Skeletal Cryptococcosis: Case Report and Review of the Literature

Abstract

A case of isolated cryptococcal skull infection is presented in a patient with unexplained CD4 lymphopenia and chronic hepatitis B. All cases of this disease reported in the English literature from 1956 to the present are reviewed. The literature suggests that skeletal cryptococcosis is manifested in only 5% to 10% of recognized cases of disseminated cryptococcosis and that isolated skeletal disease without evidence of other tissue involvement is even less common. When isolated bony disease does occur it tends to occur in immunocompromised hosts, particularly those with defects of cell mediated immunity. Any bony site can be involved, most commonly the vertebrae, with the presentation often being a soft tissue swelling and pain in the affected area. Systemic constitutional symptoms occur in a minority of patients. Radiographic investigations are nonspecific and the gold standard of diagnosis remains culture isolation from bone tissue. The most commonly employed therapy for isolated bone disease is amphotericin alone or combined with surgical debridement. The new azoles may have a role in future therapy.

Cryptococcal osteomyelitis: a report of 5 cases and a review of the recent literature

“…In each of our five patients, symptoms and findings associated with osseous involvement were the first signs of cryptococcosis, and the pursuit of these findings ultimately led to the diagnosis. Prior authors have reported the most common site of infection was the vertebral column, seen in a quarter to one‐third of patients . In our review, 12 of 42 (29%) had vertebral infection.…”

“…Most experts agree that fluconazole alone is sufficient therapy for most patients with localised osseous cryptococcosis . Some have suggested that skeletal cryptococcosis be treated initially with a lipid formulation of amphotericin B plus flucytosine, based on concerns of haematogenous dissemination . The vast majority of these patients can be transitioned to oral fluconazole once they are clinically improved and if there are no signs of disseminated or CNS disease .…”

“…These included patients with positive blood cultures, CSF cultures, or those with a positive cryptococcal CSF antigen. In 1995, Wood and Miedzinski published a review of all reported skeletal infections attributed to C. neoformans , identifying 45 cases …”

“…Extrapulmonary disease is common and the organisms have a propensity for the central nervous system. Isolated osteomyelitis as a manifestation of extrapulmonary cryptococcosis is rare, occurring in 5% of patients with cryptococcal disease . Herein, we present 5 cases of osteomyelitis as the sole extrapulmonary manifestation of cryptococcal disease seen at our institution and a review of the recent literature pertaining to cryptococcal osteomyelitis.…”

Cryptococcus neoformansosteomyelitis and intramuscular abscess in a liver transplant patient

“…C. neoformans infection in solid organ transplant patients most frequently occurs in the late post-transplant period, often between 16 and 21 months 14. It can be due to reactivation of a pre-existing host colonisation or can represent primary infection after new exposure 2 15.…”