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Kuwahara M, Yurugi S, Ando J, Takeuchi M, Miyata R, Harada M, Masuda Y, Kanagawa S, Yoneda T, Fukumori T, Ogawa T, Nakamura-Uchiyama F, Kasahara K. A case of cryptococcal necrotizing fasciitis and immune reconstitution inflammatory syndrome in a renal transplantation recipient. Int J Surg Case Rep 2021; 85:106199. [PMID: 34280874 PMCID: PMC8318893 DOI: 10.1016/j.ijscr.2021.106199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Immunocompromised patients are at high risk of unexpectedly serious infections caused by uncommon bacteria or fungi. We experienced a case of Cryptococcus neoformans-induced necrotizing fasciitis (NF) of the lower extremities. The progress so far has been reported by the urology department [1]. Moreover, after the NF had been treated, the patient developed immune reconstitution inflammatory syndrome (IRIS). We report from surgeon's view point. CASE PRESENTATION A 51-year-old male renal transplant patient complained of pain in both lower extremities (LE). After the initial debridement, periodic acid-Schiff after diastase digestion (D-PAS) staining confirmed the diagnosis. No symptoms were seen in the lungs or cerebrospinal system. The patient was reluctant to undergo surgical treatment but several debridement improved patient's condition. After the LE wound healed, prednisolone was discontinued, then painful nodules appeared on both LE. Based on the negative culture results and the fact that the patient had been treated with flucytosine and fluconazole, we suspected that the nodules had been caused by IRIS. CLINICAL DISCUSSION It was difficult to diagnose Cryptococcus-induced NF and paradoxical IRIS. Cooperation from other specialists was essential. CONCLUSION We think this patient needed earlier and more definitive debridement. Fortunately, we were able to save the patient's life and maintain his LE function. In immunocompromised patients, cryptococcus can be a pathogen. In addition, IRIS can occur during treatment. Management of IRIS is the capital point of sepsis management, careful anti-inflammatory drug control by specialists is required.
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Affiliation(s)
- Masamitsu Kuwahara
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Satoshi Yurugi
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Junji Ando
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Mika Takeuchi
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Riyo Miyata
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Masayuki Harada
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Yasumitsu Masuda
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Saori Kanagawa
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Tatsuo Yoneda
- Division of Dialysis Unit, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Tatsuya Fukumori
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Taku Ogawa
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Fukumi Nakamura-Uchiyama
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan; Department of Infectious Diseases, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo 130-8575, Japan.
| | - Kei Kasahara
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
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