thickness along the midline buccolingually for the demineralized specimen were obtained, mounted on a glass slide, stained with hematoxylin-eosin, covered, and viewed under the light microscope. Results: The histologic investigation of the pulp tissue revealed thickening, stenosis, and occlusion of the vessel wall, ectopic calcication of the pulp tissue in close association with pulpal blood vessels, interrupted and vacuolated odontoblastic layer in the coronal pulp chamber, with an inammatory cell inltrate throughout the pulpal tissue. Conclusions: Cryoglobulinemia associated with uncontrolled hepatitis C virus infection in patients endangers the dental pulp vasculature and alters its normal tissue architecture. (J Endod 2011;:13)

Key Words
Cryoglobulinemia, dental pulp vasculature, hematoxylin and eosin, hepatitis C virus

From the *Oral Biology Department, Faculty of Dentistry, Mansoura University, Mansoura, Dakahlia, Egypt; and Hepatology Research Group, Peninsula College of Medicine and Dentistry, University of Plymouth, Plymouth, United Kingdom. Address requests for reprints to Dr Mohammed El-Awady Grawish, Oral Biology Department, Faculty of Dentistry, Mansoura University, Miet El Amel, Aga, Mansoura, Dakahlia 35516, Egypt. E-mail address: Grawish2005@yahoo.com 0099-2399/$ - see front matter Copyright 2011 American Association of Endodontists. doi:10.1016/j.joen.2011.06.033

gypt has the highest prevalence of hepatitis C virus (HCV) infection of any country in the world. It is estimated to be 8% in urban and 25% in rural areas, with 810 million inhabitants having HCV antibodies (anti-HCV) and 57 million having active infections (1). The HCV is a small ($5565 nm), spherical, enveloped, hepatotropic single-stranded RNA positive strand that causes acute and chronic hepatitis in humans. Persistent virus infection with HCV often leads to cirrhosis and hepatocellular carcinoma. At present there is neither a selective antiviral therapy nor a preventive vaccine (2). Patients who are chronically infected with HCV often develop mixed cryoglobulinemia (MC), a B-cell proliferative disorder with polyclonal activation and autoantibody production (3). The syndrome of MC represents the consequence of an immune complextype vasculitis. It is characterized by the clinical triad of purpura, arthralgia, and asthenia and might involve numerous organs, particularly the peripheral nervous system and the kidneys (4). HCV-related systemic vasculitis might occur in the absence of detectable MC. The ndings of Terrier et al (5) suggested that such vasculitis probably results from immune-mediated mechanisms, and that the therapeutic management of such vasculitis should be similar to that of HCV-MC vasculitis. During the past decade, many case reports (Table 1) exist demonstrating that infection with HCV is involved in the pathogenesis of most MC vasculitis. To date, there have been no reports in the literature of HCV-associated cryoglobulinemia effects on dental pulp vasculature and on its tissue quality in patients with uncontrolled disease. Thus, the purpose of this report was to present 1 case in which HCV was a major cause of cryoglobulinemia and to discuss the effects of vasculitis on dental pulp tissue quality. Translation of biological knowledge into the clinical setting can simply involve the adoption of a more biological frame of mind during treatment planning, with the knowledge that the overall response of the tooth to injury represents the complex interplay between injury, defense, and regenerative processes. The balance of all of these events will impact signicantly on the opportunity and nature of any regenerative processes within the dental pulp tissue (14).

Case Report
A 30-year-old man was referred to the Department of Oral Surgery, Faculty of Dentistry, Mansoura University by his dental practitioner with a complaint of bone pain and diagnosis of impacted lower third molar. The patient had chronic HCV with no history of regular medical control of the disease and was free from any other medical problems. The HCV-RNA serum level (Amphcor HCV Monitor; Roche Molecular System, Basel, Switzerland) was 1.4 106 genomes/mL, liver enzyme tests showed an increase of alanine aminotransferase serum levels (72 IU/L; normal value, <45 IU/mL), and immunoglobulin (Ig) M with rheumatoid factor activity is found in cryoprecipitates. Radiographic investigations showed that the impacted tooth needed surgical removal. After the impacted tooth was removed, the root apical thirds of the extracted tooth were removed and discarded. Then the tooth was xed in 10% neutral-buffered formalin for 3 days and kept in 0.5 mol/L ethylenediaminetetraacetic acid (Merck 8417, Darmstadt, Germany) for 20 days for demineralization. Specimen was sectioned longitudinally along the midline buccolingually; both halves were dehydrated and embedded in parafn. Serial sections of 4-mm thickness were obtained by using a rotary microtome.

