An unusual cause of cutaneous ulceration

Abstract

A 71-year old white man presented with a 2-month history of bilateral forearm ulceration, which was managed with dressings by his primary care practitioner. On direct questioning, he described 'bumps' forming under the skin, which would then 'crust over and break down'. He had a history of bronchiectasis and chronic obstructive pulmonary disease requiring home oxygen. He had undergone successful fullthickness forearm skin grafts 10 months earlier for bilateral necrotic cellulitis. He was on a number of regular medications, which included prednisolone 15 mg daily, which he had been taking for many years.On physical examination, painful superficial ulceration was seen, affecting both forearms and extending onto the dorsal hand. The ulcers were noninflammatory and did not have an undermined edge (Fig. 1). Proximal to both elbows were three nodules, one of which was ulcerated. An incisional biopsy was taken from one of these. Histopathological findingsSkin biopsy showed surface ulceration and a diffuse dermal infiltrate of histiocytes, neutrophils and lymphocytes. Most histiocytic intracellular vacuoles contained pale basophilic bodies (Fig. 2).Blood tests revealed neutrophilia (10.3 9 10 9 /L; normal range 1.5-7 9 10 9 /L) and lymphopenia (0.61 9 10 9 /L; 1.5-4 9 10 9 /L), HIV antibody was negative, and there was a stable IgG lambda paraprotein at 1 g/L with no evidence of immune paresis. Direct microscopy of the tissue specimen stained with the optical brightener Calcofluor revealed multiple spherical budding organisms (Fig. 3a). Indian ink stain highlighted encapsulated structures (Fig. 3b). The tissue was cultured on Sabouraud glucosepeptone agar at 37°C, and colonies grew after 48 h (Fig. 3c).What is your diagnosis?

Disseminated cryptococcosis presenting with cutaneous involvement in an immunocompromised patient

“…Cryptococcus neoformans is an encapsulated yeast that causes cryptococcosis and colonizes pigeon excrement, soil, and dust [1][2][3]. It most often affects patients with impaired cell-mediated immunity, such as those with HIV [3].…”

“…Cryptococcus neoformans is an encapsulated yeast that causes cryptococcosis and colonizes pigeon excrement, soil, and dust [1][2][3]. It most often affects patients with impaired cell-mediated immunity, such as those with HIV [3]. The lungs are usually the primary site of infection, where it can remain localized or spread hematogenously to other organs such as the central nervous system (CNS) and skin [3][4][5].…”

“…It most often affects patients with impaired cell-mediated immunity, such as those with HIV [3]. The lungs are usually the primary site of infection, where it can remain localized or spread hematogenously to other organs such as the central nervous system (CNS) and skin [3][4][5]. Disseminated C. neoformans infection in immunocompetent individuals is extremely rare and usually involves the lungs and CNS [1,6].…”

“…Disseminated C. neoformans infection in immunocompetent individuals is extremely rare and usually involves the lungs and CNS [1,6]. Cutaneous cryptococcal infection can be an early sign of disseminated disease or it can occur via primary inoculation [3][4][5]. Primary cutaneous cryptococcal infection caused by local inoculation usually presents as a solitary lesion [3,5].…”

“…Cutaneous cryptococcal infection can be an early sign of disseminated disease or it can occur via primary inoculation [3][4][5]. Primary cutaneous cryptococcal infection caused by local inoculation usually presents as a solitary lesion [3,5]. Disseminated cryptococcosis presents as multiple lesions, which may be the first indication of disseminated infection [6].…”