Cryptococcal disease presenting as cellulitis

Severe Bullous Erysipelas/Cellulitis, Atypically Caused by Escherichia coli, in Kidney Transplant Recipient - Case Report and Review of Literature

Erysipelas/cellulitis are severe skin infections that are especially dangerous for immunocompromised patients. The most common cause of these diseases is streptococcal infection, but sometimes they may be caused by other Gram-positive or negative bacteria or other factors. Proper diagnosis and treatment should be implemented accurately to prevent dangerous complications. We present a case of severe bullous erysipelas caused by Escherichia coli and discuss the diagnosis, differential diagnosis, and treatment of cellulitis in kidney transplant patients.

Cryptococcal meningitis and cerebral vasculitis in a patient with primary intestinal lymphangiectasia: a case report

Primary intestinal lymphangiectasia (Waldmann's disease) is a rare exudative enteropathy without precisely assessed infectious risk. We report the case of a 49-year-old male patient with meningitis and cerebral vasculitis due to Cryptococcus neoformans complicating Waldmann's disease diagnosed 12 years ago. The treatment combined liposomal amphotericin B, 3 mg/kg daily plus flucytosine 25 mg/kg/6 h, both intravenously during 15 days, then fluconazole 800 mg daily during 8 weeks, and finally 200 mg daily indefinitely. Dexamethasone 0.4 mg/kg daily during the first week was gradually decreased over 2 months. The outcome was good, and the patient is still followed 3 years later without any recurrence.

When in Doubt, Cut It Out: Biopsy as Key in Diagnosing Cryptococcal Soft Tissue Infection

Soft tissue infection is an uncommon presentation of Cryptococcus in the absence of immunosuppression. Most infected patients present with pneumonia or meningitis, often with signs of disseminated disease, which may be fatal. We present a case of an 81-year-old mildly immunocompromised woman with multiple comorbidities, who presented with an extensive soft tissue infection on her right medial thigh. Superficial skin culture grew vancomycin-resistant Enterococcus; however, both initial and subsequent antibacterial therapies failed to resolve the infection. Subsequent biopsy revealed abundant yeasts, and mucicarmine staining confirmed Cryptococcus infection in a patient with no evidence of disseminated disease. Wound debridement and fluconazole for six months resulted in complete resolution of the lesion. In this report, we emphasize the need for tissue biopsy and microbial cultures in diagnosing patients with atypical skin and soft tissue infections who do not respond to appropriate antibiotics.

Primary Cutaneous Cryptococcosis due to Cryptococcus neoformans in an Immunocompetent Host Treated with Itraconazole and Drainage: Case Report and Review of the Literature

Cryptococcus neoformans is an opportunistic germ, usually causing infections in immunocompromised patients. The main sources of infection with C. neoformans are excrement from birds, decomposing wood, fruit, and vegetables. Primary cutaneous cryptococcosis (PCC) is a clinical entity, differing from secondary cutaneous cryptococcosis and systematic infection. We report the case of an immunocompetent 60-year-old woman with PCC due to C. neoformans in her right thumb. She reported an accidental injury caused by a rose thorn while she was gardening. Clinical examination showed the presence of an erythematous ulcerated nodule with elevated borders, suppuration, and central necrosis. Skin histology examination showed cutaneous and subcutaneous fibrinoid necrosis with bleeding, abscess, neutrophil-rich cellular infiltration, and the presence of PAS-, Grocott- and mucin-positive spores. The mycological culture showed milky and creamy colonies of C. neoformans after 3 days. As there was no previous history of pulmonary cryptococcosis, we diagnosed PPC. We treated the patient surgically with accurate debridement of nonvital tissues in the right thumb. In addition, we started itraconazole treatment 100 mg twice daily for 6 months, which led to rapid clinical improvement without relapse. PCC is a rare infection that can present with quite unspecific clinical pictures including acneiform lesions, purpura, vesicles, nodules, abscesses, ulcers, granulomas, pustules, draining sinuses, and cellulitis. Prolonged systemic antifungal therapy is necessary in order to get a healing result without relapse. We summarize all the cases of PCC in immunocompetent patients published so far in the literature.

