Beneath the Surface: The Search for Answers in a Necrotic Leg Lesion

This case report discusses the diagnostic challenges associated with a necrotic lesion on the left lower leg of a 28-year-old female located in Northern Virginia, initially suspected to be caused by a brown recluse spider bite (loxoscelism). The lesion evolved from a blister to a necrotic eschar after several weeks, and despite clinical features consistent with a spider bite, the patient’s geographic location and lack of risk factors for loxoscelism led to the exclusion of this diagnosis. Cross-specialty consultations, including dermatology, infectious disease, and plastic surgery, were involved in the management of the wound. Histopathological analysis revealed shallow ulceration with fat necrosis but no signs of vasculitis or fungal infection, suggesting a resolving infectious process of trauma rather than a venomous bite. The patient was managed with topical silvadene and compression therapy, with progressive healing observed over several weeks. This case highlights the importance of a comprehensive diagnostic approach and the role of geographic and clinical context in diagnosing necrotic skin lesions.