A 56-year-old man presented with a 1-week history of digital tip ulcers and ischemic gangrene. He also reported the recent onset of Raynaud phenomenon and diffuse joint pain.
His past medical history included diabetes, hypertension, and hepatitis C. The results of his physical examination were significant for palpable purpura (photograph, left) and necrotic fingertips (photograph, below).
The results of serologic testing showed high titers of antinuclear antibody (ANA) (1:10,240 in speckled pattern; normal, negative), the presence of rheumatoid factor (RF) (1:320; normal, less than 1:80), and low levels of C4. The man’s erythrocyte sedimentation rate was elevated, and an active urinary sediment was present. A polymerase chain reaction (PCR) test for hepatitis C virus (HCV) generated more than 2 million copies, and the results of a type 2 (essential mixed) cryoglobulins assay were positive.
A limited arteriogram of the hands revealed multiple fixed digital artery occlusions without proximal disease.
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