Clostridioides difficile-related toxic megacolon after Cryptococcus neoformans cellulitis: A complex of two rare infections in an immunocompromised host

A 76-year-old Japanese woman was admitted due to uncontrolled cellulitis of the right lower leg. She had deep vein thrombosis on the right limb. Moreover, she had a long history of rheumatoid arthritis treated with corticosteroids. Skin biopsy and lumbar puncture were performed to diagnose disseminated cryptococcosis. She was administered antifungal agents (liposomal amphotericin B and 5-fluorocytosine). On treatment day 14, debridement was performed, and cryptococcosis was controlled. However, she developed toxic megacolon due to Clostridioides difficile infection (CDI). On day 32, she was transferred to the intensive care unit due to severe acidosis and acute kidney injury secondary to CDI-related toxic megacolon. Vancomycin, metronidazole, and tigecycline were administered for treatment of CDI. After several weeks of intensive care, toxic megacolon was improved, but renal replacement therapy was discontinued according to the patient's will. On day 73, she died of renal failure. We experienced a complex of rare diseases, Cryptococcus neoformans cellulitis and Clostridioides difficile-related toxic megacolon. Both diseases were presumed to be the result of corticosteroid and methotrexate use. Hence, careful monitoring is required when treating immunocompromised hosts to reduce the risk of developing complications.

Disseminated cryptococcal infection initially presenting as cryptococcal cellulitis in an HIV-negative patient on long-term steroids

Cryptococcosis is an invasive fungal infection caused by encapsulated yeasts of the Cryptococcus species. Inoculation usually occurs by inhalation through the respiratory tract, where it can then spread haematogenously to various sites, such as the central nervous system or the skin, in susceptible patients. We present the case of a 68-year-old male patient on long-term steroids who presented with a right upper limb cellulitis not responding to antibiotics. This was subsequently diagnosed as cryptococcal cellulitis on an urgent skin biopsy. Wound swabs and blood cultures, which were initially negative, were repeated and confirmed the presence of disseminated cryptococcal disease. The patient's neighbours kept racing pigeons and this was hypothesised as a potential source of infection.

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.

Disseminated cryptococcosis presenting initially as lower limb cellulitis in a renal transplant recipient - a case report

Background

Cellulitis is an unusual presentation of disseminated cryptococcosis, a serious infection seen predominantly in immunocompromised hosts. Disseminated cryptococcosis carries significant morbidity for transplant recipients, especially of the pulmonary and central nervous systems, and carries a high mortality risk.

Case presentation

We report a 59-year-old renal transplant recipient who presented with bilateral lower leg cellulitis without other symptoms or signs. Failure of conventional therapy for cellulitis prompted a skin biopsy confirming cryptococcal cellulitis. Additional evaluation to exclude disseminated disease revealed Cryptococcus neoformans in blood cultures and cerebrospinal fluid (CSF). Treatment included reduction in immunosuppression regimen and targeted treatment for cryptococcal disease with liposomal amphotericin B and flucytosine followed by fluconazole consolidation and maintenance therapy. Treatment with liposomal amphotericin B and flucytosine followed by fluconazole consolidation and maintenance therapy achieved a good clinical response. Our patient achieved significant reduction in leg cellulitis and recovered without serious complication.

Conclusions

This case suggests that cutaneous cryptococcosis in immunosuppressed patients warrants a low threshold for investigation for disseminated disease even in the absence of other symptoms or signs.

