Primary Cutaneous Cryptococcosis and Secondary Antigenemia in a Patient with Long-Term Corticosteroid Therapy

Abstract

We report a case of a 71-year-old male who developed severe cellulitis of his right forearm and hand after he had an accidental injury from the sharp edge of a metal plate of a birdhouse. The patient suffers from chronic asthma and has been treated with systemic corticosteroids for years. Culture of aspirates from two sites of the wound area revealed growth of Cryptococcus neoformans in one and Acinetobacter lwoffii in the other. After combined treatment including antibiotics, antifungal therapy with fluconazole 400 mg/d and surgical debridement followed by a mesh graft, the patient achieved complete healing of the wound. Five months after the infection, the patient was still positive for cryptococcal antigen at a titer of 1:64 despite oral treatment with fluconazole 50 mg/d, and maintenance therapy with fluconazole 200 mg/d was recommended for 6 months, or longer depending on further results. The clinical and microbiological characteristics of this patient as well as therapeutical and epidemiological aspects of primary cutaneous cryptococcosis (PCC) are discussed.

Primary cutaneous cryptococcosis in an immunocompetent man: A case report

“…Cutaneous involvement occurs in 10-20% of cases of disseminated cryptococcosis. 2,8,15 However, direct inoculation is a possible route, which causes primary cutaneous cryptococcosis (PCC). 11 A history of trauma is the most frequently reported risk factor to provide a portal of entry, and foreign body puncture and animal-related trauma are the most common related causes.…”

“…neoformans has a lower thermotolerance compared with the other serotypes, which may explain its dermatotrophism. 15,16 The diverse clinical manifestations of PCC include papules, pustules, nodules, plaques, vesicles, ulcers, ecchymosis, cellulitis, subcutaneous lesions resembling erythema nodosum, herpetiform or molluscum contagiosum-like lesions, and polymorphic lesions. 5,8,12 Therefore, cutaneous cryptococcosis should be suspected if the skin eruptions respond poorly to standard treatment, and a diagnostic skin biopsy should be performed.…”

Primary Cryptococcal Tenosynovitis in a Patient with Rheumatoid Arthritis

“…A recent set of guidelines provided by the Infectious Diseases Society of America (IDSA) recommends oral fluconazole administration (400 mg/ day for 6 to 12 months) only if CNS disease is excluded, fungemia is not present, the infection occurs at a single site, and there are no immunosuppressive risk factors [19]. Most reported cases of primary cryptococcal SSTI were treated with azole monotherapy (200 mg-400 mg/day of fluconazole or 200 mg/day of itraconazole for 3 to 6 months), and responses were favorable even in an immunosuppressed state [3,5,20]. Although our patient was in an immunosuppressed state, there was no evidence of involvement of the CNS or internal organs.…”

“…Among these manifestations, cellulitis is more common in immunocompromised patients and rapidly progresses to deep structures [3][4][5][6].…”

Kaposi’s Sarcoma after Long-Acting Steroids: Time until Remission and Drug Washout

“…After long-term administration, intramuscular TA inhibits the hypothalamic-pituitary-adrenal axis for up to 10 months after the last dose [2]. LAS are also strong immunosuppressors and can result in severe opportunistic infections and immunodeficiency-related malignancies [3,4,5,6]. The time needed for immune recovery after withdrawal of LAS remains unknown.…”