Hrev_master Question Given the patient’s history, what is the likely mechanism of his skin lesions? 1. Porphyria cutanea tarda 2. Calcific uremic arteriolopathy (calciphylaxis) 3. Immune Thrombocytopenia Purpura (ITP) 4. Cryoglobulinaemic Vasculitis (CryoVas) [page 28] [Emergency Care Journal 2022; 18:10425] Emergency Care Journal 2022; volume 18:10425 Necrotic lesions of the hands Davide Bastoni, Erika Poggiali Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy An 82-year-old man with a history of end-stage renal disease due to glomerulonephritis requiring haemodialysis, hepatitis C-relat- ed liver cirrhosis and hypertensive cardiomyopathy presented with painful and necrotic lesions of both his hands. He had no other symptoms. Laboratory results showed leucocytosis (13,000 per cubic millimetre, reference range 4,000 to 10,000) and increased C-reactive protein (5 mg/dL, reference range 0 to 0.5) and procalcitonin values (9.4 ng/mL, reference range < 0.5). Skin lesion culture resulted positive for Klebsiella pneumoniae and Enterococcus faecium. The patient was urgently referred to the vascular clinic and treated with partial bilateral hand amputation and parenteral antibiotic therapy. Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, Via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39 0523 303044 E-mail: poggiali.erika@gmail.com Key words: Cryoglobulinemia; vasculitis; necrotic skin lesions; hepati- tis C virus; CryoVas. Conflicts of interest: The authors declare no conflict of interest. EP is member of the editorial board of Emergency Care Journal. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Erika Poggiali, poggiali.erika@gmail.com. Ethics approval and consent to participate: As this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: The patient provided consent for the access to med- ical records at the time of admission. Received for publication: 22 February 2022. Revision received: 7 March 2022. Accepted for publication: 7 March 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10425 doi:10.4081/ecj.2022.10425 Non -co mmerc ial us e o nly Answer Crioglobulinaemic Vasculitis (CryoVas) is the most likely. Serum cryoglobulins were detected and a diagnosis of necrotizing CryoVas was done. Cryoglobulins are antibodies that precipitate at low temperatures and dissolve after rewarming. The presence of circulating cryoglobulins is called cryoglobulinemia and it can lead to an inflammatory syndrome of the small and medium-sized blood vessels, characterized by fatigue, arthralgia, purpura, ulcers, neuropathy and/or glomerulonephritis.1 Cryoglobulinemia is clas- sified into three types (I, II and III) on the basis of immunoglobulin composition.2 Lymphoproliferative, autoimmune diseases and hep- atitis C virus infection are predisposing causes. CryoVas is the most common extrahepatic manifestation in patients with hepatitis C. The diagnosis is based on clinical features and laboratory detec- tion of serum cryoglobulins. The treatment strategy depends on the cause of cryoglobulinemia. Antiviral therapy is indicated in patients with chronic C hepatitis, while immunosuppressive or immunomodulatory therapy, including steroids, plasmapheresis, and cytotoxic agents, is reserved for organ-threatening manifesta- tions.3 The prognosis is poor, particularly in elderly patients.4 The main causes of death are renal failure and widespread vasculitis with the involvement of the gastrointestinal system.5,6 Liver fibro- sis at the time of diagnosis is the poorest prognostic factor in patients with C hepatitis.7 References 1. Davuluri S, Bansal P. Cryoglobulinemic Vasculitis. 2021 Jan 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 2. Brouet JC, Clauvel JP, Danon F, Klein M, Seligmann M. Biologic and clinical significance of cryoglobulins. A report of 86 cases. Am J Med 1974;57:775-88. 3. Silva F, Pinto C, Barbosa A, et al. New insights in cryoglobu- linemic vasculitis. J Autoimmun 2019;105:102313. 4. Della Rossa A, Marchi F, Catarsi E, et al. Mixed cryoglobu- linemia and mortality: a review of the literature. Clin Exp Rheumatol. 2008;26:S105-8. 5. Berera S, Gomez A, Dholaria K, et al. A Rare Case of Hepatitis C-Associated Cryoglobulinemic Duodenal Vasculitis. ACG Case Rep J 2016;3:e134. 6. Calle Toro JS, Davalos DM, Charry JD, et al. Hepatic and Mesenteric Vasculitis as Presenting Manifestation of Mixed Cryoglobulinemia Related to Chronic Hepatitis C Virus Infection in a Female Patient. J Clin Rheumatol 2016;22:212- 4. 7. Terrier B, Semoun O, Saadoun D, et al. Prognostic factors in patients with hepatitis C virus infection and systemic vasculi- tis. Arthritis Rheum 2011;63:1748-57. Mini Review Images in Emergency [Emergency Care Journal 2022; 18:10425] [page 29] Non -co mmerc ial us e o nly