Conclusions

Recurrent, antibiotic-unresponsive, dependent lower-extremity purpura should raise suspicion for cutaneous small-vessel vasculitis, and in patients with chronic HCV, for cryoglobulinemic vasculitis in particular. A focused workup with serum cryoglobulins with appropriate warm-handling, complement (notably C4), urinalysis for renal involvement, antinuclear and antineutrophil cytoplasmic antibodies to address mimics, and HCV testing can establish the diagnosis and redirect care from repeated antibiotics toward antiviral and, when indicated, immunosuppressive therapy. In patients who use cocaine, levamisole-adulterated cocaine vasculopathy is an important differential, and anti-HNE antibody testing should be considered.

In this patient, HCV eradication with direct-acting antivirals led to complete resolution of cutaneous vasculitis, normalization of serial urinalysis without evidence of active glomerulonephritis, and successful corticosteroid tapering. The patient remains on 5 mg prednisone daily with ongoing taper toward discontinuation. Early rheumatologic co-management facilitated systematic monitoring for renal involvement, titration of corticosteroids as a bridge to antiviral effect, and structured evaluation of levamisole-adulterated cocaine vasculopathy as a concurrent mimic. This case reinforces antiviral cure as the primary treatment target in HCV-associated cryoglobulinemic vasculitis and highlights the importance of early diagnosis in shortening diagnostic delay and redirecting therapy toward the underlying driver.