bony involvement is extremely rare and most common site is vertebrae and usual presentation is monofocal . we present 18-year - old male with bifocal osteomyelitis of scapula and tibia in immunocompetent male . cryptococcal osteomyelitis should be kept as a differential diagnosis in a patient as a primary diagnosis to avoid diagnostic delay and morbidity associated with it . the most common clinical presentation of this organism is meningitis , but involvement of bone has been reported in 10% of cases as part of a systemic infection . we describe a case of osteomyelitis due to c. neoformans involving both scapula and tibia in an immune - competent and previously healthy patient . the clinical and radiological features of osseous cryptococcosis are non - specific and are similar to those of tuberculosis ( tb ) . an 18-year - old male presented to us with the complaint of pain and swelling around the right scapula since 20 days , which was gradually increasing in size and developed fever since 2 days . on history , patient was on akt for pulmonary tb since 6 months which was diagnosed based on clinical history of a cough and chest x - ray finding and blood report showing raised erythrocyte sedimentation rate ( esr ) ; sputum examination was normal . considering it as possible tubercular swelling akt was continued but after 3 days patient also developed left ankle swelling and pain difficulty in walking . repeat blood investigation was done and magnetic resonance imaging ( mri ) of both right shoulder and left ankle was done ( fig . 1 , 2 , 3 ) . blood investigation showed raised esr 73 mm , c - reactive protein ( crp ) positive 96 . we aspirated swelling and sent for culture and sensitivity and histopathology considering it as possible multi drug resistant ( mdr ) tb . cd4 percentage 16% ( normal = 27 - 51% ) and absolute 345 ( normal = 448 - 1611 cells / ul ) . sagittal t1 image magnetic resonance imaging of right lower end tibia showing intensity ( hypointense ) changes of the lower end tibia and sequestrum at the metaphyseal region . sagittal stir image of right lower end tibia showing hyperintensity changes suggestive of inflammation of metaphysis . the patient was taken for surgery of debridement saucerization and bone grafting of dead space for tibia and debridement of scapular swelling and removal of loose fragments . patient was started on amphotericin b injection and tab flucytosine for 14 days and on fluconazole for maintenance phase for 9 months . the vertebrae have been reported as the most common bony site for disease [ 5 , 6 ] , especially affecting the femur , tibia , rib , and humerus . it has been documented that 75% of patients had only one single site of bone involvement . the scapula is a less frequent target , with only four previously reported cases [ 6 , 7 ] . no cases of osteomyelitis due to c. neoformans involving both scapula and tibia simultaneously have been reported in the literature . most patients with cryptococcal osteomyelitis present with soft tissue swelling and tenderness . in the setting of symptoms and signs , cryptococcal osteomyelitis can be diagnosed by radiological features , antigen detection , typical features on histopathologic examination , and culture of the organism . however , there is often a delay in the diagnosis partly because radiological image usually lags behind the clinical findings by weeks or months . the current guidelines of the infectious diseases society of america recommend amphotericin b based combination treatment with flucytosine as induction therapy for disseminated cryptococcosis ( at least two non - contiguous sites involvement ) followed by consolidation and maintenance therapy with fluconazole . for cryptococcal osteomyelitis occurring at single site in immunocompetent patients without , central nervous system involvement , fluconazole treatment ( 400 mg / day ) could be considered [ 1 , 7 ] . because there have not been substantial specific studies , it depends on the severity of infection , the response to therapy and the patient s immune status . although unusual , it should be part of the differential diagnosis to be considered in any patient with osteolytic lesions on radiological images , even in an immunocompetent patient . early recognition of cryptococcal osteomyelitis and administration of appropriate antifungal therapy have a great impact on the successful outcome . in developing countries like india where tb is the leading cause of any infection like osteomyelitis , we should keep other differential diagnoses like cryptococcus in our case some other cause and mdr tb back of the mind . and should insist on biopsy before starting long course of treatment and when standard akt does not show the result .
introduction : cryptococcus neoformans commonly affects lungs and central nervous system that to in immunocompromised individual . 
 bony involvement is extremely rare and most common site is vertebrae and usual presentation is monofocal.case report : we present 18-year - old male with bifocal osteomyelitis of scapula and tibia in immunocompetent male.conclusion:cryptococcal osteomyelitis should be kept as a differential diagnosis in a patient as a primary diagnosis to avoid diagnostic delay and morbidity associated with it .