ZSFG Pearls 6/27: Leg ulcer ddx, cryoglobulinemias, complement levels


54M h/o IVDU, HCV untreated who p/w leg pain, worsening ulcers in s/o skin popping, found to have vasculopathy/vasculitis likely levamisole related vs cryoglobulinemic.

Seeing a patient who uses IV drugs? Make sure to ask about these ROS points:

  • The last time you injected, was there something different?
  • Have you had any complications/past infxns related to use?
  • What is your filter type/syringe source?
  • What is the route of administration of drugs?
  • Have you ever been clean?
  • Do you use by yourself or other people?
  • Have access to naloxone?
  • Do you have any hardware in you?

Leg ulcer ddx:


  • bacterial, viral, fungal, spirochete, protozoal


  • Common: Venous, arterial, neuropathic
  • Physical/Bites: thermal burns, cold injury, radiation, trauma, spiders
  • Vasculopathies: livedoid, buerger’s dz (Thromboangiitis obliterans)
  • Vasculitis of small/medium vessels…see compliment diagram below!
    • Small vessel: idiopathic, infxn, drugs, mixed cryoglobulinemia, SLE, RA, malignancies, GPA, eosinophilic granulmatosis with polyangitis (Churg-Strauss), microscopic polyangiitis, Henoch-Schonlein Purpura, levamisole induced vasculitis
    • Medium vessel: GPA, Churg-Strauss, cutaneous and systemic polyarteritis nodosa
  • Hypercoagulable states: Factor V Leiden, APLS, Protein C/S deficiency
  • Vaso-occlusive disorders: calciphylasix, cholesterol emboli, type I cryoglobulinemia, cryofibrinogenemia, oxalosis
  • Pyoderma gangrenosum
  • Panniculitis: alpha-1 antitrypsin deficiency, pancreatic fat necrosis, erythema induratum
  • Malignancy: SCC, BCC, cutaneous T/B cell lymphoma, KS
  • Drugs: Hydroxyurea, warfarin, heparin
  • Systemic Sclerosis
  • Hematologic dz: hemoglobinopathies, thrombocytosis


Brouet classification of cyroglobulinemia based on immunological analysis:

  • Type 1: Presence of isolated monoclonal Ig (typically IgG or IgM), usually Waldenstrom’s macroglobulinemia or multiple myeloma, generally malignancy related
  • Type 2: Mixture of polyclonal Ig in association with a monoclonal Ig such as IgM or IgA, w/ RF activity. Usually due to persistent viral infxns, particular HCV and HIV
  • Type 3: Mixed version consisting of polyclonal Ig without monoclonal component. These are generally secondary to autoimmune disorders (CTD), but can be associated with infxn’s



How to interpret complement levels in vasculitis? Here is an algorithm from rheumatology based on when biopsies confirm the dx with the finding of Leukocytoclastic Vasculitis on path.

vasc leuko

Evernote link: https://www.evernote.com/shard/s354/sh/617c18e0-520e-4bd2-aab6-f48b6e07dfa7/3c6f27a1eca641bac4da2eb3f99c599f


One thought on “ZSFG Pearls 6/27: Leg ulcer ddx, cryoglobulinemias, complement levels”

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s