Refractory type I cryoglobulinaemia requiring serial amputations

We present a rare case of a man in his 40s who presented with bilateral lower extremity necrosis. After an extensive workup, he was diagnosed with type I cryoglobulinaemia (TIC) based on severe vaso-occlusive symptoms, presence of serum cryoglobins and tissue biopsy showing small-vessel vasculitis. Treatment was multimodal and targeted both his underlying lymphoproliferative disorder (monoclonal gammopathy of undetermined significance) and inflammatory state. Steroids, plasmapheresis and immunotherapy were administered with temporary remission of symptoms. After discharge, patient continued to repeatedly present with progressive bilateral lower extremity necrosis and new upper extremity digital necrosis necessitating further pharmacological treatment and surgical intervention-bilateral above the knee amputation and multiple digital hand amputations. This case illustrates a severe example of TIC where diagnosis was difficult due to atypical presentation, and disease was refractory to multimodal therapies necessitating surgical intervention to achieve temporary remission.