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

Angioimmunoblastic T-Cell Lymphoma

Angioimmunoblastic T-cell lymphoma (AITL) is one of the most common types of T-cell lymphoma, representing about 15-20% of cases of peripheral T-cell lymphoma (PTCL). It is characterized by a unique clinical presentation and distinct pathologic and molecular features. Classes of drugs particularly active in AITL are emerging; however, treatment of relapsed and refractory disease remains a challenge. This chapter reviews the epidemiology, clinical presentation, pathogenesis, diagnosis, and treatment of AITL.

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.

Angio-immunoblastic T-cell lymphoma in evolution: a case report

Angio-immunoblastic T-cell lymphoma (AITL), a rare disease that constitutes 1% to 2% of non-Hodgkin's lymphomas, presents in middle-aged and elderly individuals. This report describes a patient with high-grade fever and lymphadenopathy. An extensive in-hospital work-up that included lymph node biopsy yielded negative results. The patient became asymptomatic for 4 wk, but then symptoms recurred with more pronounced lymphadenopathy. A computed tomography scan documented recurrent diffuse lymphadenopathy. Another lymph node biopsy revealed florid changes that strongly suggested AITL. Flow cytometry confirmed this diagnosis. The patient was treated with hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) and achieved complete remission after the first cycle. The patient developed sepsis during the second cycle and expired within 4 mo of diagnosis. The prognosis and natural course of AITL are poor when the classic chemotherapy protocol is administered. When infection has been ruled out, physicians should be wary of aggressive lymphomas that present with diffuse lymphadenopathy and fever.

A case of disseminated Cryptococcosis with skin eruption in a patient with acute leukemia

Disseminated cryptococcosis is a life-threatening infection caused by Cryptococcus neoformans and cutaneous dissemination occurs in 10-15% of patients. We report a case of a 49-y-old leukemic patient with disseminated cryptococcosis who presented with fever, headache, normal cerebrospinal fluid profile and multiple skin lesions mimicking molluscum contagiosum.

[Disseminated cryptococcosis with extensive cutaneous involvement in AIDS]

BACKGROUND

Diagnosis of an ulceratively decaying indolent papule in the skin of an AIDS patient.

CASE REPORT

In a 36-year-old HIV-positive man with a CD4 lymphocyte count of 60/microliters, a diagnosis of disseminated cryptococcosis was established based on a biopsy of an ulceratively decaying indolent papule in the skin of the left side gluteal region. In additional papulopustular skin lesions of neck, upper arm, upper thigh, and rima ani, Cryptococcus neoformans var. neoformans was detected by specific culture. The Cryptococcus neoformans antigen titre in serum was 1:160. The extensive cryptococcal skin involvement was accompanied by symptoms of meningeal cryptococcosis like hearing at an abnormal sound volume, a sensation of high pressure in the head and a change of behaviour, but absence of cephalgia and stiff neck. Attention is drawn to the importance of biopsy for the differential diagnosis of the skin lesions and to the significance of a specific cultural detection of Cryptococcus neoformans in view of the therapy and epidemiology of this mycosis. Under a combination therapy, consisting of amphotericin B, flucytosine and fluconazole, a healing of the skin lesions and disappearance of the neurological symptoms followed by negative cultural and serological tests were seen. Specific comments on the epidemiology of cryptococcosis in AIDS are made.

CONCLUSION

In case of doubt, papulopustular skin lesions of HIV-positive patients should be biopsied. Cryptococcosis should also be considered.

Primary cutaneous cryptococcosis following trauma of the right forearm

A 62-year-old woman with sarcoidosis II, status post systemic steroid treatment, developed an inflammatory, infiltrative skin lesion in the area of a traumatic haematoma of the right forearm. The clinical appearance at first corresponded to bullous erysipelas. Antibiotic therapy, which was instituted immediately, proved to be ineffective. A microbiological swab revealed infection with Cryptococcus neoformans. A systemic cryptococcosis could be excluded. Therapy with 200 mg itraconazole twice daily resulted in a prompt improvement.

Disseminated cryptococcosis with cutaneous lesions

A case of disseminated cryptococcosis in an HIV-negative patient presenting with cutaneous lesions is described for the first time in Egypt. The patient, a 16-year-old male, presented with cough, expectoration, loss of weight, and cutaneous lesions, mainly on the face and trunk. The lesions consisted of vegetating crusted plaques discharging purulent to sanguinous fluid and flattened, shiny, erythematous to brownish plaques. Anorexia, headache and personality changes soon followed. Histopathological examination of lesions was highly suggestive of a deep mycosis, particularly cryptococcosis. The fulminant disease advanced with central nervous system involvement. The progression was not arrested when systemic antifungal therapy was administered late in the disease course. Pathological examination of lungs, liver, pancreas and spleen revealed disseminated infection with no evidence of other underlying pathology. Disseminated cryptococcosis is a morbid infection, rare in an area where heightened awareness and raised index of suspicion will surely allow earlier diagnosis, management and better prognosis.