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History: The patient is a 59 yo black female wo presented with exquisitely painful hemorrhagic bullae and palpable purpuric lesions on her finger tips of 6 weeks duration. She also complained of increasing fatigue, neck stiffness, sore throat, rhinorrhea and transient arthralgias of the knees and ankles. One week prior to her visit she developed tender nodules on both lower extremeties and had 2 episodes of hemoptisis. No history of fever, sinusitis or oral ulcerations.

Physical Examination: Multiple palpable purpuric lesions and shallow ulcerations were present on the distal fingers of both hands. Erythematous, tender nodules were present on both lower extremeties. A swollen right knee joint and a transient erythematous plaque involving the left forehead and infraorbital region were noted

Laboratory Findings: ESR 110, ANA 1:640 (nucleolar pattern), c-ANCA 1:1280, elevated C3, urinalysis-1+ protein, trace blood, RBC casts. WBC 15.5, H/H 10.9/32.7 platlets 488. SPEP - polyclonal increase in gamma globulins, UPEP - glomerular proteinuria. Hepatitis panel, ENA screen, hepatitis panel, VDRL, RF and Cryoglobulins, were within normal limits.


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