CASE PRESENTATION: A 77 year old male presented with gangrene, ulceration of his left foot and shortness of breath. A Chest CT angiogram which revealed bilateral PE’s with large clot burden. Physical examination showed multiple necrotic wounds in both the upper and lower extremities along with palpable purpura affecting all extremities. Labs showed a -ve ANCA but +ve ANA, high rheumatoid factor titer, low C3 and C4 levels and positive results for cryoglobulins with trace Cryocrit. Screen for both Hep B DNA and Hep C antibody are negative. Patient had a 15 year of history of rheumatoid arthritis and his previous medications including azathioprine, hydroxychloroquine, prednisone and aspirin. Patient was started on ACE- inhibitors due to proteinuria. An IVC filter was also placed due to a subdural hematoma a year before. Patient underwent 3 rounds of plasmapheresis along with the steroids, hydroxychloroquine and rituximab infusions. This lead to a marked improvement in his overall condition with improved dyspnea, oxygenation, skin ulcers, renal function, cryoglobulin levels and hematocrit. He was ultimately discharged after 23 days in the hospital with a near total recovery.