Cryptococcal cellulitis: A rare entity histologically mimicking a neutrophilic dermatosis

Cutaneous Cryptococcus infection presents classically with granulomatous and gelatinous reactive patterns. Cases mimicking neutrophilic dermatoses have not been described. Conversely, neutrophilic dermatoses with degrading cells mimicking cryptococcal organisms have been reported. We report a case of cryptococcal cellulitis in an immunocompromised male with a robust neutrophilic infiltrate raising histologic consideration for a neutrophilic dermatosis.

Disseminated cryptococcosis in a patient taking tocilizumab for Castleman's disease

Infections occur more frequently in patients receiving biologics. However, cryptococcal infection is uncommon in patients receiving tocilizumab, an interleukin-6 inhibitor, in contrast to patients receiving tumor necrosis factor-α inhibitors. In this report, we describe a case of disseminated cryptococcosis in a 55-year-old man who was receiving tocilizumab every 2 weeks along with daily prednisolone and cyclosporine for Castleman's disease. He initially developed cellulitis on both upper limbs, and his condition worsened despite antibacterial therapy. Chest X-ray scanning and computed tomography demonstrated bilateral pulmonary infiltration. Cryptococcus neoformans was detected in blood, skin, and sputum cultures. He was diagnosed with disseminated cryptococcosis, and successfully treated with liposomal amphotericin B for a week followed by oral fluconazole for 11 months. The findings of this study indicate that cryptococcosis should be considered during the differential diagnosis of infection in patients receiving tocilizumab, especially in the presence of other risk factors for infections or a short tocilizumab dosing interval.

Disseminated cryptococcosis with recurrent multiple abscesses in an immunocompetent patient: a case report and literature review

Background

Cryptococcus neoformans is frequently present as an opportunistic pathogen mainly affecting immunocompromised populations. Disseminated C. neoformans infection in immunocompetent population is rare and usually involves lung and central nerve system. Cryptococcus from biologic samples can easily grow on routine fungal and bacterial culture media. Besides, cryptococcal latex agglutination test has been established as a reliable diagnostic tool with overall sensitivities of 93–100%.

Case presentation

We report a rare disseminated cryptococcosis case which presented with chronic recurrent multiple abscess in an immunocompetent male involving skin, lung, spine and iliac fossa without evidence of central nerve system involving. The results of serum cryptococcal latex agglutination tests and standard microbial cultures were negative. The patient underwent empirical anti-bacterial and anti-tuberculosis therapy which turned out to be effectless. Finally, bedside inoculation of the pus was carried out and revealed Cryptococcus neoformans, which was confirmed by polymerase chain reaction. After the administration of anti-fungal drugs including liposomal amphotericin B, the patient recovered from fever and paraplegia.

Conclusions

This case reveals an uncommon pattern of disseminated C. neoformans infection in immunocompetent population presented with chronic multiple abscess and without central nerve system involving. Negative routine microbial cultures may not necessarily rule out cryptococcosis, especially in early stage. Besides, cryptococcal latex agglutination test does have a chance of false negative, which might be related with “capsule-deficiency”. Moreover, this phenomenon could be related with low-grade virulence and relative long illness duration.

Localized Cutaneous Cryptococcosis: Summary of Reported Cases in Japan

A 68-year-old male plasterer with no history of trauma presented to our clinic in March 2012 with a 16×14-mm ulcer that developed following a crushed small papule on the right anterior chest. In April 2012, the patient was referred to another hospital, where cutaneous cryptococcosis was diagnosed based on discharge culture results. The patient was treated with oral itraconazole at a dose of 150 mg/day for 10 weeks; however, the ulcer remained unchanged and he discontinued the treatment. In May 2014, when he revisited our clinic, the ulcer with crust had grown to 29×13 mm. No regional lymph node swelling was noted. India ink staining showed a yeast-like fungus with a thick, clear capsule. A cream-colored, viscous yeast-like colony was observed on Sabouraud dextrose agar. Genetic testing identified the isolate as Cryptococcus neoformans serotype A. The patient was negative for serum cryptococcal antigen. Neither chest radiography nor computed tomography revealed any abnormalities. The patient had no underlying disease. Oral fluconazole (400 mg/day for 12 weeks) was prescribed, resulting in scar formation. The patient has remained free of relapse for one year to date, since the end of treatment. Localized cutaneous cryptococcosis is not a commonly used disease name overseas. However, 36 cases of this disease have been reported in Japan (since in 1968). We herein report a new case with localized cutaneous cryptococcosis and summarize previously reported cases in Japan.

