Systemic cryptococcosis with solitary cutaneous lesion in an immunocompetent patient

Abstract

A 55‐year‐old white farmer from north‐east Brazil presented with a 1‐month history of headache and a solitary nodular lesion on his face. He was a smoker and had reported contact with pigeons. He did not complain of any other systemic symptom such as cough or pain. Physical examination of the skin lesion revealed a nodule measuring approximately 3 cm in diameter with central ulceration and overlying crust ( ). The lesion clinically resembled a keratoacanthoma. 1 Nodular, single, keratoacanthoma‐like lesion with a necrotic crust on the face Routine admission blood investigations, including a full blood count, liver function tests, and renal electrolytes, were normal. Serology for human immunodeficiency virus (HIV) (enzyme‐linked immunoabsorbent assay (ELISA) and Western blot) was negative. Intradermal cutaneous tests for Streptococcus, Staphylococcus, E. coli, candida, and trichophytin were negative, whilst tuberculin reaction showed a weakened reactor. Potassium hydroxide (KOH) examination and tissue culture of the skin lesion demonstrated Cryptococcus neoformans. Chest X‐ray revealed hilar and perihilar tumor localized to the anterior mediastinum. Cytology of cerebrospinal fluid (CSF) from lumbar puncture revealed 90% monocytes and 10% polymorphs. Glucose (11 mg%) and protein (405 mg%) levels of the CSF were elevated, whilst flow cytometry of the CSF gave 125 cells/mm3. KOH examination and culture of the CSF were negative. Histologic examination of the cutaneous nodule demonstrated a dermal lymphohistiocytic infiltrate with a granulomatous reaction. On hematoxylin and eosin stained sections, microorganisms were seen, characterized by spores surrounded by a pale capsule. Alcian blue/periodic acid‐Schiff (PAS) staining further highlighted fungal structures. The microscopic findings seen were characteristic of Cryptococcus neoformans (). Cryptococcus neoformans was grown in tissue culture confirming the diagnosis of cutaneous cryptococcosis. After thoracotomy, biopsy of the chest tumor demonstrated a few fungus cells in a dense fibromatous tissue ( ) consistent with the diagnosis of a cryptococcoma. Surgical removal of this tumor was deemed inappropriate due to the proximity of the heart and major vessels. 2 Histology of the nodule showing epidermal hyperplasia and numerous fungal cells in the absence of an inflammatory response (Alcian blue/PAS staining, ×63) 3 Higher magnification showing details of the Cryptococcus neoformans. The radiate or spiny appearance is given by the shrinkage during processing of the tissue (Alcian blue/PAS staining, ×400) 4 Higher magnification of the pulmonary lesion with Cryptococcus neoformans (PAS staining, ×1000) After 1 month of therapy with fluconazole intravenously (400 mg/day), we observed total resolution of the lesion on the face. Repeated lumbar puncture revealed normalization of the CSF protein, whilst skin biopsy from the previously affected site became negative on KOH examination and culture. We continued treating our patient with oral flucon...

CNLAC1Is Required for Extrapulmonary Dissemination ofCryptococcus neoformansbut Not Pulmonary Persistence

“…We propose that the pathogenesis and tropism of C. neoformans is mediated in a stepwise fashion by specific virulence factors. C. neoformans is an environmental microbe (14,27,32) that is initially inhaled (28,29) and yet exhibits a tropism for the CNS (17,30,34). We believe the dissemination from the lungs to the bloodstream occurs initially through the lymphatics draining the lungs.…”

Localized Cutaneous Cryptococcosis in a Patient with Chronic Myeloproliferative Disease

“…Acquired immune deficiency syndrome (AIDS) is the most frequent predisposing factor, but it also occurs in other immunosuppressed individuals. The usual risk factors for HIV‐negative cutaneous cryptococcosis are immunosuppressive therapy for cancer or organ transplantation, sarcoidosis, Hodgkin's disease, systemic lupus erythematosus, and long‐term treatment with corticosteroids (1, 2).…”

“…Cutaneous manifestations of cryptococcosis can take multitude of forms, making the diagnosis difficult. They can resemble granulomas, cellulitic infections, draining sinuses, herpes simplex infections, molluscum contagiosum, or pyoderma gangrenosum (2). In the present case, we first speculated that the lesion was a skin metastasis of hepatic cancer or cutaneous infiltration of hematopoietic malignancy.…”

“…Current approaches to localized cutaneous cryptococcosis favors the use of oral triazole antifungals, such as fluconazole, which provide excellent tissue concentration and antifungal activity without the toxicity of amphotericin B. There is no consensus in the world literature regarding the duration of treatment (2, 4). Two months of treatment with oral fluconazole (400 mg/day) healed the lesion without relapse in our case.…”

Cutaneous Cryptococcosis Mimicking Basal Cell Carcinoma in a Patient with Sézary Syndrome

“…Skin involvement is a feature in 10-20% of cases of disseminated cryptococcal infection (1). We report here a case of a 63-year-old woman with Sézary syndrome (T4, N3, MO, Bl) with an ulcerated preauricular tumour that developed during photopheresis with a combination of methotrexate and steroid treatment.…”