Abstract

Lower extremity cellulitis is an infrequent presenting symptom of disseminated cryptococcosis which poses a serious health risk to immunocompromised individuals. For renal transplant recipients, this infection also carries an increased risk of graft failure due to standardized treatment with nephrotoxic agents. We report a case of a 65-year-old renal transplant recipient who presented with persistent right lower extremity (RLE) cellulitis with no other symptoms following treatment with intravenous antibiotics at an outside hospital. Blood cultures from the outside hospital grew Cryptococcus Neoformans which we confirmed on repeat culture. A skin biopsy and tissue culture of the RLE cellulitis was requested and confirmed the presence of cryptococcal cellulitis. Further evaluation revealed multiple lung nodules, hilar lymphadenopathy, and no central nervous system involvement. Treatment with reduced immunosuppression, liposomal amphotericin B and flucytosine were completed and the patient discharged on fluconazole consolidation and maintenance therapy with an initial good response. Over the next five months the patient was hospitalized three times: once for antibiotic-associated Clostridium Difficile, another for recurrent, biopsy-proven cryptococcal cellulitis without fungemia, and a third admission at an outside hospital for relapsed disseminated cryptococcosis felt to represent fluconazole resistance. The patients’ renal graft failed during their last admission requiring transition to dialysis. Their cryptococcosis was stabilized with posaconazole maintenance therapy and they are currently pursuing repeat transplant. Our case highlights the importance of having high suspicion for cutaneous cryptococcosis in renal transplant recipients in order to optimize antimicrobial selection and subsequently minimize the risk of graft failure.