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Table of Contents
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 34-36

Cutaneous lesions as marker of cryptococcal meningitis


1 Assistant Professor, Department of Skin and VD, SBKS MI & RC, Sumandeep Vidyapeeth, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
2 Professor & HOD, Department of Microbiology SBKS MI & RC, Sumandeep Vidyapeeth, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
3 Professor & HOD, Department of Skin and VD, NHL Medical College, Ahmedabad, Gujarat, India
4 Professor & HOD, Department of Skin and VD, SBKS MI & RC, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India

Date of Web Publication3-Aug-2018

Correspondence Address:
J Lakhani Som
Assistant Professor, Department of Skin and VD, SBKS MI & RC, Sumandeep Vidyapeeth, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-6486.238518

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  Abstract 


Cryptococcosis is a chronic, subacute or acute systemic infection caused by Cryptococcus neoformans. We present a case of cryptococcosis in an immunocompromised person, having meningitis with characteristic skin lesions. Apart from signs and symptoms of meningitis, he had giant molluscum contagiosum like lesions suggestive of cryptococcal infection. CSF examination by India ink preparation and cryptoccal antigen test confirmed the diagnosis. This case highlights the importance of meticulous cutaneus examination in all HIV and other immunodeficient patients as cutaneous lesions can appear prior to systemic involvement and thus can indicate a full blown systemic disease.

Keywords: Cryptococcosis, giant molluscum contagiosum like lesions


How to cite this article:
Som J L, Sucheta J L, Raval R C, Bilimoria F E. Cutaneous lesions as marker of cryptococcal meningitis. J Integr Health Sci 2015;3:34-6

How to cite this URL:
Som J L, Sucheta J L, Raval R C, Bilimoria F E. Cutaneous lesions as marker of cryptococcal meningitis. J Integr Health Sci [serial online] 2015 [cited 2019 Jul 20];3:34-6. Available from: http://www.jihs.in/text.asp?2015/3/1/34/238518




  Introduction Top


Cryptococcosis which is caused by Cryptococcus neoformans may cause systemic infection. In developing countries it is one of the common opportunistic infection present in immunocompromised persons.[1] It can also occur in patients who have received solid organ transplantion. It may present with systemic involvement which could be acute, subacute or chronic. Cryptococcal meningitis may be secondary to pulmonary infection. It may present with symptoms due to systemic dissemination, pulmonary, CNS, bone or skin involvement.[2],[3]

Cryptococcosis patient may have characteristic skin manifestations which may be in form of nodules, papules, ulcers, draining sinuses, and cellulitis with necrotizing vasculitic lesions. Cutaneous manifestations occur in 10-15% of cases. Umbilicated papules in patients with AIDS may resemble molluscum contagiosum.[4]

Cryptococcocal skin manifestion is also very important in immunocompetent hosts as it may be the only site of infection. In comparison, cutaneous manifestations may be evidence of dissemination in immunosuppressed patients, especially those with AIDS.[4]

Case report:

A 55 years old HIV positive male patient presented with complaints of fever, projectile vomiting, headache and altered sensorium of 10 days duration. The patient had multiple asymptomatic skin lesions on the face and extensor aspects of elbows since last 3 months. He was on antiretroviral therapy in the form of zidovudine, lamivudine and nevirapine since last 4 months.

On systemic examination, he was febrile (1010 F), pulse was 102 per minute and respiratory rate was normal. Keming’s and Brudzinski’s sign were positive with bilateral extensor plantars. Rest of the systemic examination was normal.

On cutaneous examination he had multiple, well demarcated, painless, atypical papulonodular and vesicular lesions without surrounding erythema. These lesions were of 3-4 centimeter size and were present on the extensor aspects of the knee and face. Clinically the lesions resembled giant molluscum contagiosum [Figure 1].
Figure 1: Multiple umbilicated papulonodular lesions on forehead

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The CD4 count of the patient was 150. India ink preparation from the lesions was positive. CSF examination showed increased CSF pressure, increased lymphocytes, increased protein and globulin and decreased sugar and chloride. India ink preparation from CSF showed characteristic wide gelatinous capsule.

