Address reprint requests and correspondence to Paul Y. Takahashi, MD, Division of Community Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: takahashi.paul@mayo.edu). A 73-year-old woman presented to the hospital because of a 6-week history of progressive bilateral lower extremity ulcers. The initial ulcer began as a painful area beneath the skin over her right lateral calf. The ulcer expanded and became painful. Two weeks before admission, a painful ulcer appeared on the patient’s left shin. This ulcer also enlarged and expanded. The patient experienced intermittent and mild swelling of her lower extremities. She had no history of bites, trauma, or claudication; experienced no fever, night sweats, or chills; and denied having any numbness or tingling sensations of the lower extremities. She applied topical silver sulfadiazine ointments to the ulcers, with no improvement. The patient had a 4-year history of type 2 diabetes mellitus but was unaware of any associated complications. Forty years previously, a unilateral nephrectomy had been performed for an unknown cause. Five years previously, she developed end-stage renal disease secondary to hypertensive nephrosclerosis. The patient was undergoing hemodialysis 3 times a week and was receiving long-term anticoagulation with warfarin for stroke prevention secondary to chronic atrial fibrillation. She had chronic hypertension that required multiple medications to control and chronic obstructive pulmonary disease with resultant pulmonary hypertension. The patient denied current use of alcohol or tobacco. Medications on admission included lisinopril, furosemide, diltiazem, metoprolol, doxazosin, digoxin, warfarin, sevelamer, and insulin.