Primary Cutaneous Cryptococcosis in an Immunocompetent Iraq War Veteran

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Primary Cutaneous Cryptococcosis in an Immunocompetent Iraq War Veteran

To the Editor:

Disseminated cryptococcosis is a well-known opportunistic infection in patients with advanced human immunodeficiency virus (HIV) infection, but it is not frequently seen as a primary infection of the skin in immunocompetent hosts. We report a case of primary cutaneous cryptococcosis (PCC) of the lower legs in an immunocompetent Iraq War veteran.

A 28-year-old female service member presented to the dermatology clinic with progressively enlarging plaquelike lesions on the shins of 6 months’ duration. The patient had resided and worked as a deployed soldier in the lower level of a bullet hole–laden, pigeon-infested observation tower in southern Iraq 9 months prior to the current presentation. During her 7-month deployment, she reported daily exposure to pigeon excreta on equipment and frequently sustained superficial abrasions and lacerations to the legs due to the cramped and hazardous working environment. The patient noticed intensely pruritic, bugbitelike papular lesions on the shins and calves 1 month after residing in the observation tower. She sought medical treatment and was given hydrocortisone cream 1% and calamine lotion for a presumed irritant dermatitis. Over the ensuing 3 months, the pruritus worsened, and the primary lesions coalesced into annular erythematous plaques (Figure).

Figure1
Annular, confluent, erythematous plaques on the posterior right calf 5 months after onset of primary cutaneous cryptococcosis (A and B).

After returning to the United States, the patient presented again for medical care and was given ketoconazole cream 1% for presumed tinea corporis, which resulted in no improvement. A dermatologic consultation and evaluation ensued with subsequent microbial workup showing no bacterial growth on wound culture and no fungal elements on a potassium hydroxide preparation. Hematoxylin and eosin, periodic acid–Schiff, and Grocott-Gomori methenamine-silver staining did not demonstrate any organisms. Tissue cultures for bacteria and acid-fast bacilli showed no growth. A fungal tissue culture ultimately confirmed the presence of Cryptococcus neoformans. A lumbar puncture showed no evidence of Cryptococcus on DNA probe testing. Serologic testing for HIV was negative, and brain magnetic resonance imaging showed no lesions. Sputum culture and staining showed no fungal elements, and a chest radiograph was normal. A diagnosis of PCC was made and therapy with oral fluconazole 200 mg twice daily was initiated, with the intention of completing a 6-month course. During the treatment, the pruritus resolved within 3 weeks and the lesions involuted over 3 months. From the time of onset of the lesions throughout treatment, the patient showed no pulmonary, neurologic, or other systemic symptoms. She currently is healthy with no evidence of recurrence.

Primary cutaneous cryptococcosis mainly affects individuals with underlying immunosuppression, most commonly due to advanced HIV, prolonged treatment with immunosuppressive medications, or organ transplantation.1 The most common route of inoculation is by inhalation of Cryptococcus spores with subsequent hematogenous dissemination.2 Primary cutaneous cryptococcosis with skin lesions and no concomitant systemic involvement has rarely been reported, and when encountered, it usually is associated with environments that predispose patients to skin wounds with simultaneous exposure to soil or vegetative debris contaminated with bird excreta.3 Primary cutaneous cryptococcosis can present in a myriad of ways, including papules, nodules, plaques, and even necrotizing fasciitis–like skin lesions.4,5 This variable presentation often creates clinical confusion and diagnostic delay; therefore, a high index of suspicion is required for timely diagnosis.

Due to the worldwide deployment of US military service members, exotic cutaneous infectious diseases such as PCC may be encountered in dermatology practice. Prompt clinical and histologic diagnosis is imperative to assess for systemic disease and avoid cutaneous spread and morbidity in US service members and travelers returning home from the Middle East.

