Localized cutaneous cryptococcosis successfully treated with ketoconazole

Multifocal Soft Tissue Cryptococcosis in a Renal Transplant Recipient: The Importance of Suspecting Atypical Pathogens in the Immunocompromised Host

Cryptococcal infection has been documented in 2.8% of solid-organ transplant recipients, with the median time to disease onset being 21 months. Renal transplantrecipients accountforthe majority of cases. Most patients present with central nervous system or disseminated disease, with only a minority having cutaneous manifestations. We present the case of a 47-year-old female renal transplant recipient who presented with refractory acute cellulitis 7 months after transplant. She had received thymoglobulin induction and was on a maintenance immunosuppressive regimen oftacrolimus, mycophenolic acid, and prednisone (5 mg/d). She did not respond to broad-spectrum antibacterial therapy for presumed bacterial cellulitis. Skin and soft tissue biopsies subsequently showed the presence of yeast; Cryptococcus neoformans was recovered in culture. Blood cultures, chest radiography, and cerebrospinal fluid sampling were negative, which resulted in a diagnosis of multifocal soft tissue cryptococcosis, a form of disseminated disease. Serum cryptococcal antigen testing was strongly positive (≥ 1:2560). The patient's immunosuppression was reduced, and she received treatment with liposomal-amphotericin B and flucytosine for 2 weeks, which resulted in symptomatic improvement. This was followed by 1 year of consolidation and subsequent maintenance therapy with fluconazole. This case should increase awareness of the broader differential diagnosis of soft tissue infection in immunocompromised patients. Her case mimicked bacterial cellulitis, which delayed administration of effective therapy. Although our patient was initially diagnosed via biopsy, early clinical suspicion and serum cryptococcal antigen testing can lead to the correct diagnosis more rapidly. As transplant patients return to their community providers, heightened vigilance for unusual infections and presentations is warranted.The possibility of a cryptococcal cause for acute soft tissue infection should be considered, even in the absence of pulmonary or central nervous system involvement.

Intracranial Granuloma and Skull Osteolysis: Complication of a Primary Cutaneous Cryptococcosis in a Kidney Transplant Recipient

Cryptococcosis is the third most common invasive fungal infection in organ transplant recipients after candidiasis and aspergillosis. It occurs almost exclusively in the late posttransplantation period (>6 months after the initiation of immunosuppression). Subclinical onset of meningitis is the usual clinical presentation. Despite initiation of therapy, the mortality rate associated with this infection in this patient population remains high. To the best of our knowledge, this report describes one of the first cases of a rare entity: a primary cutaneous cryptococcosis in a renal transplant recipient disclosed by skull osteomyelitis and pseudotumoral intracranial extension. Surgical debridement and azole antifungal therapy were performed. Ten months after the onset of treatment, the patient feels good, clinical examination findings are normal, and no sign of evolutive cryptococcosis is noted.

Antifungal Management Practices and Evolution of Infection in Organ Transplant Recipients with Cryptococcus Neoformans Infection

BACKGROUND

Therapeutic practices for Cryptococcus neoformans infection in transplant recipients vary, particularly with regards to antifungal agent employed, and duration of therapy. The risk of relapse and time to recurrence is not known. We assessed antifungal treatment practices for cryptococcosis in a cohort of prospectively followed organ transplant recipients.

METHODS

The patients comprised 83 transplant recipients with cryptococcosis followed for a median of 2.1 and up to 5.2 years.

RESULTS

Patients with central nervous system infection (69% vs. 16%, P = 0.00001), disseminated infection (82.7% vs. 20%, P = 0.00001), and fungemia (29% vs. 8%, P = 0.046) were more likely to receive regimens containing amphotericin B than fluconazole as primary therapy. The use of fluconazole, on the other hand, was more likely for infection limited to the lungs (64% vs. 14%, P = 0.00002). Survival at 6 months tended to be lower in patients whose CSF cultures at 2 weeks were positive compared to those whose CSF cultures were negative (50% vs. 91%, P = 0.06). Maintenance therapy was employed in 68% (54/79) of the patients who survived >3 weeks. The median duration of maintenance therapy was 183 days; 55% received maintenance for > or = 6 months and 25% for >1 year. Relapse was documented in 1.3% (1/79) of the patients.

CONCLUSIONS

A majority of the organ transplant recipients with cryptococcosis receive maintenance antifungal therapy for 6 months with low risk of relapse. These data can assist in trials to assess the optimal therapeutic approach and duration of therapy for cryptococcosis in transplant recipients.

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.