JOE Volume -, Number -, - 2011

Vasculitis of Dental Pulp Associated with Cryoglobulinemia in HCV Patients

Case Report/Clinical Techniques

TABLE 1. Representative Case Reports in Past Decade Describing the Effects of HCV-associated Cryoglobulinemia on Different Tissues and Organs
Blood vessels Renal Erythema induratum or nodular vasculitis (6) Polyarteritis nodosa (7) Vasculitis complicated with membranous proliferative glomerulonephritis (8) Polyarteritis nodosa and cryoglobulinemic glomerulonephritis (9) Cutaneous vasculitis (10) Palpable purpura (11) Systemic lupus erythematosus (12) Cerebral vasculitis (13)

Skin Systemic Central nervous system

The thin slices were then mounted on a glass slide, stained with hematoxylin-eosin, covered, and viewed under light microscope.

Discussion
Treatment planning involves appropriately selecting cases, determining how difcult the treatment might be to perform on a specic individual, and sequencing treatment procedures to achieve a healthy and functional dentition (15). Vital pulp therapy performed timely and with effective biocompatible pulp-capping materials as an alternative to routine endodontic treatment contributes to the successful healing and protection of pulp vitality (16). The status of the pulp at the time of capping is the predominant factor in determining the healing of exposed pulps (17). The purpose of this report was to describe the histopathologic alterations of the dental pulp in a patient with uncontrolled hepatitis C and to alert clinicians to determine the type of pulp therapy for those patients. Infection with HCV mainly affects the liver, but it has extrahepatic manifestations. HCV plays an important role in the development of MC, renal syndrome, lymphoproliferative disorder, and diabetes (18). The pathologic investigation of this case reported thickening, stenosis, and occlusion of the vessel wall, ectopic calcication of the pulp tissue in close association with pulpal blood vessels, interrupted and vacuolated odontoblastic layer in the coronal pulp chamber, with inammatory cell inltrate throughout pulpal tissue (Figs. 1 and 2). These ndings might be attributed to the cryoglobulins that precipitated inside the walls of pulpal blood vessels. It is known that HCV-induced MC leads to systemic vasculititis; the cryoproteins have large molecular weight and increase blood viscosity, which might directly precipitate and induce thrombosis in small vessels of some tissues including the dental pulp. Our ndings

Figure 2. Photomicrograph at area of dentin-pulp complex showing disorganization of pulp tissue with inammatory cell inltrate throughout the pulpal tissue (hematoxylin-eosin stain; original magnication, 200).

are in accordance with Galossi et al (19), who reported that MC is a systemic vasculitis characterized by the deposition of circulating immunocomplexes in small and medium-sized blood vessels, resulting in clinical manifestations. The pathophysiologic basis for the HCV-related complications is thought to be immunologic. The deposition of cryoglobulin might act as inammatory mediator and induce immune-mediated reaction. Ferri et al (20) reported that cryoglobulinemic vasculitis is caused by vascular deposition of circulating immune complexes, mainly cryoglobulins, and complement, with the possible contribution of both hemorheological and local factors. Altered dental pulp tissue quality might be attributed to cryoglobulins that had been precipitated within the microvasculature and led to tissue blood ow restriction and tissue hypoxia. This explanation is in compliance with Ramos-Casals et al (21), who stated that cryoglobulinemia leads to systemic vasculitis because of inammation of the vessel walls induced by the deposition of IgM-IgG complexes and subsequent complement activation or causes an ischemic phenomenon because of a direct obstruction of vessels. The patient in this study did not have a history of regular HCV treatment, and the long-term chronic infection seems to be the main risk factor for the histopathologic alterations.

Figure 1. Photomicrograph of coronal pulp tissue (A) and radicular pulp tissue (B) showing thickening, stenosis, and occlusion of vessel wall (BV), ectopic calcication of pulp tissue in close association with pulpal blood vessels (EC), interrupted and vacuolated odontoblastic layer (O), disorganized pulpal tissue with inammatory cell inltrate (DC) (hematoxylin-eosin stain; original magnication, 100).

Grawish et al.

