Cryptococcus neoformans infection in malignancy

Cryptococcosis is an opportunistic invasive fungal infection that is well described and easily recognised when it occurs as meningitis in HIV-infected persons. Malignancy and its treatment may also confer a higher risk of infection with Cryptococcus neoformans, but this association has not been as well described. A case of cryptococcosis in a cancer patient is presented, and all cases of coincident C. neoformans infection and malignancy in adults published in the literature in English between 1970 and 2014 are reviewed. Data from these cases were aggregated in order to describe the demographics, type of malignancy, site of infection, clinical manifestations, treatment and outcomes of cryptococcosis in patients with cancer. Haematologic malignancies accounted for 82% of cases, with lymphomas over-represented compared to US population data (66% vs. 53% respectively). Cryptococcosis was reported rarely in patients with solid tumours. Haematologic malignancy patients were more likely to have central nervous system (P < 0.001) or disseminated disease (P < 0.001), receive Amphotericin B as part of initial therapy (P = 0.023), and had higher reported mortality rates than those with solid tumours (P = 0.222). Providers should have heightened awareness of the possibility of cryptococcosis in patients with haematologic malignancy presenting with infection.

Primary cutaneous cryptococcosis in an immunocompetent patient due to Cryptococcus gattii molecular type VGI in Brazil: a case report and review of literature

Primary Cutaneous Cryptococcosis is an uncommon infection caused by the yeast Cryptococcus neoformans and C. gattii. Few case reports are available in the literature describing in detail primary cutaneous cryptococcosis due to C. gattii in immunocompetent patients. Herein, we present a case of a 68-year-old immunocompetent male patient with erythematous nodular lesions on the right forearm due to C. gattii mating-type α and molecular type VGI. The virulence factors test was performed for capsule diameter, melanin production and phospholipase activity. In vitro fluconazole testing showed the sensitivity profile of this clinical isolate. In addition, a review of the literature on this subject was carried out and verified that this is the first reported case of VGI in the south-east region of Brazil.

Epidemiology of invasive mycoses in North America

The incidence of invasive mycoses is increasing, especially among patients who are immunocompromised or hospitalized with serious underlying diseases. Such infections may be broken into two broad categories: opportunistic and endemic. The most important agents of the opportunistic mycoses are Candida spp., Cryptococcus neoformans, Pneumocystis jirovecii, and Aspergillus spp. (although the list of potential pathogens is ever expanding); while the most commonly encountered endemic mycoses are due to Histoplasma capsulatum, Coccidioides immitis/posadasii, and Blastomyces dermatitidis. This review discusses the epidemiologic profiles of these invasive mycoses in North America, as well as risk factors for infection, and the pathogens' antifungal susceptibility.

Fungal Infections

The incidence of invasive fungal infections has increased dramatically over the past two decades, mostly due to an increase in the number of immunocompromised patients.1–4 Patients who undergo chemotherapy for a variety of diseases, patients with organ transplants, and patients with the acquired immune deficiency syndrome have contributed most to the increase in fungal infections.5 The actual incidence of invasive fungal infections in transplant patients ranges from 15% to 25% in bone marrow transplant recipients to 5% to 42% in solid organ transplant recipients.6,7 The most frequently encountered are Aspergillus species, followed by Cryptococcus and Candida species. Fungal infections are also associated with a higher mortality than either bacterial or viral infections in these patient populations. This is because of the limited number of available therapies, dose-limiting toxicities of the antifungal drugs, fewer symptoms due to lack of inflammatory response, and the lack of sensitive tests to aid in the diagnosis of invasive fungal infections.1 A study of patients with fungal infections admitted to a university-affiliated hospital indicated that community-acquired infections are becoming a serious problem; 67% of the 140 patients had community-acquired fungal pneumonia.8

Primary cutaneous cryptococcosis in immunocompetent and immunocompromised hosts

A case of primary cutaneous cryptococcal infection is presented and cases of primary cutaneous cryptococcosis in normal and immunocompromised hosts are reviewed. Cutaneous cryptococcosis can occur from local inoculation or dissemination from a distant site of infection. Risk factors associated with development of primary cutaneous cryptococcosis are those which affect cell-mediated immunity, such as corticosteroid usage, solid organ transplantation, sarcoidosis and immunosuppression. The cutaneous manifestations of cryptococcosis are protean and may mimic other cutaneous diseases. Patients with a diagnosis of cryptococcosis from a skin biopsy or culture should undergo evaluation to exclude disseminated disease and an evaluation of cell-mediated immunity. Although some patients do well without antifungal therapy, these patients cannot be discerned prospectively and therefore antifungal therapy appears warranted in all patients with localized disease. Choice of therapy depends on the extent of disease and immunocompetence of the host.

