15672 A cutaneous crypt for cryptococcosis: The skin as a marker for disseminated disease

Abstract

Cutaneous cryptococcosis is caused by Cryptococcus neoformans, an opportunistic, encapsulated yeast that can cause significant morbidity and mortality. Cutaneous cryptococcosis can affect both immunocompromised and immunocompetent individuals, and can result from direct inoculation or hematogenous spread to skin. In primary cutaneous cryptococcosis, localized infection is subsequent to direct inoculation. In contrast, the more common, secondary skin involvement is due to hematogenous dissemination, which can be accompanied by spread to other organs such as the lungs and central nervous system. Here, we present a case of a 66-year-old man with a history of deceased-donor renal transplant secondary to polycystic kidney disease on chronic immunosuppression. He presented with a 2-month history of an enlarging, deep tender ulceration with heaped up borders and yellow purulent crust on the left eyelid. HSV and VZV PCR, bacterial culture and blood culture were negative. Lumbar puncture results were consistent with cryptococcal meningitis. Similarly, a biopsy of the periphery of the lesion demonstrated granulomatous and suppurative inflammation and refractile yeast forms, findings compatible with cryptococcosis. Gomori methenamine silver stain highlighted many fungi and mucicarmine stain highlighted their capsules. The patient was treated with intravenous amphotericin B and flucytosine for disseminated cryptococcal infection with cutaneous involvement. In immunocompromised patients, the diagnosis can be challenging, as cutaneous findings are nonspecific and can often mimic other conditions. Cutaneous involvement can serve as a helpful clue of underlying disseminated disease, and dermatologists play a crucial role in the diagnosis and early treatment of this opportunistic, often life threatening disease.