Cutaneous cryptococcosis and AIDS

Cutaneous cryptococcosis: an underlying immunosuppression? Clinical manifestations, pathogenesis, diagnostic examinations and treatment

Due to constantly growing population of immunocompromised patients the fungi became a widespread threat to modern medicine. HIV carriers, solid organ transplant recipients constitute most of those patients. Cryptococcosis is a frequent cause of life-threatening infections, affecting mostly immunosuppressed patients. This article presents current knowledge on cryptococcal infections, including epidemiology, clinical aspects, diagnosis and recommended treatment. In reference to our patient, who developed a disseminated and fulminant subtype of the disease, we wanted to underline the need to examine patients thoroughly. The highest aim of those measures would be to avoid lethal consequences.

Primay cutaneous cryptococcosis in an immunocompetent patient

The authors report a primary cutaneous cryptococcosis, caused by Cryptococcus neoformans in immunocompetent patient, a farmer who developed extensive lesions at the site of an injury caused by one of the chickens on his right forearm, while he was cleaning out his barn. Oral treatment with fluconazole was totally successful. A review of the literature showed the rarity of cutaneous cryptococcosis in immunocompetent patients and in contrast, that skin lesions frequently occur in immunocompromised patients.

Primary cutaneous cryptococcosis due to Cryptococcus neoformans var. gattii serotype B, in an immunocompetent patient

The authors report a male patient, a seller with no detected immunosuppression, with an extensive ulcerated skin lesion localized on the left forearm, caused by Cryptococcus neoformans var. gattii serotype B. Oral treatment with fluconazole was successful. A review of the literature showed the rarity of this localization in HIV-negative patients. In contrast, skin lesions frequently occurs in HIV-positive patients, with Cryptococcus neoformans var. neoformans serotype A predominating as the etiological agent. In this paper, the pathogenicity of C. neoformans to skin lesions in patients immunocompromised or not, is discussed, showing the efficacy of fluconazole for the treatment of these processes.

Cutaneous cryptococcosis mimicking basal cell carcinoma in a patient with AIDS

BACKGROUND

Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus neoformans. This ubiquitous organism has emerged as a frequent finding in immunosuppressed patients, especially those with underlying malignancies, organ transplants, and the acquired immune deficiency syndrome (AIDS). Cutaneous manifestations of cryptococcosis occur in 10 to 15% of patients having systemic involvement. These skin lesions may simulate a variety of different disease entities.

METHODS

A case of crytococcosis mimicking a basal cell carcinoma is the subject of a case report presentation.

RESULTS

A case of cutaneous cryptococcosis mimicking basal cell carcinoma occurred in a patient with AIDS, who did not appear to have dissemination, but was treated aggressively to stem possible occult systemic disease.

CONCLUSION

Cutaneous crytococcosis may mimic other dermatologic disorders.

Fungal infections in HIV-infected patients

Opportunistic fungal infections are commonly encountered in the acquired immunodeficiency syndrome (AIDS) patient population. Fungal infections in the patient infected with the human immunodeficiency virus (HIV) are a major cause of morbidity and mortality. The yeasts Candida and Cryptococcus neoformans, the dimorphic fungi Histoplasma capsulatum and Sporothrix schenckii, and the dermatophyte fungi are the most common pathogenic fungi in patients infected with HIV. The characteristics of these and other relevant mycotic pathogens, and their clinical presentation are discussed. Mycoses in the patient infected with HIV are often atypical, and can be masked by other infections. Cutaneous manifestations may provide valuable diagnostic clues. The clinician must maintain a high index of suspicion to establish an early diagnosis and rapidly institute therapy. Treatment may suppress rather than cure the mycosis, because host immunity in conjunction with antifungal agents is necessary to eliminate infection.

Diagnosis and treatment of infectious diseases in HIV-infected hosts

Treatment of infectious diseases in patients with HIV infection is of primary importance in patient care. Viral, bacterial, parasitic, and fungal pathogens all may affect these patients. It is essential that accurate diagnoses be made and appropriate therapy be administered as early as possible.

Primary cutaneous cryptococcosis following trauma of the right forearm

A 62-year-old woman with sarcoidosis II, status post systemic steroid treatment, developed an inflammatory, infiltrative skin lesion in the area of a traumatic haematoma of the right forearm. The clinical appearance at first corresponded to bullous erysipelas. Antibiotic therapy, which was instituted immediately, proved to be ineffective. A microbiological swab revealed infection with Cryptococcus neoformans. A systemic cryptococcosis could be excluded. Therapy with 200 mg itraconazole twice daily resulted in a prompt improvement.

Disseminated cryptococcosis with cutaneous lesions

A case of disseminated cryptococcosis in an HIV-negative patient presenting with cutaneous lesions is described for the first time in Egypt. The patient, a 16-year-old male, presented with cough, expectoration, loss of weight, and cutaneous lesions, mainly on the face and trunk. The lesions consisted of vegetating crusted plaques discharging purulent to sanguinous fluid and flattened, shiny, erythematous to brownish plaques. Anorexia, headache and personality changes soon followed. Histopathological examination of lesions was highly suggestive of a deep mycosis, particularly cryptococcosis. The fulminant disease advanced with central nervous system involvement. The progression was not arrested when systemic antifungal therapy was administered late in the disease course. Pathological examination of lungs, liver, pancreas and spleen revealed disseminated infection with no evidence of other underlying pathology. Disseminated cryptococcosis is a morbid infection, rare in an area where heightened awareness and raised index of suspicion will surely allow earlier diagnosis, management and better prognosis.

