Cold haemagglutinin disease misdiagnosed as hand-arm vibration syndrome

A patient with a diagnosis of hand-arm vibration syndrome was referred for a second opinion. He worked as a multi-skilled operative in the housing department of a local authority, a job not normally associated with high levels of exposure to hand-transmitted vibration ( > 2.5 m/s(2) A(8)). He described blanching of his fingers and a blue discolouration of his extremities in cold weather. On examination, his fingertips, toes and pinnae were acrocyanotic, the fingers were patchily pale and sensation was subjectively impaired in all of the digits. Investigations revealed a haemolytic anaemia and haemagglutination. He was diagnosed with idiopathic cold haemagglutinin disease. Exposure to vibration may confound with exposure to cold in which case the differential diagnoses of cold haemagglutinin disease or cryoglobulinaemia should be excluded before diagnosing hand-arm vibration syndrome.