Disseminated Cryptococcosis
A 49-year-old woman presented to the emergency department with a 2-week history of headache, dizziness, and pruritic rash. She had undergone kidney transplantation for focal segmental glomerulosclerosis 4 months earlier. Her medications included prednisone, mycophenolate mofetil, and tacrolimus. Physical examination revealed diffuse, umbilicated, pink papules with crusting on her face (Panel A), trunk, arms, and legs. On lumbar puncture, the opening pressure was 22 cm of water (reference range, 6 to 25). India ink staining of the cerebrospinal fluid showed encapsulated budding yeast. Cryptococcal antigen titers of the serum and cerebrospinal fluid were 327,680 U and 20,480 U, respectively (reference range, <2). Cryptococcus neoformans was grown on culture of the cerebrospinal fluid. A biopsy specimen of the skin obtained from the patient’s left arm showed numerous yeastlike organisms surrounded by mucinous capsules (Panel B), confirming a diagnosis of disseminated cryptococcosis. In immunocompromised patients, umbilicated skin lesions may represent cryptococcal infection. Treatment with liposomal amphotericin B and flucytosine was initiated, and the cutaneous and central nervous system symptoms resolved.
