Abstract:

A 58-year-old male with a history of renal transplant on immunosuppression presented with recalcitrant cellulitis of the left hand. He previously completed multiple courses of broad-spectrum antibiotics without significant improvement in his rash. Physical examination revealed edema of the left hand extending to the wrist with focal crust over the lateral left 5th digit and a tense pustule over the ventral 1st digit. Imaging was not concerning for osteomyelitis. Punch biopsy with hematoxylin and eosin stain revealed neutrophilic and lymphocytic inflammation with gelatinous and refractile spherical structures within empty spaces. Additional studies with Grocott’s methenamine silver stain, fungal tissue culture, and serum cryptococcus antigen were consistent with a diagnosis of cellulitis secondary to Cryptococcus neoformans. The patient was started on amphotericin B and flucytosine then transitioned to oral fluconazole for a prolonged treatment course of roughly 1 year. Immunosuppressed patients can have unique clinical presentations, and atypical organisms should be suspected when patients do not respond as expected to empiric antibiotics. This case represents the utility of performing further diagnostic procedures when patients do not respond as expected to standard therapies.

Financial Disclosure:
No current or relevant financial relationships exist.

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Robert Borucki, MD