Cryofibrinogenemia has been associated with a variety of
skin manifestations including
purpura,
livedo reticularis, and ulceration. Our patient, who had undergone axillobifemoral bypass 5 years previously, presented following the spontaneous development of a necrotic
wound involving the left groin
scar. The location of the
wound suggested the possibility of underlying graft
infection, but
indium-111 white blood cell scan and MRI failed to show any evidence of
infection. The patient was initially treated with oral
antibiotics and outpatient
debridement with no improvement. A more aggressive approach with inpatient operative
debridement and intravenous
antibiotics produced moderate improvement. Three months later, the patient developed an identical necrotic
wound in the right groin and subsequently a third lesion involving a
scar distant from any of the patient's grafts. No evidence of active
vasculitis was seen on microscopic examination of the excised tissues.
Cryoglobulin and
cryofibrinogen assays were positive, and urinary and plasma
homocysteine levels were elevated. The patient was subsequently treated with
stanozolol, a low-
methionine diet, and outpatient intravenous
antibiotics with rapid improvement of her
wounds. In patients with spontaneous ulceration of the extremities, particularly when they do not respond appropriately to standard
therapy, the possibility of
cryoglobulinemia or
cryofibrinogenemia should be considered.