J Korean Soc Transplant.  2013 Sep;27(3):132-137. 10.4285/jkstn.2013.27.3.132.

Disseminated Cryptococcosis with Cutaneous Manifestation in a Renal Transplant Recipient: A Case Report

• Lee SK
• Kim HS
• Lee JG
• Choi JM
• Jung IS
• Yhi JY
• Hwang SW
• Lee CH
• Kwon OJ
• Kang CM

• KMID: 1495871
• DOI: http://doi.org/10.4285/jkstn.2013.27.3.132

Abstract

Cryptococcosis commonly affects patients with immune dysfunction, as in the case of immunosuppression in organ transplant patients or as acquired immunodeficiency syndrome in patients afflicted with human immunodeficiency virus. The varied appearance of cryptococcal skin lesion makes clinical diagnosis of cutaneous cryptococcosis difficult. Cryptococcosis proves to be a fatal fungal infection in the immunocompromised patient. Therefore, diagnosis and early treatment of cryptococcosis become vital. A 56-year-old renal transplant recipient, with an ongoing immunosuppression regimen of cyclosporine, prednisolone, and mycophenolate mofetil, was admitted with a 2-week history of pain and edema of right arm without respiratory symptoms. Despite empiric antibiotic therapy, the patient continued to complain of severe tenderness of the involved arm and fever persisted as well. On the third day of hospital stay, a biopsy of the erythematous skin lesion was acquired. On the eighth day of hospital stay, results of both skin biopsy and blood cultures showed the presence of Cryptococcus neoformans. The treatment was begun with intravenous fluconazole (400 mg/day). After 4 days of antifungal treatment, the patient developed fever along with cough with purulent sputum. As the new developing symptoms were suggestive of pneumonia, especially of pulmonary cryptococcosis, the antifungal agent was changed from fluconazole to amphotericin B treatment (0.8 mg/kg, 50 mg/day). Chest computer tomography showed improvement in the pneumonic infiltration and consolidation after 4 weeks of amphotericin B treatment. In conclusion, cellulitis in immunocompromised patients should be suspected in case of highly atypical infectious etiology, and skin biopsy should not be delayed if empiric antibiotic therapy does not control the inflammatory response. Additionally, the patient should be treated with intravenous amphotericin B treatment in case of severe cryptococcosis.

Keyword

Kidney transplantation; Cryptococcosis; Fungal infection

MeSH Terms

Acquired Immunodeficiency Syndrome
Amphotericin B
Arm
Biopsy
Cellulitis
Cough
Cryptococcosis
Cryptococcus neoformans
Cyclosporine
Edema
Fever
Fluconazole
HIV
Humans
Immunocompromised Host
Immunosuppression
Kidney Transplantation
Length of Stay
Middle Aged
Mycophenolic Acid
Pneumonia
Prednisolone
Skin
Sputum
Thorax
Transplants
Amphotericin B
Cyclosporine
Fluconazole
Mycophenolic Acid
Prednisolone

Figure

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  Fig. 1. (A) Multiple erythematous plaque of right forearm. (B, C) Multiple erythematous plaque of left thigh, right sole.

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  Fig. 2. (A) PAS stain of skin biopsy (×400). (B) Alcian blue stain of skin biopsy (×400). There are nu-merous encapsulated yeast in sub-cutaneous layer. Some of the organisms have a well-defined halo (arrows) due to the mucopoly-saccharide coat which surrounds them.

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  Fig. 3. (A) Chest computer tomography. There are ill-defined cen-trilobular ground-glass opacity in right upper lung and pneumonic infiltration before antifungal treatment at 11th hospital day. (B) Chest computer tomography. After the 4 weeks of intravenous amphotericin B treatement, the pneumonic infiltration disappeared and this suggested improved state of pneumonia, especially pulmonary manifestation of disseminated cryptococcal infection.

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