Cutaneous cryptococcosis mimicking basal cell carcinoma in a patient with AIDS

BACKGROUND

Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus neoformans. This ubiquitous organism has emerged as a frequent finding in immunosuppressed patients, especially those with underlying malignancies, organ transplants, and the acquired immune deficiency syndrome (AIDS). Cutaneous manifestations of cryptococcosis occur in 10 to 15% of patients having systemic involvement. These skin lesions may simulate a variety of different disease entities.

METHODS

A case of crytococcosis mimicking a basal cell carcinoma is the subject of a case report presentation.

RESULTS

A case of cutaneous cryptococcosis mimicking basal cell carcinoma occurred in a patient with AIDS, who did not appear to have dissemination, but was treated aggressively to stem possible occult systemic disease.

CONCLUSION

Cutaneous crytococcosis may mimic other dermatologic disorders.

Idiopathic CD4+ T-lymphocytopenia in a child with disseminated cryptococcosis

We describe a Malay girl with disseminated cryptococcosis affecting the lungs, liver, lymph nodes and bones. The diagnosis was made by culture of the bone marrow. Tests of immune function showed that she was HIV-negative but the CD4 percentage was persistently low. Idiopathic CD4+ T-lymphocytopenia was diagnosed. The child died despite two courses of anti-fungal therapy.

Primary unusual cutaneous cryptococcosis in an HIV former drug-abuser patient

We describe an HIV-positive patient suffering from cutaneous cryptococcosis who was a former intravenous drug abuser and who presented a nodulo-ulcerated lesion on the back of his left hand. This was caused 4 months previously when the patient was injured by a pigeon nesting in an abandoned house. After fluconazole treatment for 4 months, no other visceral infections were recorded 18 months after complete healing of the lesion.

Cryptococcal infection of a prosthetic dialysis fistula

Fungal infections of prosthetic dialysis fistulae are rare. We report the first case of infection of a polytetrafluoroethylene dialysis access graft with the yeast Cryptococcus neoformans. Therapy with antifungal agents alone failed to cure the infection and significant improvement was observed only when all prosthetic material was surgically removed. This case emphasizes the potential for fungal infection of prosthetic dialysis fistulae and the importance of removal of intravascular foreign material in conjunction with antifungal therapy for treatment of fungal prosthetic graft infections.

Cutaneous involvement with Cryptococcus neoformans in AIDS

Patients infected with HIV are susceptible to many opportunistic fungal infections. Cryptococcus neoformans infection is particularly common in patients with AIDS. We describe a patient with disseminated cryptococcosis resembling molluscum contagiosum and review the typical cutaneous manifestations of disseminated cryptococcosis. A synopsis of case reports in the English literature is also presented.

Cryptococcal skull infection: a case report with review of the literature

A case of cryptococcal osteomyelitis of the skull is presented. The patient was an immunocompetent host with skull and skin involvement without central nervous system or pulmonary extension. The radiographic findings are reviewed to include skull films, bone scan, and computed tomographic and magnetic resonance imaging scans. The patient underwent surgical debridement of the lesion as well as systemic medical therapy with amphotericin B and flucytosine. The medical and surgical therapy for such lesions is reviewed. Surgical intervention is emphasized for the removal of bony sequestrum and nonviable bone while maintaining an intact dura.

Isolated cryptococcosis of the adrenal gland

A case of isolated adrenal cryptococcosis is reported. A patient with a history of diabetes mellitus had symptoms of left flank pain. Roentgenological and sonographic findings of the adrenal gland were indicative of a malignant tumour. Tissue obtained from surgery showed fungal granuloma and a poorly encapsulated cryptococcal organism was identified by special stains. A post-operative serum cryptococcal antigen test was positive, and the patient was successfully treated with surgery and a course of amphotericin B. After a 7-month follow-up period, there is no evidence of recurrence or dissemination.

Opportunistic fungal infections in immunocompromised hosts

Fungal infections in immunocompromised hosts cause major morbidity and mortality. The Candida and Aspergillus species are the most common causes, but many rarer organisms, once considered "contaminants," are being reported. The number of patients who receive immunosuppressive agents for the treatment of malignancy or for organ transplantation is increasing as well as the potential for local or disseminated fungal infections. The diagnosis of these infections is often difficult and the existing methods for treatment are often ineffective. A high degree of suspicion to identify fungal infections and to prompt initiation of treatment must be maintained if the survival rate of these patients is expected to improve.

Secondary cutaneous cryptococcosis: case report and review of 22 cases

A 51-year-old immunosuppressed man presented with ulcerations of the abdominal wall. Biopsy of the ulcer margin was necessary for the diagnosis of cutaneous cryptococcosis. Since a variety of opportunistic organisms can present with non-specific cutaneous lesions, these infections must be ruled out by tissue diagnosis of all immunosuppressed patients. A review of 22 additional cases is included together with electron microscopic findings.

