Cryoglobulinaemic syndrome (CS) includes clinical signs and symptoms that range from the classic triad of Meltzer and Franklin (
purpura, weakness and
arthralgias) to multiple organ involvement, and it may be characterised by nociceptive or
neuropathic pain. Both types of
pain use the same pathways and
neurotransmitters, but
nociceptive pain has an adaptive system and biological function whereas
neuropathic pain does not. Managing CS means dealing with often very different clinical patterns, activity and severity with the aim of preventing irreversible organ damage, reducing
pain, improving the patients' quality of life and reducing social costs. However, treatment is still largely empirical, and it is often delayed. The Italian Group for the Study of Cryoglobulinaemia (GISC) strongly recommended a low-
antigen-content diet and
colchicine for all symptomatic CS patients. Patients with mild-moderate symptoms (such as
purpura, weakness,
arthralgia and initial neuropathy) have been treated with low or medium doses of
steroids, and, in the presence of
chronic hepatitis C virus (HCV)-related
hepatitis, an attempt has been made to eradicate HCV with pegylated
interferon plus
ribavirin. In the case of severe or rapidly progressive disease (
glomerulonephritis, neuropathy,
leg ulcers, widespread
vasculitis or hyperviscosity syndrome), more aggressive treatment should be used (e.g., high doses of
corticosteroids,
plasma exchange plus
cyclophosphamide or
rituximab).
Pain management in CS therefore depends on the type of
pain (nociceptive, neuropathic or mixed), the characteristics of the patients and their co-morbidities.
Drug therapy should be carefully monitored in order to obtain prompt and beneficial results.