Injectable Amphotericin-B (1mg/kg/day) for 2 weeks and oral flucytosine (400mg/day) for 6 weeks were administered to the patient after whom he recovered and was discharged from the hospital.


  Discussion Top


Cryptococcosis is a life-threatening opportunistic fungal infection, worldwide. It has assumed and established an important role in current clinical practice as the predisposing factors of cryptococcosis like, acquired immunodeficiency syndrome (AIDS), cancer, sarcoidosis, Hodgkin’s lymphoma, diabetes mellitus, organ transplantation, cancer chemotherapy and treatment with monoclonal antibodies in patients has become increasingly common.[2] The central nervous system (CNS) and skin are common sites affected following hematogenous dissemination from the lungs .Early diagnosis and treatment is important, as disseminated cryptococcosis without treatment is nearly always fatal. Outcome can be improved by appropriate systemic antifungal therapy.[3],[4],[5]

Our patient had cryptococcal meningitis and was HIV positive.Incidence of cryptoccal meningitis in reported literature ranges between 0.04 to 12% per year in HIV positive patients. In an year approximately 957900 cases are reported.[1]

In this patient, cutaneous lesions very earlier and later on the manifestations of cryptococcal meningitis occurred. He ignored the skin lesions however fever brought him to the hospital. Similar cases are described in the literature where cutaneous lesions developed two to eight months before development of dissemination and CNS involvement. Sarosi et al. (1971) described series of such four cases of cryptococcosis with central nervous system (CNS) involvement. Similar to our case, skin lesions developed developed before the diagnosis of disseminated cryptococcosis with meningitis.

As mentioned in earlier reports, this patient had skin lesions on face, neck and scalp which are common site of presentation. Skin lesions may have like papules, pustules, plaques, ulcers, subcutaneous masses, Cellulitis or acneiform lesions.[2],[4] This patient had giant molluscum contagiosum like lesions which is described in cryptococcal infection [Figure 1]. Thus meticulous cutaneous examination in all HIV and other immuno deficient patients could help diagnose such a deadly condition early and alter the treatment outcome of such patients. Skin lesions may be warning signal of disseminated cryptococcal disease and careful laboratory study may lead to early diagnosis and treatment.[6]



 
  References Top

1.
Park BJ, Wannemuehler KA, Marston BJ, Govender N, Pappas PG, Chiller TM. Estimation of the current global burden of cryptococcal meningitis among persons living with HIV/AIDS. Aids. 2009 Feb 20;23(4):525-30.  Back to cited text no. 1
    
2.
Chayakulkeeree M, Perfect JR. Cryptococcosis. Infectious Disease Clinics of North America. 2006 Sep;20(3):507-44, v-vi.  Back to cited text no. 2
    
3.
Chuang YM, Ho YC, Chang HT, Yu CJ, Yang PC, Hsueh PR. Disseminated cryptococcosis in HIV-uninfected patients. European Journal of Clinical Microbiology & Infectious Diseases. 2008 Apr 1;27(4):307-10.  Back to cited text no. 3
    
4.
King JW, Chandrasekar PH DeWitt ML, Talavera F, Band JD: Cryptococcosis Clinical Presentation, e medicine medscape.com /article/215354 updated on 4th April,2014.  Back to cited text no. 4
    
5.
Kiertiburanakul S, Wirojtananugoon S, Pracharktam R, Sungkanuparph S. Cryptococcosis in human immunodeficiency virus-negative patients. International journal of infectious diseases. 2006 Jan 31;10(1):72-8.  Back to cited text no. 5
    
6.
Sarosi GA, Silberfarb PM, Tosh FE. Cutaneous cryptococcosis: a sentinel of disseminated disease. Archives of dermatology. 1971 Jul 1;104(1):1.  Back to cited text no. 6
    


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