References
  1. Antony SA, Antony SJ. Primary cutaneous Cryptococcus in nonimmunocompromised patients. Cutis. 1995;56:96-98.
  2. Mirza SA, Phelan M, Rimland D, et al. The changing epidemiology of cryptococcosis: an update from population-based active surveillance in 2 large metropolitan areas, 1992-2000. Clin Infect Dis. 2003;36:789-94.
  3. Kielstein P, Hotzel H, Schmalreck A, et al. Occurrence of Cryptococcus spp. in excreta of pigeons and pet birds. Mycoses. 2000;43:7-15.
  4. Leão CA, Ferreira-Paim K, Andrade-Silva L, et al. Primary cutaneous cryptococcosis caused by Cryptococcus gattii in an immunocompetent host [published online October 28, 2010]. Med Mycol. 2011;49:352-355.
  5. Zorman JV, Zupanc TL, Parac Z, et al. Primary cutaneous cryptococcosis in a renal transplant recipient: case report. Mycoses. 2010;53:535-537.
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Dr. Twede is from the Department of Dermatology, Evans Army Community Hospital, Fort Carson, Colorado. Dr. Peters is from the Department of Dermatology, Madigan Army Medical Center, Tacoma, Washington.

The authors report no conflict of interest.The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Military.

Correspondence: Kristopher M. Peters, DO, Madigan Army Medical Center, Department of Dermatology, 9040 Jackson Ave, Tacoma, WA 98431 (kristopher.m.peters.mil@mail.mil).

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Dr. Twede is from the Department of Dermatology, Evans Army Community Hospital, Fort Carson, Colorado. Dr. Peters is from the Department of Dermatology, Madigan Army Medical Center, Tacoma, Washington.

The authors report no conflict of interest.The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Military.

Correspondence: Kristopher M. Peters, DO, Madigan Army Medical Center, Department of Dermatology, 9040 Jackson Ave, Tacoma, WA 98431 (kristopher.m.peters.mil@mail.mil).

Author and Disclosure Information

Dr. Twede is from the Department of Dermatology, Evans Army Community Hospital, Fort Carson, Colorado. Dr. Peters is from the Department of Dermatology, Madigan Army Medical Center, Tacoma, Washington.

The authors report no conflict of interest.The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Military.

Correspondence: Kristopher M. Peters, DO, Madigan Army Medical Center, Department of Dermatology, 9040 Jackson Ave, Tacoma, WA 98431 (kristopher.m.peters.mil@mail.mil).

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To the Editor:

Disseminated cryptococcosis is a well-known opportunistic infection in patients with advanced human immunodeficiency virus (HIV) infection, but it is not frequently seen as a primary infection of the skin in immunocompetent hosts. We report a case of primary cutaneous cryptococcosis (PCC) of the lower legs in an immunocompetent Iraq War veteran.

A 28-year-old female service member presented to the dermatology clinic with progressively enlarging plaquelike lesions on the shins of 6 months’ duration. The patient had resided and worked as a deployed soldier in the lower level of a bullet hole–laden, pigeon-infested observation tower in southern Iraq 9 months prior to the current presentation. During her 7-month deployment, she reported daily exposure to pigeon excreta on equipment and frequently sustained superficial abrasions and lacerations to the legs due to the cramped and hazardous working environment. The patient noticed intensely pruritic, bugbitelike papular lesions on the shins and calves 1 month after residing in the observation tower. She sought medical treatment and was given hydrocortisone cream 1% and calamine lotion for a presumed irritant dermatitis. Over the ensuing 3 months, the pruritus worsened, and the primary lesions coalesced into annular erythematous plaques (Figure).

Figure1
Annular, confluent, erythematous plaques on the posterior right calf 5 months after onset of primary cutaneous cryptococcosis (A and B).

