Cryptococcal infection presenting as soft tissue abscess and arthritis

Abstract

Rationale: Cryptococcal infection has been documented in immunocompromised patients. AIDS and renal transplant recipients account for majority of the cases. Most cases present with central nervous system or disseminated disease, with only few presenting soft tissue, bone, and joint manifestations. Patient concerns: We present a case of soft tissue mass in a 66-year-old female renal transplant recipient and that of arthritis in a 64-year-old immunocompetent man who presented pseudogout arthropathy. Chest radiographies of both cases were negative. Biopsy revealed cryptococcal organisms. Blood culture or cerebrospinal fluid sampling indicated positive results for cryptococcal antigen. Diagnosis: Cryptococcus neoformans was recovered in the wound culture. Interventions: The patients received intravenous fluconazole and flucytosine, followed by oral fluconazole administration. Outcomes: Symptomatic improvements were achieved and no subsequent relapses were observed. Lessons: The authors experienced 2 cases of cryptococcosis with very unusual clinical presentation. Early clinical suspicion and serum cryptococcal antigen testing can help in rapid appropriate diagnosis in immunocompetent as well as immunocompromised patients even in the absence of pulmonary involvement.

Orthopedic Manifestations of Disseminated Cryptococcal neoformans Infection in an Immunocompromised Patient: a Case Report

“…A rare presentation of disseminated cryptococcal infection is within the bone, occurring in 5-10% of patients with cryptococcus [ 18 ]. Cryptococcal osteomyelitis and abscess formation often present together [ 19 ]; it has been thought that cryptococcus seeds the bone first, spreading then to the surrounding musculature and forming the cryptococcal abscess [ 20 , 21 , 22 ]. Although our patient developed osteomyelitis of the left upper extremity, this was after first developing intramuscular abscesses and necrosis.…”

“…The left lower extremity was never formally debrided but similar abscess could be appreciated on CT scan without bony involvement. We were only able to identify one other case of cryptococcal dissemination manifesting as an intermuscular mass in the absence of bony invasion [ 19 ].…”

Interactions between antifungals and everolimus against Cryptococcus neoformans

“…Cryptococcus , as the causative agent of cryptococcosis, is found in various environmental sources, including contaminated milk, birds droppings, and soil. Pneumonia, meningitis, skin, soft tissue, bone, and joint infections ( Cho et al., 2021 ) are typical cryptococcal symptoms; however, the infection may spread to other organs via the lymphatic system or the circulatory system.…”

“…About 200,000 individuals a year are killed by pathogenic species of Cryptococcus ( Fonseca et al., 2019 ). Standard therapy is a typically an aggressive intravenous injection of an antifungal drug, followed by suppressive treatment taken orally for a period that varies depending on the patient’s condition ( Cho et al., 2021 ). Amphotericin B (AmB) (typically lipid formulations) plus 5-fluorocytosine (5FC) for induction treatment for 2 weeks, followed by fluconazole as suppressive therapy, is the recommended treatment ( Perfect et al., 2010 ; Cho et al., 2021 ).…”

“…Standard therapy is a typically an aggressive intravenous injection of an antifungal drug, followed by suppressive treatment taken orally for a period that varies depending on the patient’s condition ( Cho et al., 2021 ). Amphotericin B (AmB) (typically lipid formulations) plus 5-fluorocytosine (5FC) for induction treatment for 2 weeks, followed by fluconazole as suppressive therapy, is the recommended treatment ( Perfect et al., 2010 ; Cho et al., 2021 ). However, the high dosages needed for these infections, the severe toxicities of AmB have been a limiting factor in its use ( Thakur and Revankar, 2011 ).…”