PMC4332984_01
Primary cutaneous cryptococcosis of the right forearm. Progressive skin changes documented at the initial visit to the emergency department on the third day of symptoms (a), during hospitalization (b-c), and at postdischarge clinic follow-up (d). White arrows denote the outlines of the region of erythema marked on each respective day prior to presentation (i.e., Days 1-3). Fluconazole was initiated along with two interrupted doses of amphotericin on Day 3. Broad-spectrum antibacterial therapy with vancomycin and piperacillin-tazobactam (Day 5-Day 7), ampicillin-sulbactam (Day 8-Day 10), and amoxicillin-clavulanate (Day 11-Day 17) was also administered. (e) Wound improvement seen on one-week follow-up in clinic. The gram stain (f) from fluid expressed on Day 5 demonstrated abundant variably sized encapsulated spherical yeast forms (*) that were identified as C. neoformans on blood agar.
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Despite the change in antibiotic therapy, the erythema continued to expand prompting a visit to the ED (Figure 1(a)). Physical examination revealed a single 7 cm painful bulla with surrounding erythema that extended proximal to the elbow (Figure 1(b)). The expressed fluid gram stain revealed yeast forms and no bacteria (Figure 1(f)). The patient's wound improved remarkably over the course of his hospital stay with near resolution of the surrounding erythema and edema (Figure 1(d)). At a one-week follow-up visit, his wound showed great improvement (Figure 1(e)).
Healed right forearm lesion 6 months after symptom onset and at the conclusion of fluconazole therapy. The patient was seen in clinic 6 months after symptom onset and towards the end of the planned 6-month course of fluconazole therapy. Skin pigmentation changes remained, but the ulcer was entirely healed and there was no pain or evidence of subcutaneous involvement. Follow-up clinical evaluation was notable for the absence of systemic symptoms and serial serum cryptococcal antigen remained negative.
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He was last seen near completion of his fluconazole therapy (more than 6 months from symptom onset) without signs of relapse (Figure 2).