Table 2 Summarized timeline of case presentation

Week 0

Presented with left groin mass. Excisional lymph node biopsy was consistent with metastatic melanoma.

Week 4

Radical resection of melanoma with wide local excision of regressed primary and complete lymph node dissection.

Week 19

First cycle of Ipilimumab 10 mg/kg. Side effects included mild diarrhea and mouth soreness.

Week 22

Second cycle of Ipilimumab 10 mg/kg.

Week 23

Symptoms of myalgias, arthralgias, rash, vision changes, jaw pain, and discoloration of several upper and lower limb digits.

Week 24

Amlodipine 10 mg daily, Aspirin 81 mg daily, and Prednisone 10 mg daily initiated for suspected Raynaud’s phenomenon. Digital pain and discoloration progressed.

Week 25

She received Methylprednisolone 500 mg IV followed by oral Prednisone 60 mg daily. Additional dose of 500 mg Methylprednisolone IV given later in the week. Lower extremity digital pain resolved, upper extremity digital pain progressed.

Week 26

Admitted. Initiated on Methylprednisolone 2 mg/kg/day IV, calcium channel blockade, and nitropaste. Administered an additional Methylprednisolone 1000 mg dose. Epoprostenol initiated for a 5-day course. Botulinum toxin A was injected into each hand. Refer to Fig. 1 for the physical exam and Fig. 2 for the conventional angiogram.

Week 27

Transitioned to oral Prednisone 100 mg (1 mg/kg) daily and Sildenafil 20 mg BID.

Week 27-30

Initiated on weekly Rituximab 375 mg/m2. Refer to Fig. 3 for the physical exam at week 31.

Week 32

Prednisone was tapered down to 10 mg daily.

Week 34

Developed IRAE of pneumonitis, prednisone was increased to 50 mg daily and symptoms improved.

Week 48-52

Surgical amputation of multiple distal digits.

Week 49

Prednisone completely weaned off.