Primary cutaneous cryptococcosis: a distinct clinical entity

Cryptococcus neoformans is an encapsulated yeast responsible for disseminated meningitis in immunocompromised hosts. Controversies persist on the existence of primary cutaneous cryptococcosis (PCC) versus cutaneous cryptococcosis being only secondary to hematogenous dissemination. Thus, we reviewed cryptococcosis cases associated with skin lesions reported in the French National Registry. Patients with PCC (n=28) differed significantly from those with secondary cutaneous cryptococcosis (n=80) or other forms of the disease (n=1866) by living area (mostly rural), age (older), ratio of men to women (approximately 1:1), and the lack of underlying disease. Evidence of PCC included the absence of dissemination and, predominantly, a solitary skin lesion on unclothed areas presenting as a whitlow or phlegmon, a history of skin injury, participation in outdoor activities, or exposure to bird droppings, and isolation of C. neoformans serotype D. Therefore, PCC is a distinct epidemiological and clinical entity with a favorable prognosis even for immunocompromised hosts.

Fungal skin infections in organ transplant recipients

Transplantation is now currently and increasingly performed for the treatment of various acute and chronic diseases. Today the kidney, heart, lung, heart-lung, liver, pancreas, kidney-pancreas, small bowel and bone marrow are being transplanted. The immunological status of patients receiving such transplants exposes them to the risk of developing bacterial, viral and fungal infections. The etiological agents of mycotic diseases involving the skin of transplant recipients range from the common dermatophytes through yeasts such as Candida spp., Malassezia spp. and dimorphic fungi to the emerging molds Fusarium spp. and Pseudallescheria boydii. The very wide spectrum of fungi causing cutaneous disease produces equally varied clinical aspects. Lesions may be typical, but are very often aspecific or ambiguous. Cutaneous lesions may be the sign of a trivial mycotic disease or the marker of a disseminated, potentially lethal fungal illness, so great attention should be given to their early recognition. Cutaneous manifestations due to Candida spp., Aspergillus spp., dematiaceous fungi and Pityrosporum folliculitis are usually observed early after transplant, cryptococcosis more than 6 months later, while the frequency of dermatophytoses increases as time goes by. Coccidioides immitis, Histoplasma capsulatum and Blastomyces dermatitidis may appear any time after transplantation. The management of the more severe forms of cutaneous mycosis in transplant recipients is difficult. Besides the fact that early recognition is not easy, there are also problems regarding the effectiveness and the toxicity of the therapy and drug-drug interactions. Prophylactic measures to avoid fungal contamination must be performed during hospitalization; patients should be taught how to avoid contamination, not only during the first period after transplantation, when high dosage immunosuppressive drugs are given, but also later when a normal lifestyle is resumed.

Cryptococcus neoformans infection in organ transplant recipients: variables influencing clinical characteristics and outcome

Unique clinical characteristics and other variables influencing the outcome of Cryptococcus neoformans infection in organ transplant recipients have not been well defined. From a review of published reports, we found that C. neoformans infection was documented in 2.8% of organ transplant recipients (overall death rate 42%). The type of primary immunosuppressive agent used in transplantation influenced the predominant clinical manifestation of cryptococcosis. Patients receiving tacrolimus were significantly less likely to have central nervous system involvement (78% versus 11%, p =0.001) and more likely to have skin, soft-tissue, and osteoarticular involvement (66% versus 21%, p = 0.006) than patients receiving nontacrolimus- based immunosuppression. Renal failure at admission was the only independently significant predictor of death in these patients (odds ratio 16.4, 95% CI 1.9-143, p = 0.004). Hypotheses based on these data may elucidate the pathogenesis and may ultimately guide the management of C. neoformans infection in organ transplant recipients.

Cryptococcus neoformans is a facultative intracellular pathogen in murine pulmonary infection

