Cryptococcosis mimicking cutaneous cellulitis in a patient suffering from rheumatoid arthritis: a case report

Abstract

BackgroundCryptococcus neoformans is an encapsulated yeast and the most frequent cryptococcal species found in humans. Cryptococcosis is considered an opportunistic infection as it affects mainly immunosuppressed individuals. In humans, C. neoformans causes three types of infections: pulmonary cryptococcosis, cryptococcal meningitis and wound or cutaneous cryptococcosis.Case PresentationAn 81-year-old woman developed severe necrotizing cellulitis on her left arm without any preceding injury. The patient had been treated with systemic corticosteroids over twenty years for rheumatoid arthritis (RA). Skin biopsies of the wound area were initially interpreted as cutaneous vasculitis of unknown etiology. However, periodic acid Schiff staining and smear analysis later revealed structures consistent with Cryptococcus neoformans, and the infection was subsequently confirmed by culture. After the initiation of therapy with fluconazole 400 mg per day the general condition and the skin ulcers improved rapidly and the patient was discharged to a rehabilitation facility. Subsequently surgical debridement and skin grafting were performed.ConclusionsOpportunistic infections such as cryptococcosis can clinically and histologically mimic cutaneous vasculitis and have to be investigated rigorously as a differential diagnosis in immunosuppressed patients.

Cryptococcal meningitis with secondary cutaneous involvement in an immunocompetent host

“…Acneiform, nodular, herpetiform lesions and lesions mimicking cellulitis are also recorded. Cellulitis, ulceration, and whitlow are the most common clinical features of primary cutaneous cryptococcosis [13,14]. The frequency of cutaneous involvement in disseminated infection is higher in liver transplant recipients receiving tacrolimus or in patients infected with serotype D [15].…”

Primary cutaneous cryptococcosis in an immunocompetent man: A case report

“…4,9,16 Because the optimal treatment regimen for cutaneous cryptococcosis is not well established, treatment usually varies according to the extent of disease and host immunocompetence. 16,21,22 In immunocompetent patients, the Infectious Disease Society of America guidelines recommend treating cryptococcal CNS infection or dissemination with amphotericin B (0.7-1 mg/kg/day) plus flucytosine (100 mg/kg/day) for at least 4 weeks, followed by consolidation therapy with fluconazole (400-800 mg/day) for a minimum of 8 weeks and maintenance therapy with fluconazole (200 mg/day) for 6-12 months. 11,21,22 As for pulmonary disease, fluconazole 400 mg daily for 6-12 months is recommended in mild to moderate disease.…”

“…16,21,22 In immunocompetent patients, the Infectious Disease Society of America guidelines recommend treating cryptococcal CNS infection or dissemination with amphotericin B (0.7-1 mg/kg/day) plus flucytosine (100 mg/kg/day) for at least 4 weeks, followed by consolidation therapy with fluconazole (400-800 mg/day) for a minimum of 8 weeks and maintenance therapy with fluconazole (200 mg/day) for 6-12 months. 11,21,22 As for pulmonary disease, fluconazole 400 mg daily for 6-12 months is recommended in mild to moderate disease. The regimen differs in severe or progressive disease, which is the same as treating CNS involvement.…”

Complete Remission of Primary Cutaneous Cryptococcosis in an Immunosuppressed Patient after Fluconazole Treatment

“…A secondary involvement of the skin is seen in approximately 15% of patients with systemic dissemination and cutaneous lesions are also found in 5% of patients affected by cryptococcal meningitis [12]. Skin lesions can represent the initial clinical manifestation of a disseminated disease.…”