Cryptococcus neoformans: a central nervous system isolate from an AIDS patient that is rhinotropic in a normal mouse model

A strain of Cryptococcus neoformans that was isolated from the cerebrospinal fluid of a human diagnosed as having acquired immunodeficiency syndrome (AIDS), and that produced cutaneous lesions in experimentally infected, normal mice is described. Although no unusual cutaneous manifestations were noted in the patient's records, this isolate of C. neoformans proved to be dermotropic when injected intravenously into CD-1 mice. The LD50 at 28 days post infection ranged from 3.6-7.5 X 10(5) cells per mouse, and in vitro growth rate studies demonstrated that this isolate grew well at 35 degrees C and at 37 degrees C, but did not grow at 40 degrees C and higher. This isolate was rhinotropic producing large granulomatous lesions in the nasal tissues. Other cutaneous tissues affected were the periocular tissues, ears, feet and tail, although the granulomas were nodular in structure and less necrotic than the nasal lesions. The brain, lungs, liver, kidneys and spleen also were culture positive for C. neoformans. Histopathologically, each affected tissue examined had large densities of yeast cells and a chronic, granulomatous host response. Animals surviving the infection appeared to develop a commensal-type relationship with the infective yeast. This is the first report of an isolate of C. neoformans from an AIDS patient that has caused cutaneous manifestations in an animal model. The model described in this report may be useful for elucidating pathogenic mechanisms of cryptococcosis, particularly cutaneous manifestations of the disease.

Cryptococcal cellulitis with multiple sites of involvement

Cryptococcal cellulitis is an uncommon cutaneous manifestation of generalized cryptococcal disease. We describe the only reported incidence with multiple sites of cutaneous involvement. In an immunosuppressed patient an apparent cellulitis, even with multiple sites of involvement, that does not respond to appropriate antibiotics should alert one to the possible diagnosis of cryptococcal cellulitis.

Localized cutaneous cryptococcosis successfully treated with ketoconazole

A 27-year-old female recipient of a renal allograft, treated with systemic steroids and azathioprine, developed progressive cutaneous lesions (an ulcer, a nodule, and an abscess). Histopathologic and tissue-culture examination of the skin lesions led to the diagnosis of cutaneous cryptococcosis. A description of the light and electron microscopic features of the cutaneous lesions is reported. A thorough visceral investigation failed to detect systemic involvement. The patient was treated with oral ketoconazole (400 mg daily) for 6 months. A gradual healing of the lesions was obtained, and cultures performed 3 months after the onset of treatment failed to show Cryptococcus neoformans. No relapse or dissemination has so far been observed.

Cutaneous side effects of cancer chemotherapy

Chemotherapeutic agents are used with increasing frequency to treat a wide variety of neoplastic and inflammatory disorders. These drugs may inadvertently affect the skin, mucous membranes, hair, and nails, producing many undesirable reactions including alopecia, stomatitis, hyperpigmentation, hypersensitivity reactions, and photosensitivity. Awareness of these relatively common complications may help physicians caring for patients on these medications.

Cryptococcal infection of the central nervous system

The pathogenesis, clinical signs and symptoms, laboratory manifestations, and laboratory diagnosis of cryptococcal infection of the central nervous system are reviewed, as well as the interaction between the organism and the immune system of the host. In addition, based on our own experience and that of others, the therapy and prognosis of cryptococcal meningitis are discussed.

Cutaneous cryptococcosis without evidence of systemic involvement

As many as 15% of cases of systemic infection with Cryptococcus neoformans have cutaneous involvement. The existence of primary cutaneous disease is controversial. We report a patient with cutaneous cryptococcosis without evidence of visceral involvement at the time of diagnosis. She has been followed up for 5 years and remains free of systemic involvement. Cutaneous cryptococcosis does not always signify systemic disease.

Disseminated cryptococcosis presenting as herpetiform lesions in a homosexual man with acquired immunodeficiency syndrome

A 31-year-old homosexual man with acquired immunodeficiency syndrome (AIDS) had cutaneous herpetiform lesions that showed numerous encapsulated organisms on Tzanck preparation. Subsequent cultures of cerebrospinal fluid and skin biopsy specimens substantiated a diagnosis of disseminated cryptococcosis. Cutaneous cryptococcosis should be considered in the differential diagnosis for skin lesions in the population with AIDS.

Cutaneous cryptococcosis simulating pyoderma gangrenosum

A 33-year-old white man with a history of chronic ulcerative colitis presented with multiple cutaneous ulcers and an indurated cellulitic area on his right thigh. Clinically, the ulcers were considered to represent pyoderma gangrenosum. However, tissue biopsy revealed copious yeast forms that were identified as Cryptococcus neoformans. The indurated area on the right thigh later ulcerated, and tissue culture of this area also revealed Cryptococcus. This case illustrates that when pyoderma gangrenosum is diagnosed, the possibility of deep fungal infection should be considered and excluded by appropriate studies.