Necrotic Skin Lesions in

a 61-Year-Old Woman
Marc Hare, MD

Case study presented by Dawn Feliciano, Jessi Harwood and Laura Kemp
 Patient Presentation
• 61-year old women presenting with venous leg ulcers

• Lesions on both thighs, black with surrounding redness

• Denies easy bruising or bleeding

• No recent trauma to legs

• Physical Exam
o Oral temperature 97.8oF
o Pulse 86 bpm
o Blood pressure 128/81 mm Hg
o Respiratory rate 14 breaths/min
o Multiple black ulcers on both ankles, unchanged from previous examination
o Trace edema of the ankles
 Past Medical History
• Diabetes Mellitus
• Essential Hypertension
• Obesity
• Angioimmunoblastic lymphadenopathy
o Over 15 years ago
o Benign/ Peripheral
o Treated with Prednisone
• No history of smoking, alcohol or illicit drug use
Lab Results
 Diagnosis
• Patient is Positive for Cryoglobulins: Primary class = IgG
o These are globulins that precipitate at low temperatures
• This mechanism is poorly understood, but it can lead to a syndrome of systemic
inflammation caused by immune complexes.
• Renal complications are seen in all types of Cryoglobulinemias; Hepatitis C
complicates these renal problems and can lead to renal failure.
• Hypertension and nephritic-range proteinuria with resultant edema are characteristic.
• Current condition is complicated by:
o Diabetes Mellitus
• Individuals with this disease tend to have poor circulation in their lower limbs.
• This patient’s wounds are on her lower limbs
o Essential Hypertension
o Obesity
• Obesity restricts the blood flow to areas post bent joints causing the tissues to cool
down
o Edema of ankles (doesn’t include legs)
 Type I Cryoglobulinemia
• Type I is monoclonal, usually IgM.
• This is usually related to an underlying lymphoproliferative disease and may be
difficult to distinguish from Waldenstrom macroglobulinemia, Multiple Myeloma,
or chronic Lymphocytic Leukemia.
o Patient has a history of Angioimmunoblastic Lymphadenopathy
• Type I can result in hyperviscosity with so many circulating cryoglobulins; causing
damage to vessels.
o Patient is positive for cryoglobulins
• Clinical Manifestations: Acrocyanosis, Retinal hemorrhage, Raynaud phenomenon,
Purpura (characterized by dermal vasculitis that extends variably to the
subcutaneous tissue), Arterial thrombosis
o Patient suffers from Dermal Vasculitis
 Type II & III
Cryoglobulinemia
• Types II & III include rheumatoid factor (RF) and are immunocomplexes
formed by monoclonal or polyclonal IgM.
o These types are associated with chronic inflammatory states; such as
Lupus erythematosus & Sjogren syndrome.
o Tissue damage results from immune complex deposition and
complement activation.
o Clinical Manifestations
• Dyspnea
• Cough
• Pleuritic pain
• Neuropathy
 Follow-up
• Patient was referred to Rheumatology and Dermatology
• Prescribed oral corticosteroids and azathioprine
• Serial debridements and continued wound care led
to complete resolution of most lesions
• Developed persistent pancytopenia
despite discontinuation of azathioprine
• Diagnosed with Multiple Myeloma
based on bone marrow biopsy
• Continued positive cyroglobulin tests
Question 1
Knowing the patient’s history of an immunoproliferative
disorder, being negative for Rheumatoid Factor, and having an
increase of IgG; what type of cryoglobulinemia does this patient
most likely have?

a. Type I
b. Type II
c. Type II-III
d. Type III
Question 2
Which of the following diseases will increase the risk of renal
failure in patients with cryoglobulinemia?

a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
Question 3
What would be appropriate test(s) to order for suspected
cryoglobulinemia?

a. BMP
b. CBC with differential
c. Specific immunological assays
d. Hepatitis serologies
e. All the above
Question 4
Which of the following treatments would be indicated for a
patient with asymptomatic cryoglobulinemia?

a. Limiting the precipitation of cryoglobulins

b. Suppression of the immune response
c. Treating the underlying conditions
d. NSAIDs
Question 5
Why is this patient’s hypertension and diabetes considered
complications for her cryoglobulinemia?

a. Cryoglobulins can cause hyperviscosity of the blood, worsening

her hypertension
b. Cryoglobulins can cause vessel damage and renal
complications with nephritic-range proteinuria
c. Both a & b
d. None of the above
Question 6
Why was this patient sent to a Wound Clinic for her wounds?

a. They are wounds – treating wounds is what wound clinics do

b. Diabetics normally suffer from hard-to-heal wounds that need
special treatment
c. Since diabetics have poor capillary perfusion, wounds can
take a long time to heal
d. Both b & c
References