Primary cutaneous cryptococcal infection due to fingolimod – Induced lymphopenia with literature review

Patil, Sachin M.; Beck, Phillip Paul; Arora, Niraj; Acevedo, Bran Andres; Dandachi, Dima

doi:10.1016/j.idcr.2020.e00810

Cited by 10 publications

(13 citation statements)

References 12 publications

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Section: Discussionmentioning

confidence: 57%

“…Our patient's case, with a lesion on the upper thigh, was a unique presentation compared to previous cases reported involving the scalp and forehead [1,2]. To our knowledge, there are only two other reported cases of primary cutaneous cryptococcosis with associated fingolimod therapy (Table 1) [1,2]. Primary cutaneous cryptococcal infections may present with chancriform syndromes, involving an ulcerative lesion at the primary site of inoculation and regional lymphadenopathy [8].…”

Section: Discussionmentioning

confidence: 61%

“…Early diagnosis can be challenging, and sources of immunosuppression should be investigated. Previous cases have involved older patients, with a history of trauma and associated pain at the lesion site (Table 1) [1,2]. 62-year-old female with a painful 3-week nodule on the forehead with a history of trauma 6 months prior 3 years 6 weeks of fluconazole 800 mg loading dose followed by 400 mg daily.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…Notably, prior to deciding on a definitive therapy regimen and mode of delivery, clinical and radiographic exclusion of a disseminated infection is of utmost importance. While the cutaneous cryptococcal infection is known to be associated with disseminated disease in immunocompromised patients, there are increasing reports concerning primary cutaneous cryptococcosis infection associated with fingolimod immunosuppressive therapy on exposed skin [ 1 , 2 ]. This is the first report of a case involving an unexposed skin surface and effective resolution with continued fingolimod therapy for multiple sclerosis.…”

Section: Introductionmentioning

confidence: 99%

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Primary Cutaneous Cryptococcosis in a Patient on Fingolimod: A Case Report

Dahshan¹,

Dessie²,

Cuda³

et al. 2021

Cureus

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Primary cutaneous cryptococcosis is an uncommon condition. Patients with immunosuppression and those of older age are more susceptible to infection, warranting investigations into underlying systemic disease. We report the case of a 49-year-old male with multiple sclerosis in remission on fingolimod who presented with a non-healing skin lesion on his upper thigh for a duration of two years. Skin biopsy showed dermal parasitized histiocytes, and serum antigens for histoplasmosis and Cryptococcus were negative. Further investigation with polymerase chain reaction (PCR) demonstrated cutaneous cryptococcal infection, with no associated systemic signs or symptoms. This case report highlights an uncommon presentation of cutaneous cryptococcosis on an unexposed skin surface with successful and rapid improvement following fluconazole therapy without fingolimod discontinuation.

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Section: Discussionmentioning

confidence: 57%

Section: Discussionmentioning

confidence: 61%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Primary Cutaneous Cryptococcosis in a Patient on Fingolimod: A Case Report

Dahshan¹,

Dessie²,

Cuda³

et al. 2021

Cureus

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Fingolimod

2020

Reactions Weekly

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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...

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