Track

Abstract

A 77-year-old man with history of diabetes, prostate cancer, hypertension, and renal transplantation on mycophenolate mofetil, tacrolimus, and prednisone presented for a one year history of chronic left leg ulcers presumed to be secondary to peripheral arterial disease. Despite diligent wound care and hyperbaric oxygen therapy, the ulcers had not improved. A punch biopsy from the left lower leg revealed sheets of pleomorphic yeast forms with thin walls and narrow-based budding consistent with cryptococcus.  Yeast forms were highlighted by GMS and a mucicarmine stain highlighted a mucinous capsule.  Tissue culture identified C. neoformans and lumbar puncture revealed high opening pressure, yeast, and cryptococcal antigen titer of 1:1280.  Upon hospitalization, the patient complained of headaches over the past several days. He received amphotericin and flucytosine for 14 days with fluconazole as consolidation treatment with improvement in his headache and ulcerations. Cutaneous cryptococcosis occurs as an opportunistic infection in immunocompromised patients and is caused by the species C. neoformans or C. gatti, both of which are ubiquitous in nature.  Various clinical presentations have been described including nodules, papules, cellulitis, erythema-nodosum type lesions, and ulcers similar to pyoderma gangrenosum. This case emphasizes the importance of biopsy in the evaluation of chronic, non-healing wounds, particularly in immunocompromised patients. Histopathology and culture are essential diagnostic tools for early identification and can significantly improve patient outcomes.