Blue Hands

57 y, white gentleman, with PMH of Hepatitis C, comes to office as a new patient, complaining of constant pain in both hands accompanied by bluish discoloration for the past year. His previous PCP diagnosed him with SLE and prescribed Plaquenil (Hydroxychloroquine), which he discontinued because of inadequate relief and GI side-effects. He has used Oxycontin in the past with some relief. He has a 40 + pack-year h/o of smoking and drinks at least a dozen beers along with a pint of Vodka everyday. He has used IV drugs in the past, but claims to be off them for a long time. His family history is non-contributory. Review of systems suggest diffuse arthralgias, most pronounced in the feet. On exam, his vital signs are stable. He has pronounced seborrhea on the face. As shown in the picture, fingers of both the hands have a bluish hue, with a small superficial ulcer on the Lt index finger-tip. Lab results are as follows:
AST:214, ALT:124, Hep C Ab +, Type Ia, ANA +, speckled pattern >1:640,
Anti ds-DNA negative, C3:99, C4: 24, Cryoglobulins: negative (not collected in a frozen specimen), Anti Scl-70: negative, Anti-Centromere Ab: negative, Anti-Sm + 1.22 (nml <1.0), Anti-ENA: 6 (Nml <1.0), Anti-CCP: negative, RF + 1:160, Anti-Ro/ La: negative, HIV: negative, TSH: 1.6

Which of the following is the most likely diagnosis?

1. Primary Raynaud phenomenon
2. SLE- ANSWER
3. Mixed cryoglobulinemia
4. Buerger’s disease/ TAO
5. Undifferentiated connective tissue disease