CLINICAL HISTORY:

Signs and symptoms:  A 55 year old white male who presented to our clinic with a 2 week history of a painful sore on the right post auricular region.

Previous Treatment:  None

Other information:  The patient has a past medical history of multiple non-melanoma skin cancers including five squamous cell carcinoma and six basal cell carcinomas, three of which required Mohs. He reports no other significant past medical history and is on no medications. He smokes approximately one pack per day. The patient has no medical insurance and was concerned with procedural costs. He was willing to pay for a complete excision but did not want to pay for a biopsy, since due to his history, he was convinced it was another skin cancer which needed to be removed

PHYSICAL EXAM:

Cachectic 55 year old white male with poor hygiene. Large (approx 4.3x 3.5 cm), tender, ulcerated, erythematous plaque with impetiginized crusts and purulent drainage was present around and within the right retro-auricular sulcus.

Retroauricular ulcer with impetiginized crust

LABORATORY TESTS:

None

DERMATOHISTOPATHOLOGY:

Microscopic examination revealed a dome shaped, granulomatous infiltrate of foreign body giant cells, lymphocytes, and macrophages.

Dome shaped, granulomatous infiltrate

Foreign body giant cells composed of lymphocytes, neutrophils, eosinophils and macrophages present in the dermis.

Numerous encapsulated, round to ovoid spores were present within macrophages and giant cells as well as in free spaces.

Numerous encapsulated, round to ovoid spores were present within macrophages and giant cells as well as in free spaces.

A PAS stain was performed which highlighted the spores.

PAS stain

A mucicarmine stain was positive confirming the diagnosis of cutaneous cryptococcosis

Mucicarmine stain

DIFFERENTIAL DIAGNOSIS:

1.   Squamous Cell Carcinoma
2.   Basal Cell Carcinoma
3.   Infectious
4.   Factitial/Traumatic
5.  

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Cutaneous Cryptococcosis

DISCUSSION:

Cryptococcosis is caused by the opportunistic mycosis cryptococcus neoformans. Cutaneous cryptococcosis may result from primary inoculation or from pulmonary dissemination. The latter, secondary form of cutaneous cryptococcosis commonly results from inhalation of pigeon droppings and, although may occur in immunocompetent hosts, is more common in immunocompromised patients, particularly those with AIDS. The diagnosis of primary cutaneous cryptococcosis should be made only after a thorough workup for systemic disease.
Cutaneous features vary from ulcerations to cellulitis, as well molluscum contagiosum-like lesions. Diagnosis is made by histopathologic evaluation of lesions which demonstrate characteristic capsulated yeasts. Mucicarmine or alcian blue are used to highlight the capsule as well as India ink which is used to evaluate CSF preparations in cases of cryptococcal meningitis. Disseminated disease carries a poor prognosis and is frequently fatal.

The suspicion for cutaneous cryptococcus in this particular case was low when taking into account the close clinical resemblance and the patient’s strong history of non-melanoma skin cancers. It would have been reasonable to assume the patient had a BCC or SCC and to perform a wide excision or Mohs rather than begin the correct treatment with oral antifungals. This case demonstrates the importance of preventing patient demands from taking precedent over proper diagnostic and treatment plans. Even though we must take into account patient’s financial and social needs, we must not deviate from the standard of care. Although indicated and highly suspicious in this case, our patient refused an immunocompromise workup as well a workup for systemic cryptococcosis.

TREATMENT:

Treatment for primary cutaneous cryptococcus is oral antifungal medication, most commonly fluconazole, which is also used as prophylaxis in immunocompromised patients. Surgical excision of small, localized lesions may also be performed in conjunction with antifungal treatment.

REFERENCES:

Christianson JC. Engber W. Andes D. Primary cutaneous cryptococcosis in immunocompetent and immunocompromised hosts. Medical Mycology. 41(3):177-88, 2003 Jun.
Hontanilla B. Ruiz de Erenchun R. Toledo G. Idoate M. Case report. Primary cutaneous Cryptococcosis in an immunocompetent patient: surgical management. Annals of Plastic Surgery. 47(6):683-4, 2001 Dec.
Micalizzi C. Persi A. Parodi A. Case reports. Primary cutaneous cryptococcosis in an immunocompetent pigeon keeper. Clinical & Experimental Dermatology. 22(4):195-7, 1997 Jul.
Revenga F. Paricio JF. Merino FJ. Nebreda T. Ramirez T. Martinez AM. Primary cutaneous cryptococcosis in an immunocompetent host: case report and review of the literature. Dermatology. 204(2):145-9, 2002.
Vijaya D, et al: Case report. Disseminated cutaneous cryptococcosis in an immunocompetent host. Mycoses 2001;44:113.
Yao Z, et al: Management of cryptococcoccosis in non-HIV-related patients. Med Mycol 2005;43:245.

Additional Comment:

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