Cryptococcal meningitis with secondary cutaneous involvement in an immunocompetent host

Abstract

Cryptococcosis is a potentially fatal fungal disease caused by variants of Cryptococcus neoformans species. The respiratory tract is the usual portal of entry, with a peculiar predilection to invade the central nervous system. The skin can be secondarily involved in disseminated infection or be exceptionally involved as primary cutaneous infection by inoculation. The disease is mostly seen in immunodeficiency states. The diagnosis is frequently unsuspected in immunocompetent patients. We report a case of disseminated cryptococcal meningitis in an immunocompetent young adult. The cutaneous eruption prompted the accurate diagnosis. The patient, a 20-year-old female, had fever, cough, headache and intractable vomiting for the past two months and was being managed as a case of tuberculous meningitis. Two weeks after starting antituberculous treatment she developed umbilicated papules on the head and neck region. Necessary laboratory workup identified C. neoformans in cerebrospinal fluid (CSF) and skin specimens. The titers of cryptococcal antigen were measured in CSF and serum for diagnostic and prognostic purposes. Anti-fungal treatment resulted in regression of the cutaneous lesions and resolution of systemic complaints. The case highlights the need for high degree of suspicion, especially in healthy young adults, in the diagnosis of cryptococcosis. The cutaneous eruptions can be the first manifestation or a diagnostic clue of enormous significance.

Disseminated cryptococcosis manifested as a single tumor in an immunocompetent patient, similar to the cutaneous primary forms

“…Lesions can appear in any type: umbilicated (mimicking molluscum contagiosum), acneiform, nodular, herpetiform, and cellulitis-like lesions. 4 , 9 However, lesions mimicking PCC, as reported in our case, are an exceptional feature.…”

“…Skin involvement in DC patients occurs in approximately 10% of cases, which may be the primary manifestation of the disease and an early sign of dissemination. 2 , 4 , 8 However, PCC is rare and still controversial.…”

“…Another portal of entry is the inoculation of the fungus via skin injury (primary cutaneous cryptococcosis - PCC). 4 …”

A Case of Recurrent Cryptococcal Meningoencephalitis in an Immunocompetent Female

“…Most patients present with signs and symptoms of subacute meningoencephalitis. Regimen and duration of antifungal treatment usually depend on underlying immunosuppression [3, 4]. …”

Cryptococcosis in the Immunocompetent Host: Incidence and Outcomes

“…Cryptococcosis is an invasive fungal infection caused by Cryptococcus neoformans or Cryptococcus gatti that typically occurs in the setting of immunosuppression, often in patients with uncontrolled HIV infection or AIDS. 1,2 Groups at risk for infection also include immunosuppressed individuals without HIV infection and patients on immunosuppressive medications, such as chemotherapeutics or steroids. However, there is a growing body of recent literature reporting C. neoformans infection in immunocompetent individuals.…”