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Cutaneous Cryptococcus Clinical Presentation

  • Author: David G Moskowitz, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Feb 16, 2016
 

History

A patient's presenting symptoms are determined by the site of initial and subsequent infection and by his or her immune status. Factors favoring primary cutaneous infection include a solitary lesion, lesions on uncovered parts, a history of primary inoculation, and regional lymph node involvement. Factors favoring secondary cutaneous infection include the presence of systemic involvement, lesions on covered parts, multicentric skin involvement, and deep dermal or subcutaneous lesions. Cryptococcal meningitis with skin involvement in a 20-year-old woman has been reported and indicates that immunosuppression is not necessary for cryptococcal infection to occur and that skin manifestations can give clues to meningitis.[6]

Several reports in 2011 have noted that Cryptococcus gattii can affect immunocompetent hosts, so this must be considered when examining otherwise-well patients.[7, 8] C gattii type VGII resulted in primary infection after trauma in one patient.[9]

Cryptococcus laurentii in a renal transplant recipient resulted in primary cutaneous cryptococcosis.[10] An immunosuppressed psoriatic patient with palmopustular involvement experienced generalized Cryptococcus albidus infection manifesting as generalized hemorrhagic plaques.[11]

Primary cutaneous infection findings are as follows:

  • History of trauma and direct inoculation
  • Most often occurs in immunosuppressed patients but may occur in nonimmunosuppressed patients
  • Single lesion develops at the site of infection
  • Solitary nodules that may ulcerate
  • Cellulitis
  • Ulcers
  • Abscesses
  • Panniculitis [12]  (eg, primary in renal transplant patient [13] )
  • Sporotrichoid-pattern, capsule-deficient cutaneous cryptococcosis [14]

Disseminated cutaneous Cryptococcus infection findings are as follows:

  • Occurs in 10-15% cases
  • Occurs in only approximately 6% of HIV-infected patients
  • Cutaneous signs possibly preceding other symptoms of disseminated disease by 2-8 months
  • Lesions mostly found on head and neck
  • First present as painless papules or pustules, which then become nodules that may ulcerate (eg, pustular eruption in cardiac transplant patient with cryptococcal meningitis and headache [15] )
  • Numerous other cutaneous manifestations (eg, acneiform papules or pustules, warty or vegetating crusted plaques and ulcers, hard infiltrated plaques or nodules, subcutaneous swellings, abscesses, blisters, tumorlike masses, eczematous plaques, granulomas, vasculitic lesions resembling palpable purpura [especially in transplantation patients])

Primary pulmonary infection findings are as follows:

  • May be limited to fever, cough, and pleuritic chest pain
  • Can progress to acute respiratory distress syndrome

CNS Cryptococcus infection findings are as follows:

  • Nuchal rigidity
  • Headache
  • Vertigo
  • Nausea and vomiting
  • Changes in consciousness
  • Mental changes
  • Nerve palsies

Immunosuppressive medications are as follows:

  • Treatment with methotrexate and adalimumab [16]
  • Corticosteroid therapy [17] (including cutaneous cryptococcosis secondary to C gattii) [18]

Other possible developments are as follows:

  • Hepatitis
  • Osteomyelitis
  • Prostatitis
  • Pyelonephritis
  • Peritonitis
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Physical

Primary cutaneous Cryptococcus infection findings are as follows:

  • The patient may have solitary nodules that break down and ulcerate (eg, facial ulceration [19] ).
  • Other signs include local lymphadenopathy, cellulitis, and abscesses.

Disseminated cutaneous Cryptococcus infection findings are as follows:

  • Numerous manifestations may be seen, but seldom are they pathognomonic.
  • Lesions are most often found on the head, neck, mouth, and nose.
  • Xanthomalike lesions (crusted yellowish brown plaques, which were accompanied by smaller papules with telangiectasia) histologically and clinically have been noted. [20]
  • The most common manifestations are molluscum contagiosum-like umbilicated papules of varying sizes (approximately 50% of patients with HIV infection), as seen in the image below, which may have a gelatinous quality and develop a central hemorrhagic crust.
    Umbilicated papule of cutaneous Cryptococcus infec Umbilicated papule of cutaneous Cryptococcus infection on the face of a male.
  • Cellulitis is seen most commonly in transplantation patients. In one report, 72% of organ transplantation patients with cutaneous Cryptococcus infection presented with cellulitis. Of these, 94% had cellulitis on the extremities. A particularly high rate was found among patients treated with tacrolimus. Cellulitis is the rarest skin finding associated with cryptococcosis. Primary cryptococcal cellulitis caused by C neoformans var. gattii has also been reported in an immunocompetent host.
  • Patients may have acneiform papules or pustules and/or warty or vegetating crusted plaques and ulcers.
  • Other signs include hard infiltrated plaques or nodules, subcutaneous swellings, abscesses, blisters, tumorlike masses, eczematous plaques, granulomas, and/or vasculitic lesions resembling palpable purpura (especially in transplantation patients).
  • Disseminated cryptococcosis initially presenting as cellulitis in a rheumatoid arthritis patient was noted by Lu et al. [21] Cryptococcal cellulitis should be suspected in any immunosuppressed patient with cellulitis that is unresponsive to antibiotics.
  • Hoang and Burruss [22] described localized cutaneous Cryptococcus albidus infection in a 14-year-old boy on etanercept therapy.
  • Dilhuydy et al [23] reported on a patient who had cutaneous cryptococcosis with alemtuzumab; this patient was being treated for chronic lymphocytic leukemia.
  • Van Grieken et al [24] described a case of primary cryptococcal cellulitis in a lung transplant recipient.
  • Cutaneous cryptococcosis can resemble molluscum. [25]
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Causes

Exposure to C neoformans, most often through exposure to pigeon droppings, is a primary cause. Immunosuppression (eg, HIV infection, leukemia/lymphoma, sarcoidosis, long-term immunosuppression or prednisone therapy for organ transplantation or connective-tissue disease) is a key factor in developing disseminated disease.

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Contributor Information and Disclosures
Author

David G Moskowitz, MD Associate Physician, Department of Dermatology, Kaiser Permanente in Oakland, California

David G Moskowitz, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Umbilicated papule of cutaneous Cryptococcus infection on the face of a male.
 
 
 
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