Interactive Case Study - May 2026

A 69-year-old woman with digital ischemia

Marissa Yaldo, BS

Raymond Zhao, MD

Mardeen Salah Karim, MD

Ben J. Friedman, MD

Sasank Konda, MD

A 69-year-old woman with a history of myocardial infarction post-percutaneous coronary intervention and prior tobacco use presented with a fifteen-month history of ischemic fingers and toes. She described initial painful episodes of whitish and violaceous discoloration of her fingers which seemed to be precipitated by cold weather. However, she later began to experience persistent and temperature-independent blue-black discoloration of her fingers and toes, leading to ischemic necrosis and eventual amputation of two digits.
Physical examination revealed a blue grey to violaceous patch on the left third fingertip as well as amputations of the left second and right third fingers at the distal interphalangeal joints (Figure 1). Purpuric macules and patches were additionally observed on the left dorsomedial foot, left great toe, and right third toe.
Antiphospholipid antibody testing was negative. Monoclonal protein serum screening demonstrated an elevated free light chain ratio at 140.36 (normal: 0.88 – 1.91), markedly elevated kappa light chains at 1010.6 mg/L (normal: 12.5 – 51.5 mg/L), and the presence of an IgG kappa monoclonal protein with marked suppression of polyclonal gamma globulins. Bone marrow biopsy was pursued and demonstrated 16% plasma cells that were kappa monotypic. Serum cryoglobulin testing was negative.

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Figure 1: Clinical image of left hand

Figure 2: Hematoxylin and eosin

Figure 3: Kappa light chain immunohistochemical stain

Figure 4: Lambda light chain immunohistochemical stain

What is the diagnosis?

Buerger disease (thromboangiitis obliterans)

Calciphylaxis

Cholesterol Emboli

Cryofibrinogenemia

Polyarteritis Nodosa

Which of the following is the first-line treatment for this disorder?

Corticosteroids and low-dose aspirin

Fibrinolysis

Plasmapheresis

Sevelamer

Smoking cessation

Olin JW. Thromboangiitis obliterans. Curr Opin Rheumatol. 1994;6(1):44-49. doi:10.1097/00002281-199401000-00008
Chang JJ. Calciphylaxis: Diagnosis, Pathogenesis, and Treatment. Adv Skin Wound Care. 2019;32(5):205-215. doi:10.1097/01.ASW.0000554443.14002.13
Pennington M, Yeager J, Skelton H, Smith KJ. Cholesterol embolization syndrome: cutaneous histopathological features and the variable onset of symptoms in patients with different risk factors. Br J Dermatol. 2002;146(3):511-517. doi:10.1046/j.1365-2133.2002.04611.x
Ghanem F, Vodnala D, K Kalavakunta J, et al. Cholesterol crystal embolization following plaque rupture: a systemic disease with unusual features. J Biomed Res. 2017;31(2):82-94. doi:10.7555/JBR.31.20160100
Michaud M, Pourrat J. Cryofibrinogenemia. J Clin Rheumatol. 2013;19(3):142-148. doi:10.1097/RHU.0b013e318289e06e
Sankarasubbaiyan S, Scott G, Holley JL. Cryofibrinogenemia: an addition to the differential diagnosis of calciphylaxis in end-stage renal disease. Am J Kidney Dis. 1998;32(3):494-498. doi:10.1053/ajkd.1998.v32.pm9740168
Chung SA, Gorelik M, Langford CA, et al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Polyarteritis Nodosa. Arthritis Rheumatol. 2021;73(8):1384-1393. doi:10.1002/art.41776

Acknowledgements

Author Profiles

Marissa Yaldo, BS

Wayne State University School of Medicine

Marissa is a fourth-year medical student at Wayne State University School of Medicine. She completed her undergraduate education at the University of Michigan. Marissa is applying to dermatology residency in 2025 and has an interest in dermatopathology.

Raymond Zhao, MD

Henry Ford Health System Department of Dermatology

Raymond Zhao, MD, completed his undergraduate education and medical school at the University of Michigan. He then went on to complete his intern year at Trinity Health in Livonia, Michigan. Currently, Dr. Zhao is a PGY-3 dermatology resident at Henry Ford Health in Detroit, Michigan, where he continues to advance his training in the field of dermatology.

Mardeen Salah Karim, MD

Henry Ford Health

Mardeen Salah Karim, MD, completed her undergraduate education at the University of Virginia and medical training at the Tulane University School of Medicine. She then went on to complete her intern year in medicine at Mercy Medical Center in Baltimore, Maryland. Currently, Dr. Karim is a PGY-4 dermatology resident at Henry Ford Health in Detroit, Michigan where she will serve as Chief Resident during her final year of training.

Ben J. Friedman, MD

Henry Ford Health System

Benjamin Friedman, MD, received his undergraduate degree in biopsychology from Cornell University and medical degree from the University of Pennsylvania. He then moved to Michigan in 2013 to complete a dermatology residency at Henry Ford Hospital. After pursuing additional subspecialty fellowship training in dermatopathology at Thomas Jefferson University, he returned to Henry Ford as a full-time senior staff member in 2017.

Sasank Konda, MD

Henry Ford Health System Department of Dermatology

Sasank Konda, MD, completed his undergraduate education at Harvard College and medical education at The University of Chicago before moving to Detroit to complete his residency training in Dermatology. Subsequently, he joined the Henry Ford Medical Group as its inaugural Dermatology Hospitalist -- in this capacity, he divides his time evenly between routine clinic visits and hospital consultations.

Question:

Interactive Case Study - May 2026

Acknowledgements

Author Profiles

A 69-year-old woman with digital ischemia

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