Approach to the Solid Organ Transplant Patient with Suspected Fungal Infection

In solid organ transplant (SOT) recipients, invasive fungal infections (IFIs) are associated with significant morbidity and mortality. Detection of IFIs can be difficult because the signs and symptoms are similar to those of viral or bacterial infections, and diagnostic techniques have limited sensitivity and specificity. Clinicians must rely on knowledge of the patient's risk factors for fungal infection to make a diagnosis. The authors describe their approach to the SOT recipient with suspected fungal infection. The epidemiology of IFIs in the SOT population is reviewed, and a syndromic approach to suspected IFI in SOT recipients is described.

Cryptococcal panniculitis in a renal transplant recipient: case report and review of literature

BACKGROUND

Cryptococcosis is a deep fungal infection caused by Cryptococcus neoformans. The infection usually involves the lungs, the central nervous system as well as the skin, the bones and the urinary tract. Immunocompromised individuals, including solid organ transplant recipients, are at higher risk for cryptococcal infections.

MAIN OBSERVATIONS

We present a 40-year-old renal transplant recipient who developed a slightly painful, erythematous, indurated plaque on his thigh several years after a kidney transplant. Histopathology revealed cryptococcal panniculitis and cryptococcus neoformans subsequently grew from the tissue culture. There was no other systemic involvement.

CONCLUSION

The primary cutaneous form of cryptococcosis is extremely rare and early diagnosis and treatment is essential in view of possible dissemination and variable nonspecific clinical manifestations.

Cutaneous Cryptococcus: marker for disseminated infection

Cryptococcosis is an infection caused by the encapsulated yeast, Cryptococcus neoformans, a dimorphic fungus recovered from pigeon excreta, soil, dust and human skin. After a primary infection in the lungs, the disease can disseminate via a haematogenous route to various organs, including the central nervous system and skin, in susceptible individuals. Cryptococcosis can present with a variety of skin and soft tissue manifestations including acneiform lesions, purpura, vesicles, nodules, abscesses, ulcers, granulomas, pustules, draining sinuses and cellulitis. We present a case of a young man with HIV infection who developed molluscum-like cutaneous lesions secondary to pulmonary cryptococcosis. The diagnosis was confirmed by Indian ink preparation of the cutaneous lesions. Primary cutaneous infection occurs rarely due to direct inoculation. Cutaneous lesions are usually secondary and act as a key marker of disseminated infection, especially in patients with impaired cell-mediated immunity, such as those infected with HIV, solid-organ transplant recipients, and those on chronic corticosteroid therapy.

Primary cutaneous cryptococcosis treated with debridement and fluconazole monotherapy in an immunosuppressed patient: a case report and review of the literature

Cryptococcus neoformans is an opportunistic yeast present in the environment. Practitioners are familiar with the presentation and management of the most common manifestation of cryptococcal infection, meningoencephalitis, in patients with AIDS or other conditions of immunocompromise. There is less awareness, however, of uncommon presentations where experience rather than evidence guides therapy. We report a case of primary cutaneous cryptococcosis (PCC) in a patient who had been immunosuppressed by chronic high-dose corticosteroid for the treatment of severe asthma. This case highlights the importance of early recognition of aggressive cellulitis that fails standard empiric antibiotic treatment in an immunocompromised patient. It also demonstrates successful treatment of PCC with a multispecialty approach including local debridement and fluconazole monotherapy.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Paniculite criptocócica em transplantado renal

