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JAMA Clinical Challenge

Necrotic Black Eschars on the Lower Extremities in a 57-Year-Old Woman With Ovarian Cancer

Image of A, Necrotic black eschars on the lower extremities B, Stellate purpuric patches on the lower extremity

Barry Ladizinski, MD
Kachiu C. Lee, MD
A 57-year-old woman with stage IIIC ovarian cancer presents with painful leg ulcerations of 3 months' duration. She denies fevers, chills, and other systemic symptoms. Her cancer was diagnosed 6 months ago, and she was treated with primary surgical debulking, with partial omentectomy, loop ileostomy, and 4 cycles of chemotherapy with paclitaxel + carboplatin and panitumumab + gemcitabine. She denies use of alcohol or illicit substances. Physical examination reveals necrotic black eschars and scattered stellate purpuric patches on the lower extremities (Figure, A and B). All areas are exquisitely tender to palpation. The remainder of the examination is unremarkable.

Laboratory investigation demonstrates a creatinine level of 1.9 mg/dL (168.0 μmol/L), elevated from her baseline level of 1.2 mg/dL (106.1 μmol/L) 1 month ago. Lupus anticoagulant level (60.9 seconds [normal value, <43.1 seconds]), prothrombin time (14.2 seconds [normal range, 11-13.2 seconds]), and partial thromboplastin time (35.4 seconds [normal range, 21-33 seconds]) are slightly elevated. Results of liver function tests and levels of calcium, magnesium, phosphorus, parathyroid hormone, antinuclear antibody, protein C, and protein S are within normal limits.

See the full article for an explanation and discussion.

Author Affiliations: Dr Lee (kachiu@gmail.com) is affiliated with the Department of Dermatology, Brown University, Providence, Rhode Island; Dr Ladizinski is affiliated with Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.