Hematology and Oncology Q36

A 32-year-old woman is evaluated for a painful rash occurring bilaterally on her lower extremities, which began 2 days ago. She was admitted to the hospital 5 days ago for diagnosis and treatment of pulmonary embolism with heparin and warfarin. Her father had a pulmonary embolism after a long airplane ride. Her medical history is otherwise unremarkable, and she takes no other medications.

On physical examination, vital signs are normal. She has nonblanchable macules and papules and areas of cutaneous necrosis in an angulated reticular pattern on the lower legs; findings on the feet are shown. The examination is otherwise unremarkable.

Laboratory studies show a normal complete blood count, a normal peripheral blood smear, and an INR of 4.

Which of the following is the most likely diagnosis?

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