Os autores relatam um caso de paniculite criptocócica em paciente transplantado renal inicialmente tratado como celulite bacteriana. O diagnóstico definitivo só foi possível pela impressão clínica dermatológica confirmada pelo exame micológico. O tratamento foi realizado a princípio com anfotericina B e posteriormente com fluconazol, considerando-se as interações das drogas imunossupressoras utilizadas para evitar rejeição. A regressão clínica foi alcançada no sexto mês de tratamento, que, no entanto, foi mantido por 12 meses. São feitas considerações a respeito dessa forma rara de criptococose cutânea em transplantado de órgão sólido e suas implicações diagnósticas e terapêuticas.

Primary gastrointestinal lymphangiectasia presenting as cryptococcal meningitis

BACKGROUND

Opportunistic infections commonly occur in immunocompromised patients; however, it is unusual for an adult to present with a combined cellular and humoral immunodeficiency. Cryptococcal meningitis is a fatal condition if untreated and is usually found in patients with cellular immunodeficiency.

OBJECTIVE

To report the case of an adult patient with cryptococcal meningitis secondary to intestinal lymphangiectasia.

METHODS

A 59-year-old man was admitted to the hospital for disseminated cryptococcal meningitis and osteomyelitis. Laboratory evaluation, computed tomography, esophagogastroduodenoscopy, and biopsy were performed.

RESULTS

Laboratory evaluation revealed a lymphopenia, hypoalbuminemia, hypogammaglobulinemia, and negative human immunodeficiency virus test results by enzyme-linked immunosorbent assay and polymerase chain reaction. The complete blood cell count, urinalysis, serum and urine protein electrophoresis, and functional antibody responses to protein and polysaccharide antigens were normal. Results of computed tomography of the chest, abdomen, and pelvis were unremarkable. Multiple lymphangiectasias were visualized with esophagogastroduodenoscopy and confirmed by biopsy. The patient was treated with intravenous amphotericin B and flucytosine, and the meningitis resolved.

CONCLUSIONS

Based on a computerized search of the medical literature, this is the first description of cryptococcal meningitis secondary to intestinal lymphangiectasias. The combination of lymphopenia, hypogammaglobulinemia, and hypoalbuminemia should alert the clinician to the possibility of intestinal lymphangiectasias and the potential for immune dysfunction.

Disseminated cryptococcosis initially presenting as cellulitis in a rheumatoid arthritis patient

Infection with Cryptococcus neoformans often occurs in immunocompromised hosts. It is usually acquired by invasion of the respiratory tract, and then the organisms may spread hematogenously to other viscera, mainly the central nervous system. Although there are some reports of primary cutaneous cryptococcosis, cryptococcal skin disease is a rare feature of disseminated cryptococcosis, and has a poor outcome if unrecognized and untreated. We present a case of cryptococcal cellulitis in a patient with rheumatoid arthritis who was receiving long-term steroid treatment. Reviewing the literature, this is the first report of rheumatoid arthritis with disseminated cryptococcosis initially presenting as cellulitis.

Primary Cryptococcal Cellulitis in a Lung Transplant Recipient

In organ transplant recipients there remains controversy whether cutaneous cryptococcal infection represents a primary infection or a manifestation of disseminated cryptococcosis. We describe a lung transplant patient who developed primary cryptococcal cellulitis in the immediate post-operative period. At presentation, disseminated disease was excluded. The patient was treated with liposomal amphotericin B and fluconazole and, in addition, a surgical debridement was performed. Shortly afterwards, computed tomography revealed dissemination to the brain. The patient died of cerebral edema. As there was no involvement of the central nervous system at presentation, we believe that cryptococcal cellulitis was the primary site of infection and origin of dissemination. In this study we review cryptococcosis, which should always be considered in the differential diagnosis of cellulitis in transplant recipients.

