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Necrotic Black Eschars in a Patient With Cancer

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.

What would you do next?

A - Order a computed tomography scan of the lower extremities

B - Order a urine toxicology screen to check for cocaine use

C - Order an ultrasound of the lower extremities

D - Perform a biopsy of a skin lesion for pathologic evaluation