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A 62-year-old man presented with a one-month history of digital gangrene affecting the right hand (Panel A). One digit had been partially amputated 20 years before, after an accident. The skin of his arms and legs had reddish-blue, mottled discolorations in a net-like pattern (Panel B) with palpable cutaneous nodules. Otherwise, the physical examination was unrevealing. The patient did not smoke cigarettes. Urinalysis and a complete blood count were normal. Laboratory testing revealed normal renal function and liver function. Tests for antineutrophil cytoplasmic autoantibody, hepatitis B virus, and hepatitis C virus were negative. A biopsy specimen of a nodule is shown in Panel C (hematoxylin and eosin). There were no abnormalities on computed tomography of the head, neck, and thorax or on the echocardiogram. What is the diagnosis?
Editor's note: We invite our readers to submit their answers at www.nejm.org/mystery. We will publish the diagnosis in the Correspondence section of the June 1, 2006, issue and e-mail it to everyone who submits an answer. All answers must be received by April 20, 2006.
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