Rapidly Progressive Skin Lesions Requiring Admission in a Young, HIV-Infected Man

Diagnosis: Disseminated Cryptococcosis With Prominent Skin Involvement The patient’s serum cryptococcal antigen was strongly positive (titer >1:1024). After 96 hours of incubation, both blood and synovial fluid grew Cryptococcus neoformans. Cerebrospinal fluid (CSF) analysis showed no pleocytosis, and CSF cultures and cryptococcal antigen were negative. Skin biopsies revealed evidence of a granulomatous inflammation (arrow) in the dermis and subcutaneous tissue (Figure 1A). Round fungal organisms (arrowheads) were seen within the cytoplasm of histiocytes and multinucleated giant cells (Figure 1A-insert). Grocott’s methenamine silver stain demonstrated abundant budding yeasts ranging in size from 5 to 15 μm in diameter (Figure 1B). The budding cells (arrowhead) had a narrow base (Figure 1B-insert). Mucicarmine stain revealed the characteristic pink-red capsule of Cryptococcus neoformans. (Figure 2) The patient was treated with amphotericin lipid complex B and flucytosine. His highly active anti-retroviral therapy (HAART) regimen and trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis were continued. He was eventually discharged in overall better condition and with improved skin lesions, with plans to complete the induction phase of antifungal therapy with oral fluconazole. The final diagnosis was disseminated cryptococcosis with fungemia, joint and prominent skin involvement, and possible pulmonary involvement, but sparing the meninges, as well as an underlying HIV (human immunodeficiency virus) infection with a low CD4 cell count. Skin lesions in the setting of human innumodeficiency virus (HIV) infection often present a diagnostic challenge, and newly found nodules and/or ulcers can be the dermal manifestation of infectious and non-infectious diseases. Among the latter, drug reactions, neoplasms (including but not limited to Kaposi’s sarcoma), and vasculitides should be considered. Potential infectious agents include viruses such as Molluscum contagiosum, bacteria that include Treponema pallidum as well as non-tuberculous mycobacteria such as Pseudomonas Figure 1. Histology of the facial skin lesions. (A) Hematoxylin and eosin stain demonstrates granulomatous inflammation (arrow); the size bar corresponds to 100 μm. Fungal bodies (insert, arrowheads) are seen in the cytoplasm of histiocytes and giant cells. (B ) Grocott’s methenamine silver stain reveals abundant, variably sized, dark-stained, spherical yeasts. A narrow-based, budding yeast is demonstrated more clearly in the insert (arrowhead). Original magnifications, ×200 for A, ×400 for the A-insert and B, ×1000 for the B-insert. Figure 2. Mucicarmine stain. This special stain highlights the capsule of Cryptococcus neoformans in pink-red. Original magnification ×1000.