Cutaneous Cryptococcosis Mimicking Pyoderma Gangrenosum: A Report of Four Cases

Abstract

SHORT COMMUNICATIONCryptococcosis is a fungal infection caused by Cryptococcus neoformans, and frequently presents with meningitis, pneumonia, and cutaneous eruptions in immunocompromised patients. Clinical features of cutaneous cryptococcosis vary; thus, it is necessary to suspect the disease and perform a skin biopsy in order to make an early and accurate diagnosis. We herein report 4 cases of cutaneous cryptococcosis presenting with pyoderma gangrenosum-like appearance. CASE REPORTCase 1. An 85-year-old woman was admitted to hospital, complaining of fever, as well as ulcers on the face, neck, and upper extremities. She had been suffering from erythroderma and was treated with prednisolone (20 mg/day) for the previous year. Physical examination revealed deep irregular ulcers with necrosis on the upper extremities ( Fig. 1a) and nodular lesions with crusts on the neck. In addition, erythema and hemorrhagic blisters were found on the left lower leg. Laboratory examination showed leukocytosis (10,400/μl), elevated C-reactive protein (CRP) (4.21 mg/dl) and β-D-glucan (56.1 pg/dl: normal 0-11) levels, and positive C. neoformans antigen. Histological examination revealed granulomatous inflammation infiltrated with lymphocytes and histiocytes, and degeneration of the dermis and subcutaneous fat tissues. Numerous rounded fungal bodies positively stained by PAS and Grocott were found in the subcutaneous fat tissue. Microbiological culture from ulcer exudate showed C. neoformans. Examination by computed tomography (CT) revealed pneumonia, and a cerebral abscess was detected by magnetic resonance imaging (MRI). The ulcers healed after intravenous administration of fluconazole (200 mg/ day), however the patient died of sepsis.Case 2. A 74-year-old woman presented with an ulcer on the right lower leg that had appeared 6 months previously. She had been treated at an internal medicine clinic, but the ulcer deteriorated. She was also suffering from diabetes mellitus, chronic kidney disease and bronchial asthma. Physical examination revealed irregular ulcers with necrosis on the right lower leg (Fig. 1b). Laboratory examination showed a normal white blood cell count (7,500/μl), elevated CRP (0.97 mg/dl) and β-D-glucan (12.4 pg/dl) levels, and positive C. neoformans antigen. Histological examination revealed inflammatory infiltrates of lymphocytes and histiocytes in the dermis, and a number of fungal bodies stained with PAS, Grocott, and mucicarmine were found in the dermis (Fig. 2). Culture from ulcer exudates as well as blood verified C. neoformans. Chest CT revealed pneumonia, and two weeks after administration, she died of respiratory failure. Case 3. A 93-year-old woman was hospitalized, complaining of redness and swelling of the thighs for the previous month. She had been treated without response with antimicrobial drugs. Physical examination revealed irregular deep ulcers with necrosis on the right thigh (Fig. 1c). Laboratory examination showed leukocytosis (11,680/μl), elevated CRP (4.24 mg/dl) level, normal β-D-glucan (...

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