Ecthyma gangrenosum (EG) is typically pathognomonic of Pseudomonas aeruginosa bacteremia among immunocompromised patients, particularly with underlying malignancy. Recently, other pathogens and clinical histories have been implicated, challenging the classic picture of patients with EG. The cutaneous findings in patients follow a pattern of lesion progression from indurated pustules and hemorrhagic vesicles evolving to necrotic ulcers with central black eschar and surrounding erythema. While lesions typically occur on the perineum or lower extremities, their presence has also been described elsewhere. Herein, we describe a case of an immunocompromised man with chronic lymphocytic leukemia and multiple myeloma actively undergoing chemotherapy presenting with EG and sepsis symptoms but without detectable bacteremia who responded to broad spectrum empiric antibiotic coverage including double anti-pseudomonal coverage. It is important to consider EG even in cases without all of the classic presenting symptoms and manifestations of P. aeruginosa bacteremia given a potentially broad range of etiologies for this disease. As seen in this patient, clinical outcomes for patients without bacteremia may be better.