Cryptococcal Cellulitis in a Diabetic with Nephropathy on Adalimumab Therapy for Rheumatoid Arthritis

Cutaneous infection with Cryptococcus neoformans is rare but can occur in the setting of rheumatoid arthritis due to immunosuppression. Risk factors include chronic kidney disease and use of tumor necrosis factor-alpha (TNF-α) inhibitor adalimumab. We report the fourth case of primary cutaneous cryptococcosis (PCC) in a diabetic female more than 60 years old living in rural Northwest Tennessee and taking adalimumab for rheumatoid arthritis. In a literature review of existing cases, this is the second case involving simultaneous chronic kidney disease and the first case in a diabetic and following extended TNF-α inhibitor immunosuppression monotherapy. Physicians should consider cryptococcal infection in a patient who develops cellulitis that is unresponsive to empiric therapy. In addition, it is imperative to monitor rheumatoid arthritis patients taking adalimumab closely and consider alternative agents in those with pre-existing immunosuppression or known risk factors for opportunistic infections as primary prevention.