History: A 47 year old white male with a history of rheumatoid arthritis, hypertension, and diabetes presented to Barnes -Jewish Hospital with 4 to 5 days of increasing pain and bluish discoloration of his fingertips and toes.
Past Medical History: Rheumatoid arthritis. Testicular pain and orchitis requiring orchiectomy of one testis 3 months prior to hospitilization.
Myocardial Infarction diagnosed at admission.
Allergies: No known drug allergies
Physical Exam: The skin showed acrocyanosis of the palms, fingers and toes (Figs. 1, 2) and a few lesions of palpable purpura on the bilateral feet and toes (Fig.3)
Neurologic examination revealed a left sided foot drop with sensory loss between the left great and second toes in the distribution of the left deep peroneal nerve
WBC: 17,300, Creatinine: 1.99, BUN: 48, CRP: 105, ESR: 102, Rheumatoid Factor: 833, Lupus anticoagulant: negative, Cryoglobulins: negative, ANCA: negative, HIV: negative, ANA: negative, ENA: negative, Hepatitis B core Antibody: positive, Hepatitis B PCR: undetected, Hepatitis C antibody: negative, Urinalysis: normal
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