A 48-year-old male smoker with prior history of cocaine use was seen following a left posterior inferior cerebellar artery infarct in March 2019. The stroke was deemed cryptogenic by referring physicians following investigations notable for hypoplastic left vertebral artery and hypertriglyceridemia. During evaluation in the stroke clinic, additional history was obtained. In June 2018, 10 months prior to the stroke, he was diagnosed with inflammatory arthritis of the left hip. Plaquenil and methotrexate were prescribed with no improvement. In November 2018 he developed severe progressive neuropathic pain in both legs. CT in April 2019 revealed a sclerotic lesion of left ramus pubis and lymphadenopathy which was biopsied and showed plasmacytoma. Serum immunoelectrophoresis identified an IgG lambda monoclonal spike (1.19 g/dL). Neurological exam in July demonstrated mild distal weakness in lower extremities, decreased sensation in a length-dependent fashion, and areflexia. Violaceous discoloration of both feet was present. EMG showed mixed axonal-demyelinating motor > sensory polyneuropathy. Homogeneous enhancement of cauda equina was seen on MRI. Plasma Vascular Endothelial Growth Factor (VEGF) was elevated at 313 pg/mL (normal <86 pg/mL). He was diagnosed with POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, Skin changes). Other findings consistent with POEMS were thrombocytosis, low testosterone and hyperfibrinogenemia. He was initially treated with bortezomib, dexamethasone, and lenalidomide followed by autologous stem cell transplant.