A man in his mid-50s presented with progressively worsening bilateral lower extremity rash (Fig 1), symmetric paresthesias of his lower extremities, and small-volume hemoptysis. Skin biopsy showed an occlusive vasculopathy with vasculitic changes. Hypercoagulability workup results were normal. Laboratory testing for antinuclear cytoplasmic antibody and lupus serologic tests for hepatitis B and C virus and HIV were negative. Complement levels were normal. Serum protein electrophoresis demonstrated an immunoglobulin G (IgG) κ light chain monoclonal protein at a concentration of 0.3g/dL.