Cutaneous Cryptococcus Neoformans: A Fatal Warning Sign

Learning Objective #1: Understand the incidence of cutaneous manifestations of cryptococcal infections and its relation to systemic cryptococcal infection. Learning Objective #2: Identify cryptococcal skin lesions. CASE: An 81 year old woman presentedto the medical intensive care unit as an outside transfer for escalation of care. Two months prior to this hospitalization the patient was fully independent and lived alone; however, she had a recent admission for renal failure which revealed an ANCA-positive vasculitis with myeloperoxidase antibody elevation and crescen-tic pauci-immune glomerulonephritis on renal biopsy. She was discharged on a maintenance dose of prednisone, but began to clinically deteriorate shortly thereafter at home with decline in mental status and renal function. The patient was transferred from an outside hospital to our facility with acute encephalopathy and cellulitis. On arrival, physical exam revealed skin lesions on the bilateral upper extremities and right lower extremity that were violaceous and purpuritic as well as areas of induration and necrosis. Blood cultures revealed a gram positive bacteremia. Dermatology was consulted with the request of a skin biopsy given the patient's prior history. On the day of the skin biopsy the patient had further clinical deterioration with progressive hypoxia requiring intubation as well as renal failure and severe lactic acidosis. She was treated with broad spectrum antibiotics as well as anti-fungals; however her clinical status continued to deteriorate and eventually she expired within 48 hours of admission. Her skin biopsy revealed disseminated encapsulated yeast consistent with Cryptococcus neoformans. IMPACT/DISCUSSION: Cryptococcus neoformans is a dimorphic fungus that is ubiquitous in the environment, found in soil, dust, wild and domesticated birds as well as a skin contaminant. Clinically, its primary manifestation is pulmonary infection; however, 10-15% of clinical manifestations are cutaneous. Cutaneous manifestations can be diverse including plaques, crusts, nodules, or microhemorrhages. When presented with an individual with cutaneous manifestations, the patient should be assumed to have systemic infection unless proven otherwise, and this case demonstrates that delay in treatment can become fatal. The diagnostic challenge in this case was identifying a patient with known immunocom-promised status presenting with no other objective data of cryptococcal meningitis or pulmonary infection. The patient was started on antifungals; however, not with enough alacrity to become effective. Conclusion: Cryptococcosis can be encountered around the world and the majority of its clinical manifestations will be elucidated via the common infectious routes; however, there are opportunities to diagnose cryptococcosis and treat patient faster in an attempt to reduce morbidity and mortality from this infection. One of these opportunities is assessment of new dermatological manifestations of unknown origin in at risk patients.