Cutaneous Cryptococcosis Arising in a Patient with Idiopathic Lung Disease: Related Illnesses or “Ticks and Fleas”

Zoe Parker, Cary Chisholm
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Abstract

Cryptococcus is a yeast typically found in bird feces such as pigeon droppings. Infection may occur through inhalation of spores or via direct inoculation into the skin. Typically there is a history of immunosuppression, but cases are also reported in immunocompetent hosts. Cryptococcus may manifest as pulmonary disease or primary cutaneous infection, but dissemination to a systemic illness is the most life-threatening concern. We present the case of a 71-year-old man with a four-year history of idiopathic lung disease, treated with oral prednisone and mycophenolate, presents with a new onset skin rash on the right wrist. He has a history of cleaning and clearing barns and sheds after a recent storm devastated the area. Birds and bats were present in these structures while he was working. Initial therapy failed, and subsequent biopsy showed the presence of Cryptococcus yeast. Further investigation yielded a positive, low titer Cryptococcus antigen screen but negative blood cultures. This case illustrates three valuable facets of patient care. Ideally, one diagnosis will explain all of the clinical presentation, but when that is not the case then multiple etiologies must be explored. Sometimes first-line therapy is ineffective, and the clinician should not be afraid to recognize that and change course. Importantly with skin lesions, failure to respond to treatment or worsening of the lesion in the face of topical and/or oral steroids should lead one to consider the possibility of infection, particularly in an immunosuppressed patient, and prompt biopsy is prudent.
特发性肺病患者皮肤隐球菌病:相关疾病或“蜱虫和跳蚤”
隐球菌是一种酵母,通常存在于鸽子粪便等鸟类粪便中。感染可通过吸入孢子或通过直接接种到皮肤发生。通常有免疫抑制史,但在免疫能力强的宿主中也有病例报告。隐球菌可表现为肺部疾病或原发性皮肤感染,但传播到全身性疾病是最危及生命的问题。我们提出的情况下,71岁的男子有四年的特发性肺部疾病的历史,治疗与口服强的松和霉酚酸盐,提出了一个新的起病皮疹在右手腕。在最近的一场风暴摧毁了这个地区之后,他有清理谷仓和棚子的历史。在他工作的时候,这些建筑里有鸟类和蝙蝠。最初的治疗失败,随后的活检显示存在隐球菌酵母。进一步调查发现隐球菌抗原筛检呈阳性,低滴度,但血培养呈阴性。这个案例说明了病人护理的三个有价值的方面。理想情况下,一种诊断可以解释所有的临床表现,但如果情况并非如此,则必须探索多种病因。有时一线治疗是无效的,临床医生不应该害怕认识到这一点并改变治疗方案。重要的是,对于皮肤病变,局部和/或口服类固醇治疗无效或病变恶化,应考虑感染的可能性,特别是在免疫抑制的患者中,及时活检是谨慎的。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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