JOE Volume -, Number -, - 2011

Case Report/Clinical Techniques

Acknowledgments
The authors deny any conicts of interest related to this study.
10. Groves C, Devereux C, McMillan C. A case of cutaneous vasculitis with underlying hepatitis C and cryoglobulinaemia. Ulster Med J 2008;77:513. 11. Cecchi R, Giomi A, Paoli S. Palpable purpura at the site of previous herpes zoster in association with mixed cryoglobulinemia and hepatitis C virus infection. J Dermatol 2001;28:2568. 12. Niewold TB, Swedler WI. Systemic lupus erythematosus arising during interferonalpha therapy for cryoglobulinemic vasculitis associated with hepatitis C. Clin Rheumatol 2005;24:17881. 13. Arena MG, Ferlazzo E, Bonanno D, Quattrocchi P, Ferlazzo B. Cerebral vasculitis in a patient with HCV-related type II mixed cryoglobulinemia. J Investig Allergol Clin Immunol 2003;13:1356. 14. Smith AJ. Vitality of the dentin-pulp complex in health and disease: growth factors as key mediators. J Dent Educ 2003;67:67889. 15. Stewart T. Diagnosis and treatment planning are essential prior to commencing endodontic treatment: discuss this statement as it relates to clinical endodontic management. Aust Endod J 2005;31:2934. 16. Glickman GN, Seale NS. AAE and AAPD symposium overview: emerging science in pulp therapynew insights into dilemmas and controversies. J Endod 2008; 34(Suppl):S1. 17. Ward J. Vital pulp therapy in cariously exposed permanent teeth and its limitations. Aust Endod J 2002;28:2937. 18. Zein NN, Abdulkarim AS, Wiesner RH, Egan KS, Persing DH. Prevalence of diabetes mellitus in patients with end-stage liver cirrhosis due to hepatitis C, alcohol, or cholestatic disease. J Hepatol 2000;32:20917. 19. Galossi A, Guarisco R, Bellis L, Puoti C. Extrahepatic manifestations of chronic HCV infection. J Gastrointest Liver Dis 2007;16:6573. 20. Ferri C, Zignego AL, Pileri SA. Cryoglobulins (review). J Clin Pathol 2002;55:413. 21. Ramos-Casals M, Trejo O, Garc a-Carrasco M, Cervera R, Font J. Mixed cryoglobulinemia: new concepts. Lupus 2000;9:8391.

References
1. Plancoulaine S, Mohamed MK, Arafa N, et al. Dissection of familial correlations in hepatitis C virus (HCV) seroprevalence suggests intrafamilial viral transmission and genetic predisposition to infection. Gut 2008;57:126874. 2. Sharma SD. Hepatitis C virus: molecular biology and current therapeutic options. Indian J Med Res 2010;131:1734. 3. Boyer O, Saadoun D, Abriol J, et al. CD4+CD25+ regulatory T-cell deciency in patients with hepatitis C-mixed cryoglobulinemia vasculitis. Blood 2004;103:342830. 4. Cacoub P, Costedoat-Chalumeau N, Lidove O, Alric L. Cryoglobulinemia vasculitis. Curr Opin Rheumatol 2002;14:2935. 5. Terrier B, Sne D, Dechartres A, et al. Systemic vasculitis in patients with hepatitis C e virus infection with and without detectable mixed cryoglobulinemia. J Rheumatol 2011;38:10410. 6. Fernandes SS, Carvalho J, Leite S, et al. Erythema induratum and chronic hepatitis C infection. J Clin Virol 2009;44:3336. 7. Della Rossa A, Tavoni A, Lorece P, Casula F, Bombardieri S. HBV and HCV infection, polyarteritis nodosa and mixed cryoglobulinaemia: a case report. Clin Rheumatol 2000;19:5024. 8. Lo KY, Chen CY, Lee CS. Hepatitis C virus-associated type II mixed cryoglobulinemia vasculitis complicated with membranous proliferative glomerulonephritis. Ren Fail 2009;31:14952. 9. Canada R, Chaudry S, Gaber L, Waters B, Martinez A, Wall B. Polyarteritis nodosa and cryoglobulinemic glomerulonephritis related to chronic hepatitis C. Am J Med Sci 2006;331:32933.

JOE Volume -, Number -, - 2011

Vasculitis of Dental Pulp Associated with Cryoglobulinemia in HCV Patients