Thromboangiitis obliterans with cryoglobulinemia

Thromboangiitis obliterans (TAO), or Buerger's disease, is a vascular occlusive disease associated with cigarette smoking. It typically affects medium sized vessels of extremities. Basic pathology of TAO is described to be endothelial activation with highly inflammatory intraluminal thrombosis preserving internal elastic membrane. Cryoglobulins are immunoglobulins that precipitate in the cold and dissolve on re-warming. Cryoglobulinemic vasculitis is a typical small vessel disease associated with cryoglobulinemia commonly bearing typical purpuric skin lesions. An association of TAO with cryoglobulinemia is not reported yet. We report a 34-year-old male heavy cigarette smoker seen for extremity pain and cyanosis of left little finger along with skin rashes characteristic of small vessel disease. Initial presentation of his symptoms at winter and unusual purpuric skin lesions led to search for cold-agglutinating globulins in his plasma. He had severe cryoglobulinemia while the other laboratory tests were normal. TAO associated with cryoglobulinemia merges as a possibility.