A Man with Facial-Nerve Palsy and Pruritus

The patient also reported worsening arthralgias and edema of his face, arms, and legs. On evaluation, there was a scaly, erythematous rash on his legs (see Figure 1). Workup revealed liver injury (cholestasis with inflammation of the biliary system), kidney injury (nephrotic syndrome with type II cryoglobulinemia), inflammation (anemia, elevated C-reactive protein, splenomegaly, lymphadenopathy), and pulmonary infiltrates. Renal biopsy showed membranous nephropathy — but anti-phospholipase A2 receptor (PLA2R) antibodies were negative.