Fingolimod

Abstract

Lymphopenia leading to primary cutaneous Cryptococcal infection: case reportAn approximately 59-year-old man developed primary cutaneous Cryptococcal (PCC) infection due to lymphopenia, while receiving fingolimod for multiple sclerosis (MS).The man presented at the age of 63 years with a history of multiple non-healing left occipital scalp lesions for four years. On clinical examination, he had two nonhealing lesions over the left occipital scalp and one over the right occipital scalp. The right occipital scalp showed a 1.4cm pink plaque lesion, and the left superior occipital scalp lesion revealed a 1-cm pink plaque, and the left inferior occipital scalp lesion revealed 1-cm ill-defined papule. Examination of the face revealed 1-cm pink plaque with central depression located over the right parietal scalp, a 5mm erythematous papule over the right superior helix and an ill-defined 2-cm pink plaque over the right preauricular cheek. Shave biopsy of all three scalp lesions performed and specimens were subjected to histopathology. The right occipital scalp lesion revealed solar elastosis and vascular ectasia at the margins, whereas the left superior occipital scalp lesion revealed an ulcer with numerous fungal yeast forms and granulomatous dermatitis at the margins. The left inferior occipital scalp lesion demonstrated an ulcer with multiple fungal yeast forms, present at the margin. Two weeks later, owing to the abnormal histopathology report, he underwent a repeat biopsy of the left superior occipital scalp lesion for fungal tissue culture. Due to the presence of numerous fungal yeast forms on the biopsy, he presented (latest presentation) for further management. Following review of his clinical history, a decision was made to admit him to the internal medicine inpatient service for additional work-up. His past medical history was notable for MS, diagnosed more than 30 years previously. He additionally had osteoarthritis of right knee status post right knee arthroscopy, and degenerative disc disease of low back status-post surgery. For the underlying MS, he was receiving oral fingolimod [dosage not stated] since 7 years. Anamnesis revealed that he had received highdose corticosteroids [specific drugs not stated] for MS exacerbation previously. His last MS exacerbation occurred 18 years prior. He denied any other clinical symptoms. He denied any exposure to birds or farm animals and no recent significant travel history. Clinical concern was to rule out acute disseminated cryptococcosis, as he was on fingolimod therapy. However, morphology and histochemical properties of the organisms, seen on histopathology specimens were consistent with Cryptococcus species. On the day of admission, two sets of blood cultures were obtained, which returned negative. Additionally, complete blood counts, comprehensive metabolic panel and prothrombin time were within normal limits. His CSF analysis was clear and colourless; the CSF protein was 52 mg/dL, glucose was 59 mg/dL, white cell count was 0 cells/µL and RBC count was 19 cells/µL...