Cryptococcal cellulitis in a renal transplant patient

Alessandro C. Pasqualotto1, Antonio E. N. Bittar2, Maurício de Quadros3 and Luiz C. Severo4

1 Department of Infection Control, 2 Department of Nephrology, 3 Department of Dermatology and 4 Department of Clinical Mycology, Santa Casa Complexo Hospitalar, Porto Alegre, Brazil

Correspondence and offprint requests to: Alessandro Comarú Pasqualotto, Rua Prof. André Puente, 185/204, 90035-150, Porto Alegre, Brazil. Email: ac.pasqualotto{at}hotmail.com

Keywords: cellulitis; cryptococcosis

A 54-year-old male patient was admitted due to fever and cellulitis of the left leg (Figure 1). Three years before, he had undergone renal transplantation, and his immunosuppressive regimen was cyclosporine (75 mg b.i.d.) and prednisone (10 mg q.d.). His other significant medical history included previous deep venous thrombosis affecting the left leg, and type 2 diabetes, controlled with diet. At admission, he appeared healthy, with no complaints but fever and local inflammatory signs on the left leg. No abscess was perceived. He was treated with ciprofloxacin, but no improvement was seen after 96 h of antimicrobial therapy. Two out of three blood culture sets revealed the growth of yeast-like organisms (Cryptococcus neoformans var. grubii), and amphotericin B desoxycholate was started (1 mg/kg/day). Skin biopsies showed the presence of chronic panniculitis associated with round yeast forms (Figure 2), and culture of the fragments revealed C. neoformans var. grubii. The serum cryptococcal antigen titre was 1:32 768. Chest radiography and cerebrospinal fluid tests were negative, and there were no signs of intracranial hypertension. Renal function worsened after 20 days of amphotericin B deoxycholate treatment, and the antifungal therapy was changed to fluconazole (200 mg b.i.d.). During this period, a positive cytomegalovirus antigenemia (46 positive cells/100 000 leukocytes) was treated with a 14-day course of intravenous ganciclovir. The patient was discharged with secondary prophylaxis with fluconazole (200 mg q.d.). Skin lesions in patients with cryptococcosis are usually attributable to haematogenous dissemination (i.e., secondary cutaneous cryptococcosis), while primary cutaneous cryptococcosis is a rare condition. As this immunosuppressed patient had no evidence of pulmonary or central nervous system disease, it is possible that the chronic oedema caused by deep venous thrombosis had led to cellulitis and fungaemia.



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Fig. 1. Cellulitis caused by C.neoformans var. grubii in a renal transplant patient.

 


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Fig. 2. Histopathological examination of a skin biopsy specimen revealing chronic panniculitis associated with round yeast forms.

 
Conflict of interest statement. None declared.





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