Infect Chemother.  2012 Feb;44(1):22-25. 10.3947/ic.2012.44.1.22.

Primary Cryptococcal Tenosynovitis in a Patient with Rheumatoid Arthritis

• Seo AY
• Han SW
• Kwon KT
• Kwak EK
• Lee MJ
• Kang SH

• KMID: 1782394
• DOI: http://doi.org/10.3947/ic.2012.44.1.22

Abstract

Here, we report a case of primary cryptococcal tenosynovitis and arthritis caused by worsened cellulitis in a patient with rheumatoid arthritis (RA) who had been taking methotrexate and leflunomide. The patient, injured during the soybean harvest, failed to respond to empirical antibiotic therapy for presumed bacterial cellulitis on the dorsum of the right hand. An operative procedure was performed. Cryptococcocal tenosynovitis was diagnosed upon histopathological examination of the lesion. Treatment with 400 mg of fluconazole daily for 3 months led to the complete disappearance of skin lesions, with slight limitation of finger extension. The patient was examined continuously for 2 years, and there was no evidence of relapse or dissemination to other organs. This case indicates that primary cryptococcal skin and soft tissue infections must be included in the differential diagnoses of antibiotics-refractory soft tissue infections, especially in immunocompromised patients.

Keyword

Cryptococcus; Tenosynovitis; Rheumatoid arthritis

MeSH Terms

Arthritis
Arthritis, Rheumatoid
Cellulitis
Cryptococcus
Diagnosis, Differential
Fingers
Fluconazole
Hand
Humans
Immunocompromised Host
Isoxazoles
Methotrexate
Recurrence
Skin
Soft Tissue Infections
Soybeans
Surgical Procedures, Operative
Tenosynovitis
Fluconazole
Isoxazoles
Methotrexate

Figure

• 

  Figure 1 T1 weighted post-gadolinium images (A, B) show a multilobulated and low signaled lesion (arrows) with peripheral soft tissue enhancement along the right fourth and fifth extensor tendons. There is a high signal (arrow) in and around the metacarpophalangeal joint of the right fourth finger in the coronal image (C).

• 

  Figure 2 The surgical specimen of the tendon sheath shows granulomatous inflammation with multinucleated giant cells (arrows), which contain small round yeast cells presenting with a foamy cytoplasm surrounded by a clear halo (H & E ×200) (A). Periodic acid-Schiff staining of tissues reveals yeast cells (arrow) that display intense red staining along their rim (PAS ×400) (B).

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