engleski

Fungal twist - from skin to systemic cryptococcosis

Background: Cryptococcosis is common fungal infection in immunocompromised patients. The primary site of infection are usually lungs with consequential hematogenous spread to meningae and skin. Localised cutaneus cryptococcosis is extremely rare but should be noted due to possible underlying systemic disease. We report a 50-year old patient on corticosteroid therapy who presented with long-lasting skin lesions which eventually led to sistemic dissemination and fatal outcome. Case presentation: A 50-year old patient from rural area of Croatia presented with skin lesions which were sugicaly treated several times in the past two years but without any microbiologic or patohistologic examination. Due to fever associated with skin lesions which were surgically drained two weeks before, combined antimicrobial therapy with piperacillin/ tazobactam, vancomycin, clindamycin and fluconazole was initiated. The wound smear detected P.vulgaris, Candida spp and C. neoformans. Despite the broad spectrum therapy, fever persisted and he became periodically agitated. Chest X-rays as well as brain CT were normal. Lumbar puncture revealed pleocytosis and microscopic cerebrospinal fluid (CSF) examination showed yeast-like organisams and Cryptococcal antigen was positive as well. Blood cultures were negative, but C. neoformans was isolated in CSF and skin punch biopsy cultures. His skin lesion disseminated and his condition deteriorated to coma and respiratory insufficiency. Treatment was conducted with combination of lyophilized amphotericin B and fluconasol, and followed by fluconasole monotherapy. Gradually, his condition improved and he was discharged tetraparetic but in good clinical condition. Unfortunately, the patient died from sudden death two weaks afterwards and autopsy findings were unremarkable. Conclusion: Although C. neoformans infections are usually localised to lungs and may spread systemically, some reports suggest that cutaneous cryptococcal infection may serve as a portal of entry for disseminated disease. This case illustrates the need to investigate inflammatory skin changes in immunosuppressed patients, especially if not responding to conventional treatment.

Cryptococcosis ; fungal ; skin

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