Necrotic Skin Lesions in a 61-Year-Old Woman

A 61-year-old woman presents to the wound center for continued treatment of venous leg ulcers complicated by diabetes mellitus. Her past medical history is remarkable for essential hypertension and obesity. The patient also has a history of angioimmunoblastic lymphadenopathy, which occurred over 15 years ago. The patient can not remember any details of this diagnosis; consultation with her primary care clinician reveals that this was a benign/peripheral presentation. No records are available for review. According to the primary care clinician, the condition went into complete remission following a course of prednisone. The patient notes that she has developed new wounds on both of her thighs. The lesions are black, with surrounding redness and tenderness. There is no itching. She states that the lesions have been enlarging slowly over the past several days, and many are now several centimeters in diameter. She denies having any fever or chills. Her fasting serum glucose readings have been stable in the 100-200 mg/dL (5.55-11.1 mmol/L) range. She denies experiencing any easy bruising or bleeding. She has not had any recent trauma or procedures in the area of the lesions, and she has not had any recent changes in her medications. She has no history of smoking, alcohol or illicit drug use.

On physical examination, her oral temperature is 97.8°F (36.6°C). Her pulse is 86 bpm and regular, and her blood pressure is 128/81 mm Hg. Her respiratory rate is 14 breaths/min. She is in no acute distress, but she does note that the wounds are causing her discomfort. The examination of her head, neck, lungs, heart and abdomen is unremarkable. The skin of the upper extremities and torso is also unremarkable. She has a nonhealing venous ulcer on each of her medial malleolar areas, which are unchanged from previous examination. She has multiple black eschars on her thighs, each surrounded by a centimeter of erythema with a slightly reticular pattern, as well as induration. She has trace edema to her ankles, but no edema in her legs or thighs. The lesions are tender. There are no vesicles or pustules. No confluent or ascending erythema is noted. The largest lesion measures 4.4 × 2.6 cm (see Figure 1).

Laboratory testing shows a white blood cell (WBC) count of 10.1 × 103/µL (10.1 × 109/L; normal range, 4.1- 10.9 × 103/µL), a hemoglobin of 10 g/dL (100 g/L; normal range, 12.0-15.2 g/dL), platelets of 492 × 103/µL (492 × 109/L; normal range, 140-450 × 103/µL), and a normal WBC differential. The basic metabolic panel is normal. The hemoglobin A1c finding is 6.6% (0.066; normal range, 3.8-6.4%). The albumin is normal at 3.5 g/dL (35 g/L), and the erythrocyte sedimentation rate (ESR) is elevated at 80 mm/hr (normal range, 1-25 mm/hr).

Biopsies are obtained of representative lesions at their edges. They demonstrate acute and chronic inflammation in the dermis and subcutaneous fat. No viral cytopathic changes are seen. Small vessel microthrombi are limited to the base of the ulcer and are not identified in vessels away from the ulcer, which suggests a secondary thrombotic reaction. No specific changes of vasculitis or malignancy are identified.

What is the diagnosis?

Hint: Her current diagnosis is associated with her remote past medical history.

Multiple myeloma

Cryoglobulinemia

Non-Hodgkin lymphoma

Giant cell arteritis