After returning to the United States, the patient presented again for medical care and was given ketoconazole cream 1% for presumed tinea corporis, which resulted in no improvement. A dermatologic consultation and evaluation ensued with subsequent microbial workup showing no bacterial growth on wound culture and no fungal elements on a potassium hydroxide preparation. Hematoxylin and eosin, periodic acid–Schiff, and Grocott-Gomori methenamine-silver staining did not demonstrate any organisms. Tissue cultures for bacteria and acid-fast bacilli showed no growth. A fungal tissue culture ultimately confirmed the presence of Cryptococcus neoformans. A lumbar puncture showed no evidence of Cryptococcus on DNA probe testing. Serologic testing for HIV was negative, and brain magnetic resonance imaging showed no lesions. Sputum culture and staining showed no fungal elements, and a chest radiograph was normal. A diagnosis of PCC was made and therapy with oral fluconazole 200 mg twice daily was initiated, with the intention of completing a 6-month course. During the treatment, the pruritus resolved within 3 weeks and the lesions involuted over 3 months. From the time of onset of the lesions throughout treatment, the patient showed no pulmonary, neurologic, or other systemic symptoms. She currently is healthy with no evidence of recurrence.

Primary cutaneous cryptococcosis mainly affects individuals with underlying immunosuppression, most commonly due to advanced HIV, prolonged treatment with immunosuppressive medications, or organ transplantation.1 The most common route of inoculation is by inhalation of Cryptococcus spores with subsequent hematogenous dissemination.2 Primary cutaneous cryptococcosis with skin lesions and no concomitant systemic involvement has rarely been reported, and when encountered, it usually is associated with environments that predispose patients to skin wounds with simultaneous exposure to soil or vegetative debris contaminated with bird excreta.3 Primary cutaneous cryptococcosis can present in a myriad of ways, including papules, nodules, plaques, and even necrotizing fasciitis–like skin lesions.4,5 This variable presentation often creates clinical confusion and diagnostic delay; therefore, a high index of suspicion is required for timely diagnosis.

Due to the worldwide deployment of US military service members, exotic cutaneous infectious diseases such as PCC may be encountered in dermatology practice. Prompt clinical and histologic diagnosis is imperative to assess for systemic disease and avoid cutaneous spread and morbidity in US service members and travelers returning home from the Middle East.

To the Editor:

Disseminated cryptococcosis is a well-known opportunistic infection in patients with advanced human immunodeficiency virus (HIV) infection, but it is not frequently seen as a primary infection of the skin in immunocompetent hosts. We report a case of primary cutaneous cryptococcosis (PCC) of the lower legs in an immunocompetent Iraq War veteran.

A 28-year-old female service member presented to the dermatology clinic with progressively enlarging plaquelike lesions on the shins of 6 months’ duration. The patient had resided and worked as a deployed soldier in the lower level of a bullet hole–laden, pigeon-infested observation tower in southern Iraq 9 months prior to the current presentation. During her 7-month deployment, she reported daily exposure to pigeon excreta on equipment and frequently sustained superficial abrasions and lacerations to the legs due to the cramped and hazardous working environment. The patient noticed intensely pruritic, bugbitelike papular lesions on the shins and calves 1 month after residing in the observation tower. She sought medical treatment and was given hydrocortisone cream 1% and calamine lotion for a presumed irritant dermatitis. Over the ensuing 3 months, the pruritus worsened, and the primary lesions coalesced into annular erythematous plaques (Figure).

Figure1
Annular, confluent, erythematous plaques on the posterior right calf 5 months after onset of primary cutaneous cryptococcosis (A and B).

After returning to the United States, the patient presented again for medical care and was given ketoconazole cream 1% for presumed tinea corporis, which resulted in no improvement. A dermatologic consultation and evaluation ensued with subsequent microbial workup showing no bacterial growth on wound culture and no fungal elements on a potassium hydroxide preparation. Hematoxylin and eosin, periodic acid–Schiff, and Grocott-Gomori methenamine-silver staining did not demonstrate any organisms. Tissue cultures for bacteria and acid-fast bacilli showed no growth. A fungal tissue culture ultimately confirmed the presence of Cryptococcus neoformans. A lumbar puncture showed no evidence of Cryptococcus on DNA probe testing. Serologic testing for HIV was negative, and brain magnetic resonance imaging showed no lesions. Sputum culture and staining showed no fungal elements, and a chest radiograph was normal. A diagnosis of PCC was made and therapy with oral fluconazole 200 mg twice daily was initiated, with the intention of completing a 6-month course. During the treatment, the pruritus resolved within 3 weeks and the lesions involuted over 3 months. From the time of onset of the lesions throughout treatment, the patient showed no pulmonary, neurologic, or other systemic symptoms. She currently is healthy with no evidence of recurrence.

