A 66-year-old woman with a history of coronary artery disease, atrial fibrillation, and hypertension presented with worsening nonhealing necrotic ulcer over the left calf for the past few weeks. She was applying silver sulfadiazine cream and tea tree oil but did not notice any improvement. She also reported unintentional weight loss of approximately 50 pounds (~23 kg) over several months, and associated loss of appetite. On examination, the posterior aspect of the left leg revealed a 9.0 × 2.0 cm black necrotic ulcer with scant serous drainage and several other smaller ulcers with peri-ulcer induration and tenderness (Panel A). Differential diagnoses included warfarin-induced skin necrosis, calciphylaxis, antiphospholipid antibody syndrome, nephrogenic systemic sclerosis, oxalate vasculopathy, heparin-induced thrombocytopenia, pyoderma gangrenosum, and Marjolin's ulcer. Initial laboratory assessment included hemoglobin 8.9 g/ dL, platelet count 226 k/µL, leukocyte count 4.6 k/µL, serum creatinine 1.2 mg/dL, and blood urea nitrogen 22 mg/dL. Serum calcium, phosphorus, vitamin D, and parathormone levels were normal. Lupus anticoagulant, cardiolipin IgG/ IgM/IgA, and β2-glycoprotein IgG/IgM were negative. Additional investigations, including inflammatory markers,