To produce chronic infection, microbial pathogens must escape host immune defenses. Infection with the human pathogenic fungus Cryptococcus neoformans is typically chronic. To understand the mechanism by which C. neoformans survives in tissue after the infection of immunocompetent hosts, we systematically studied the course of pulmonary infection in mice by electron microscopy. The macrophage was the primary phagocytic cell at all times of infection, but neutrophils also ingested yeast. Alveolar macrophages rapidly internalized yeast cells after intratracheal infection, and intracellular yeast cells were noted at all times of infection from 2 h through 28 days. However, the proportion of yeast cells in the intracellular and extracellular spaces varied with the time of infection. Early in infection, yeast cells were found predominantly in the intracellular compartment. A shift toward extracellular predominance occurred by 24 h that was accompanied by macrophage cytotoxicity and disruption. Later in infection, intracellular persistence in vivo was associated with replication, residence in a membrane-bound phagosome, polysaccharide accumulation inside cells, and cytotoxicity to macrophages, despite phagolysosomal fusion. Many phagocytic vacuoles with intracellular yeast had discontinuous membranes. Macrophage infection resulted in cells with a distinctive appearance characterized by large numbers of vacuoles filled with polysaccharide antigen. Similar results were observed in vitro using a macrophage-like cell line. Our results show that C. neoformans is a facultative intracellular pathogen in vivo. Furthermore, our observations suggest that C. neoformans occupies a unique niche among the intracellular pathogens whereby survival in phagocytic cells is accompanied by intracellular polysaccharide production.

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.

Diagnosis and treatment of infectious diseases in HIV-infected hosts

Treatment of infectious diseases in patients with HIV infection is of primary importance in patient care. Viral, bacterial, parasitic, and fungal pathogens all may affect these patients. It is essential that accurate diagnoses be made and appropriate therapy be administered as early as possible.

Infections in solid-organ transplant recipients

Solid-organ transplantation is a therapeutic option for many human diseases. Infections are a major complication of solid-organ transplantation. All candidates should undergo a thorough infectious-disease screening prior to transplantation. There are three time frames, influenced by surgical factors, the level of immunosuppression, and environmental exposures, during which infections of specific types most frequently occur posttransplantation. Most infections during the first month are related to surgical complications. Opportunistic infections typically occur from the second to the sixth month. During the late posttransplant period (beyond 6 months), transplantation recipients suffer from the same infections seen in the general community. Opportunistic bacterial infections seen in transplant recipients include those caused by Legionella spp., Nocardia spp., Salmonella spp., and Listeria monocytogenes. Cytomegalovirus is the most common cause of viral infections. Herpes simplex virus, varicella-zoster virus, Epstein-Barr virus and others are also significant pathogens. Fungal infections, caused by both yeasts and mycelial fungi, are associated with the highest mortality rates. Mycobacterial, pneumocystis, and parasitic diseases may also occur.

Primary cutaneous cryptococcosis and Cryptococcus neoformans serotype D

We report a healthy, 73-year-old Japanese woman who presented with primary cryptococcosis on the skin of both cheeks. She had initially developed an erythematous, partly ulcerated lesion on the right cheek 2 weeks earlier following an injury. There was no regional lymphadenopathy, and chest X-rays were normal. Histopathological findings showed granulomatous cell infiltration. Periodic acid Schiff staining revealed spores that were identified by the indirect immunoperoxidase staining method as Cryptococcus neoformans. The isolate was identified as C. neoformans var. neoformans serotype D. The skin lesions healed in 1 month without antifungal therapy. A literature review indicates that this serotype tends to produce cutaneous lesions without systemic involvement.

Cutaneous cryptococcosis as the first symptom of a disseminated cryptococcosis in a patient with lymphogranulomatosis X

A 63-year-old patient, known to have suffered from lymphogranulomatosis X for 4 years is reported, in whom a cutaneous cryptococcosis appeared as first sign of a disseminated cryptococcosis. Despite systemic therapy with amphotericin B, the patient died after a period of 2 months. Differential diagnosis of skin tumours of immunosuppressed patients includes rare skin mycoses, and both histological and mycological examinations should be performed.

Current concepts in cryptococcosis

Cryptococcus neoformans has become an increasingly important pathogen. Cryptococcosis is an important cause of morbidity and mortality in immunocompromised hosts and is the second most common fungal infection complicating AIDS. In recent years, research has focused on the host defenses against Cryptococcus and has led to an improved understanding of the capsular virulence of the organism, the mechanisms of T-cell defenses, and the role of phagocytic cells in the fungistasis and killing of cryptocci. Amphotericin B with or without flucytosine has clearly improved treatment of cryptococcosis, but therapy is associated with significant toxicity. Current investigation is focused on the triazoles, which may offer improved therapy for cryptococcosis. In this report, we review recent developments in the understanding of the host defenses against Cryptococcocus and discuss current recommendations for the management of cryptococcosis.

Antifungal agents in dermatology

Development of new antifungal agents has increased significantly over the past two decades, with recent advances reflecting interest in synthetic agents as opposed to antibiotics. We review the various antifungal medications in use or under development, beginning with a discussion of over-the-counter agents, antibiotics, and older azole compounds and ending with an evaluation of newer azoles and the new class of antifungals, the allylamines.