Primary cutaneous cryptococcosis mainly affects individuals with underlying immunosuppression, most commonly due to advanced HIV, prolonged treatment with immunosuppressive medications, or organ transplantation.1 The most common route of inoculation is by inhalation of Cryptococcus spores with subsequent hematogenous dissemination.2 Primary cutaneous cryptococcosis with skin lesions and no concomitant systemic involvement has rarely been reported, and when encountered, it usually is associated with environments that predispose patients to skin wounds with simultaneous exposure to soil or vegetative debris contaminated with bird excreta.3 Primary cutaneous cryptococcosis can present in a myriad of ways, including papules, nodules, plaques, and even necrotizing fasciitis–like skin lesions.4,5 This variable presentation often creates clinical confusion and diagnostic delay; therefore, a high index of suspicion is required for timely diagnosis.

Due to the worldwide deployment of US military service members, exotic cutaneous infectious diseases such as PCC may be encountered in dermatology practice. Prompt clinical and histologic diagnosis is imperative to assess for systemic disease and avoid cutaneous spread and morbidity in US service members and travelers returning home from the Middle East.

References
  1. Antony SA, Antony SJ. Primary cutaneous Cryptococcus in nonimmunocompromised patients. Cutis. 1995;56:96-98.
  2. Mirza SA, Phelan M, Rimland D, et al. The changing epidemiology of cryptococcosis: an update from population-based active surveillance in 2 large metropolitan areas, 1992-2000. Clin Infect Dis. 2003;36:789-94.
  3. Kielstein P, Hotzel H, Schmalreck A, et al. Occurrence of Cryptococcus spp. in excreta of pigeons and pet birds. Mycoses. 2000;43:7-15.
  4. Leão CA, Ferreira-Paim K, Andrade-Silva L, et al. Primary cutaneous cryptococcosis caused by Cryptococcus gattii in an immunocompetent host [published online October 28, 2010]. Med Mycol. 2011;49:352-355.
  5. Zorman JV, Zupanc TL, Parac Z, et al. Primary cutaneous cryptococcosis in a renal transplant recipient: case report. Mycoses. 2010;53:535-537.
References
  1. Antony SA, Antony SJ. Primary cutaneous Cryptococcus in nonimmunocompromised patients. Cutis. 1995;56:96-98.
  2. Mirza SA, Phelan M, Rimland D, et al. The changing epidemiology of cryptococcosis: an update from population-based active surveillance in 2 large metropolitan areas, 1992-2000. Clin Infect Dis. 2003;36:789-94.
  3. Kielstein P, Hotzel H, Schmalreck A, et al. Occurrence of Cryptococcus spp. in excreta of pigeons and pet birds. Mycoses. 2000;43:7-15.
  4. Leão CA, Ferreira-Paim K, Andrade-Silva L, et al. Primary cutaneous cryptococcosis caused by Cryptococcus gattii in an immunocompetent host [published online October 28, 2010]. Med Mycol. 2011;49:352-355.
  5. Zorman JV, Zupanc TL, Parac Z, et al. Primary cutaneous cryptococcosis in a renal transplant recipient: case report. Mycoses. 2010;53:535-537.
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Practice Points

  • Disseminated cryptococcosis is not commonly seen as a primary cutaneous infection in immunocompetent hosts.
  • When encountered, primary cutaneous cryptococcosis (PCC) usually is associated with environments that predispose patients to skin wounds with simultaneous exposure to soil or vegetative debris contaminated with bird excreta.
  • The variable presentation of PCC can cause clinical confusion and diagnostic delay; therefore, a high index of suspicion is required for timely diagnosis, particularly in US service members and travelers returning home from endemic areas.
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