A 53-year-old website developer complained of pain and discoloration of fingertips after cold exposure. Upon his arrival nurse notice a sharp demarcated color change in 2nd, 3rd, and 4th fingers on both hands as shown in the image. On physical examination, both hands were cold, radial pulse 85 bpm, and 3+ bilateral. No numbness, tingling, burning sensation, or any skin abnormality. He had chronic systemic lupus erythematosus that was diagnosed eight years ago and denies drinking alcohol, cigarette smoking, or a history of a heart condition. His lab result reveals the presence of proteinuria and hematuria in urinalysis, antinuclear antibody titer of 1:2,560, and normal creatinine level. Renal biopsy indicated stage V membrane lupus nephritis, which was conducted due to proteinuria. Based on the patient’s history and physical examination findings,