Giant molluscum contagiosum in AIDS

A 31-year-old man, an intravenous drug user and in an advanced stage of acquired immune deficiency syndrome (AIDS), was admitted in our Department for the treatment of skin lesions that had been diagnosed as molluscum contagiosum (MC). The clinical examination revealed the presence of multiple nodular lesions, some of which were notably large and whose color resembled that of normal skin. These lesions were localized mainly to the face, and in particular on the forehead, glabellar, malar, beard, submandibular, and neck regions (Fig. 1). Smaller, crateriform lesions were detected on the hands and the upper limbs. The lymphocyte subsets ratio was 0.02, with a CD4+ T cell count of 13 cells per mm3 (1%) and a CD8+ T cell count of 624 per mm3 (48%). The patient also had leukopenia (1690 WBC per mm3), moderate macrocytic anemia, elevation of transaminases (SGOT 105 U/L, SGPT 114 U/L) and of immunoglobulins (IgG 2660 mg/dL), and a decrease of C3 (44.2 mg/dL) and C4 (16.6 mg/dL). Histologic examination revealed the presence of typical MC lesions. In addition to an important acanthosis, it was possible to detect pyriform lobules of perfectly delineated epidermal cells, radially separated by fibrous septa that merge towards the central crater. The characteristic MC eosinophil bodies were observed in infected cells (Fig. 2). The lesions were treated with cryosurgery by spray. Many courses of therapy were given with intervals of 2-3 weeks. Every session consisted of two cycles of rapid freezing followed by a slow thaw. Many lesions disappeared with this treatment, and others were reduced in size, but total destruction of all lesions was not achieved (Fig. 3).

Cutaneous cryptococcosis and Kaposi's sarcoma occurring in the same lesions in a patient with the acquired immunodeficiency syndrome

A 34-year-old woman presented with a history of fever, malaise and skin lesions. A diagnosis of Kaposi's sarcoma and acquired immunodeficiency syndrome (AIDS) was established, and in addition, the skin lesion which was biopsied also demonstrated cryptococcal infection. Disseminated cryptococcosis was later confirmed and the disease ran a florid course. The co-existence of different diseases within the same lesion is a feature of human immunodeficiency virus (HIV) infection, this being the third documented case of simultaneous Kaposi's sarcoma and cutaneous cryptococcosis occurring at the same site in a patient with AIDS. The nature of this co-existence is discussed with reference to the pathogenesis of Kaposi's sarcoma.

Case report: cutaneous manifestations of cryptococcosis

Cutaneous cryptococcosis usually is associated with concurrent systemic infection and actually may develop before clinical manifestations of cryptococcal meningitis become apparent. It is rare for a cryptococcal infection to be localized only to the skin. A case of cutaneous cryptococcosis is described in an immunocompromised patient who initially had a rash and a positive serum cryptococcal antigen titer, but no central nervous system involvement. The papular pustular skin lesions disappeared after 8 weeks of therapy with amphotericin B, which was stopped secondary to progressive azotemia. Less than 2 months after therapy, the skin lesions recurred, again without evidence of systemic disease. Treatment with oral fluconazole resulted in a gradual resolution of the cutaneous lesions. The pathogenesis of cryptococcosis is discussed, with emphasis on the management of cutaneous cryptococcosis.

Cutaneous involvement with Cryptococcus neoformans in AIDS

Patients infected with HIV are susceptible to many opportunistic fungal infections. Cryptococcus neoformans infection is particularly common in patients with AIDS. We describe a patient with disseminated cryptococcosis resembling molluscum contagiosum and review the typical cutaneous manifestations of disseminated cryptococcosis. A synopsis of case reports in the English literature is also presented.

Cutaneous cryptococcal infection without immunodeficiency

A case of cutaneous cryptococcosis (encapsulated strain) in a 67-year-old female, with no evidence of immune suppression (normal cell surface marker analysis and mitogen proliferation studies) and which responded to treatment with oral fluconazole is reported. To date her clinical progress remains satisfactory after 12 months of follow-up.

Cutaneous cryptococcosis in AIDS: successful treatment with itraconazole

A case of cutaneous cryptococcosis in a HIV-positive 46-year-old farmer is presented. The situation could be cured by applying itraconazole 400 mg day-1 for 45 days.

Dermatologic manifestations of human immunodeficiency virus infection

Human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) have become major health problems in the United States, and patients with manifestations of these diseases are seen by physicians in all areas of medicine. Cutaneous manifestations develop in as many as 92% of HIV-positive persons. Familiarity with these manifestations facilitates early diagnosis and enhances the care of HIV-infected patients. The spectrum of mucocutaneous disorders in these patients includes an acute exanthem, multiple infections, neoplastic processes, and miscellaneous disorders. Herein we review the most common and the most specific dermatologic manifestations associated with HIV infection, which often are atypical, more severe, or less responsive to treatment than the corresponding diseases encountered in non-HIV-infected persons.