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 a Lung Transplant Recipient

Cryptococcal skin lesions are found in 10 to 15% of patients with disseminated cryptococcosis. Primary skin inoculation by Cryptococcus neoformans is rare but has been reported. We report the first known case of primary cutaneous cryptococcosis in a lung transplant recipient. Our patient, a 57-year-old man, underwent left single-lung transplantation and presented with a nonhealing ulcer 50 months later. Skin histopathology and culture confirmed C. neoformans. Serum and cerebrospinal fluid cryptococcal antigen tests were negative. The lesion healed after treatment with fluconazole. To date, disseminated disease is not evident. Primary cutaneous cryptococcosis has been reported in kidney and liver recipients but not in lung transplantation recipients. Nonhealing ulcers in immunocompromised patients mandate aggressive diagnostic procedures. Differential diagnosis of these cutaneous lesions should consider fungi, including C. neoformans.

Cutaneous cryptococcosis in a diabetic renal transplant recipient

A diabetic renal transplant recipient with cellulitis caused by Cryptococcus neoformans, serotype A, is described. The diagnosis was based on the demonstration of capsulated, budding yeast cells in the aspirated material and tissue from the cellulitic lesion and isolation of the aetiological agent in culture. The isolate formed well-developed capsules in the brain tissue of experimentally infected mice and produced cherry-brown colonies on niger seed medium. The patient's serum was positive for cryptococcal antigen (titre 1 : 4) with no other evidence of systemic infection. He was successfully treated with AmBisome, followed by fluconazole, resulting in the complete resolution of cellulitis and disappearance of the cryptococcal antigen. This report underscores the fact that patients with cutaneous cryptococcosis should be thoroughly evaluated, as it may be the first manifestation of a systemic disease. Prompt diagnosis and treatment are important to improve survival.

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.

Disseminated cellulitic cryptococcosis in the setting of prednisone monotherapy for pemphigus vulgaris

Cryptococcal infections are seen mainly in immunocompromised hosts. The cutaneous manifestations of infection can include papules, plaques, nodules, vesicles, ulcers, ecchymosis, and, rarely, cellulitis. Cryptococcal meningitis is a life-threatening complication of this disease. Pemphigus vulgaris is a rare auto-immune blistering disease that can also be life-threatening. Treatment of pemphigus commonly entails both corticosteroids and steroid-sparing agents. We present a case of disseminated cryptococcal infection in a patient with pemphigus vulgaris treated with high dose corticosteroids as monotherapy. This case provides an opportunity to discuss the difficulty of managing two potentially mortal conditions in which the treatment of pemphigus vulgaris may exacerbate the disseminated cryptococcal infection.

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.

Case report. Cutaneous cryptococcosis in a patient with systemic erythematous lupus

The first case of a cutaneous cryptococcosis associated with systemic erythematous lupus (SLE) diagnosed in our Mycology Reference Centre is presented: a 24-year-old female patient diagnosed with SLE, nephrotic syndrome, arterial hypertension, renal insufficiency due to glomerulonephritis type IV and cellulitis in the right thigh and gluteus. Cryptococcus neoformans was isolated by cutaneous biopsy and haemoculture. Cryptococcal antigen was detected in serum by the latex agglutination test. As the patient did not respond to fluconazol intravenous treatment, amphotericin B administration was performed. She died of acute renal insufficiency.

Dermatologic infections in the immunocompromised (non-HIV) host

The immunocompromised host's susceptibility to infections often present a difficult diagnostic challenge to the physician. A working knowledge of the host immune defenses and microbiologic complications that can occur when these functions are compromised provides a more focused framework for further evaluation and management. Infections in these patients are often morbid and life-threatening, creating an urgent need for prompt diagnosis. The skin may manifest the first clue(s) of a serious underlying infection. Appropriate workup and diagnosis of cutaneous lesions provide an expeditious, noninvasive, and potentially life-saving approach to the immunocompromised host with a dermatologic infection.