LAUSR

A 79-year-old man with a history of treated lambda light chain myeloma in the previous year presented to the emergency department with a 2-week history of ischaemia of the hands and feet with livedo reticularis and a purpuric rash. He was admitted initially under the vascular team. Computed tomography angiography of his lower limbs was normal and he was managed conservatively with a prostaglandin analogue with little success. Within a day of being discharged by the vascular team, he was readmitted under the medical team with worsening peripheral ischaemia and multiple ulcers affecting his upper and lower limbs (Fig 1). On assessment he was drowsy and had myoclonus. His blood pressure was 107/88 mmHg and his heart rate 106 beats per minute. He was apyrexial. Chest and abdominal examination were unremarkable. He was found to have an acute kidney injury with a creatinine of 326 mmol/L from a baseline of 163 mmol/L. His C-reactive protein (CRP) was 198 mg/L.