Primary Cutaneous Cryptococcosis Treated with Debridement and Fluconazole Monotherapy in an Immunosuppressed Patient: A Case Report and Review of the Literature

Abstract

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.

Primary cutaneous cryptococcosis in an elderly pigeon breeder

“…In immunocompromised patients, Cryptococcus can disseminate to many sites, including the brain and skin. Secondary cutaneous cryptococcosis can present with a variety of clinical manifestations, including ulcers, acneiform papules and pustules, vegetating plaques, granulomas, or subcutaneous nodules 4 . The lesions can also mimic molluscum contagiosum, herpes simplex infections, pyoderma gangrenosum, and bacterial cellulitis 5, 6.…”

Cutaneous Cryptococcosis

“…Meanwhile, in an 89-year-old man, a 3-cm ulcer developing on the head was removed with a resection margin of 1 cm from the border 35) . Surgical debridement of necrotic tissue is effective in promoting wound healing 36) .…”

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

“…Interestingly, itraconazole was effective in other seven cases reported by literature. Despite the efficacy of medical treatment, some patients needed surgical debridement to remove infected tissues and repair skin damages [15,16]. observed in other patients affected by PCC, diagnosis was delayed because of the absence of risk factors and other systemic symptoms.…”

“…With this in mind, we think that the role of surgical debridement should be considered for patients at high risk of pharmacologic adverse events by use of antifungal azole (early drug intolerance, potential hepatotoxicity, QTc prolongation, drug-drug interactions) [16].…”