Primary Cutaneous Cryptococcosis in an Older Immunocompetent Patient: A Case Report

Abstract

Cryptococcus neoformans is an encapsulated yeast that can be found in decaying wood, hay, dust, and feces of birds, especially pigeons. 1) Cryptococcosis is considered an opportunistic infection in immunocompromised people, such as patients with malignancy, human immunodeficiency virus (HIV) infection, and those on long-term treatment with glucocorticoids and immunosuppressive agents after organ transplantation. 2) The infections mainly involve the lungs and central nervous system, with skin invasion considered a sign of dissemination. 3) Primary cutaneous cryptococcosis (PCC) without systemic involvement is recognized as a distinctive clinical disease and is rarely reported in immunocompetent patients. 4) Herein, we report a case of PCC misdiagnosed as cellulitis in an older immunocompetent patient. CASE REPORT A 78-year-old woman living in rural South Korea and with no history of other diseases except for hypertension presented with a Cryptococcus neoformans is an encapsulated yeast that can be found in pigeon droppings, hay, and dust. Primary cutaneous cryptococcosis (PCC) without systemic involvement is recognized as a distinct clinical condition and is rarely reported in immunocompetent patients. A 78-year-old woman with no history of other diseases except for hypertension presented with a painful diffuse erythematous plaque along with oozing on left forearm that had lasted for 7 weeks. She was treated with cefoperazone/sulbactam for 3 weeks under suspicion of bacterial cellulitis, although the lesions aggravated without any improvement. We performed bacterial and fungal cultures as well as incisional biopsy. The pathogen was identified as Cryptococcus neoformans following sequence analysis of the internal transcribed spacer gene. The patient was treated with fluconazole 400 mg/day for 3 months, and there was no evidence of recurrence after 3 months of follow-up.

Primary Cutaneous Cryptococcosis Caused by Cryptococcus neoformans in an Immunocompetent Patient

“…In a local study, cryptococcosis was an HIV/AIDS-defining disease in 40% of cases, so it is important to rule out causes of immunosuppression associated with fungal infection [7]. On the other hand, systemic cryptococcosis in hosts without impairment of immune system is rare and PCC in these immunocompetent patients even more rarely described on the literature [2,[8][9][10][11][12][13][14][15][16]. Our case contributes to the scarce data; we show an immunocompetent patient, without any typical predisposition factor for cryptococcosis, that fulfilled all criteria for PCC diagnoses caused by C. neoformans [1].…”

“…Kronstand, et al, reported that a high fungal load, to which the host is exposed, can explain the disease in immunocompetent persons, via the inhalation of a large number of infectious spores [17]. However, the route of exposure via traumatic inoculation seems more strongly related to PCC [4,16,[18][19][20]. Since the habitat of pigeons and other birds is a reservoir for Cryptococcus species in the environment, we believe this mycosis resulted from an occupational exposure in our case, as has already been described in the literature [21,22].…”

Mediastinal Small Cell Carcinoma with Primary Cutaneous Cryptococcosis: A Rare Case Report

“…12 While no definitive standard treatment protocol exists for PCC, fluconazole and itraconazole are commonly used to treat this condition, with their dose and treatment durations contingent on the patient's immune status and degree of involvement. 13,14 A treatment duration of 6-12 months is recommended by the Infectious Diseases Society of America (IDSA) for patients without dissemination and nervous system involvement. 3 There are reports of PCC in patients with lymphoma, leukaemia and rectal adenocarcinoma combined with multiple metastases who were treated with targeted drugs, immunosuppressive agents or radiotherapy.…”

“… 12 While no definitive standard treatment protocol exists for PCC, fluconazole and itraconazole are commonly used to treat this condition, with their dose and treatment durations contingent on the patient’s immune status and degree of involvement. 13 , 14 A treatment duration of 6–12 months is recommended by the Infectious Diseases Society of America (IDSA) for patients without dissemination and nervous system involvement. 3 …”