P-346: Cryoglobulinemic vasculitis with gangrene as an initial presentation of Multiple myeloma

Introduction: Type 1 Cryoglobulinemic vasculitis is a rare entity that can present with skin lesions and peripheral gangrene. Its association with lymphoproliferative disorders is well known. However cryoglobulinemia occuring in the context of newly diagnosed multiple myeloma is a rare entity. Here we describe the case of a 67 year old patient who presented with gangrene of all four limbs with renal dysfunction who was eventually diagnosed with multiple myeloma.

Methods: 67 year old male patient with no prior co-morbidities presented with progressive gangrene of both fingers and toes of 2 weeks duration.He also had worsening renal dysfunction during this period with need for intermittent dialysis during this period.He was evaluated for renal dysfunction and his renal biopsy revealed membranoproliferative glomerulonephritis with IgG Kappa restriction on renal biopsy. His peripheral smear examination showed cryoglobulin deposits. His bone marrow examination showed 15% clonal plasma cells which were kappa restricted. There was evidence of cryoglobulin deposits in his bone marrow biospy specimen also. Serum immunofixation electrophoresis showed IgG kappa M spike with kappa/lamda light chain ratio of 30 on light chain assay. His autoimmune and infective work up was negative.

Results: He was initiated on Plasma exchange for cryoglobulinemia and intermittent dialysis for renal dysfunction. Subcutaneous Daratumumab , Bortezomib, Cyclophosphamide and Dexamethasone was given as per standard protocol for the myeloma clone. He developed septic shock and worsening AKI .NDM Kleibsiella was isolated from Blood Biofire sample and he improved with appropriate anti microbial therapy . He had to undergo amputation of fingers and toes which had dry gangrene prior to initiation of treatement, however his renal function and blood parameters improved after 5 sessions of plasma exchange and Daratumumab based treatment of multiple myeloma. he was continued on standard myeloma therapy as per protocol and rehabilitation measures were initiated post amputation surgery.

Conclusions: Our case highlights one of the rare presenting symptom of patient with Multiple myeloma and highlights the role of prompt intervention and multi disciplinary approach to salvage such patients who have a high risk of fatal complications.