Dermatology Online Journal

Cutaneous cryptococcosis of the penis
Donato Calista MD¹, Carmela Grosso MD²
Dermatology Online Journal 14 (7): 9

1. Dermatology Unit, M Bufalini Hospital, Cesena, Italy. dcalista@ausl-cesena.emr.it
2. Infectious Disease Unit, M Bufalini Hospital, Cesena, Italy

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Abstract

Disseminated cryptococcosis is a well-known opportunistic infection in AIDS patients. We report an unusual patient who demonstrated an isolated plaque of cryptococcosis on the penis. Resolution of this plaque was obtained after treatment with fluconazole, but subsequent cutaneous dissemination occurred that was responsive to amphotericin B.

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Case synopsis

A 39-year-old AIDS patient presented with a tender, oval plaque, 2x3 mm in diameter, on the ventral aspect of his preputium (Fig. 1). He reported that the lesion had appeared 2 weeks earlier. The patient was afebrile and in good general condition. He firmly denied any at-risk sexual behavior in the previous 3 months. The inguinal lymph nodes were unremarkable and the patient's immunologic test results were as follows: total leukocyte count 7400/mm³ CD4+ cells 78/mm³ (3.6%); CD8+ cells 1966/mm³ (90.4%); CD4+/CD8+ ratio 0.04 (normal ratio 1-2); HIV viremia: 198.294 copies/ml (Branched). At the time of our first observation he was taking stavudine (40mgx2/day), lamivudine (150 mgx2/day), lopinavir/ritonavir 3+2 cp/day.

Figure 1	Figure 2
Figure 1. Firm plaque of the ventral aspect of the preputium Figure 2. Numerous organisms with large, polysaccharide capsules

The penile plaque was biopsied and histopathologic examination showed numerous organisms with large, polysaccharide capsules, surrounded by granulomatous inflammation of the superficial and mid-dermis (Fig. 2). On the basis of histopathological findings a diagnosis of cutaneous cryptoccoccosis was made.

Chest X-ray, abdominal ultrasonography, and CT scan of the cranium were unremarkable. Although the cryptococcal antigen was not detectable in serum, the patient started therapy with fluconazole 400 mg/day. The preputial lesion healed in 10 days, but on day 14, while he was still under antimycotic therapy, multiple, dome-shaped, flesh-colored, umbilicated papules and ulcerated nodules appeared on the face and the dorsal aspect of the patient's hands. A second punch biopsy of one of these latter lesions was obtained, and the histopathologic examination confirmed the clinical suspicion of disseminated cryptococcosis. Cryptococcal antigen was now detectable in the patient's serum at a titer of 1:1256. Fluconazole was discontinued and intravenous liposomial amphotericin B, 3 mg/kg/day, was begun. The lesions completely healed over the following 2 weeks and the patient was discharged after 6 weeks of treatment. At a follow up of 10 months there was no relapse of the disease.

Cutaneous cryptococcosis is a rare infection caused by Cryptococcus neoformans, an encapsulated yeast, 4-8 μm in diameter, surrounded by a polysaccharide capsule. Cryptococcus neoformans is a saprophyte found in dust and soil contaminated by the excreta of pigeons [1].

Over the past 2 decades, almost 90 percent of cases of cryptococcosis have developed in patients in the late stages of HIV disease. Less frequently, the disease can be diagnosed in other immunosuppressed patients or in immunocompetent hosts exposed to pigeon droppings [2, 3, 4]. Infection in humans is mainly the result of inhalation and occasionally penetration of the yeast through the skin. Primary pulmonary infection is usually asymptomatic. When symptomatic, the course of the disease may range from a mild, self-limited influenza-like illness to severe pneumonia [4]. Cryptococcus neoformans may spread hematogenously to any organ of the human body producing life-threatening diseases such as meningo-encephalitis, hepatitis, pericarditis, endocarditis, or prostatitis, endophthalmitis, and renal abscesses [5, 6]. Cutaneous manifestations occur in about 15 percent of cases. Typical clinical cutaneous manifestations are multiple, discrete, flesh-to-red colored umbilicated papules resembling molluscum contagiosum. Less often, violaceous papules, vesicles, crusted plaques, or subcutaneous nodules appear, mimicking a variety of dermatological diseases such as Kaposi's sarcoma, basal cell carcinoma, cellulitis or acneiform lesions, or varicella [2, 3]. The widespread use of HAART has led to a marked reduction in the rate of cryptococcosis associated with HIV disease. Now, with the onset of drug resistance and longer life expectancy, cryptococcosis is returning as a significant cause of morbidity and mortality in western countries. The prognosis of cryptococcosis depends on the degree of the patient's immunosuppression, the involvement of CNS, and time to onset of treatment [3-6]. The case presented herein is instructive for its deceptive and unusual clinical presentation. In addition, the sentinel lesion preceded the spread of the cryptococcal infection by 2 weeks, which occurred even during systemic antimycotic therapy.

References

1. Wai FN, Ka TL. Cutaneous cryptococosis-primary versus secondary disease. Report of two cases and review of literature. Am J Dermatopathol 1993;15:372-7.

2. Murakawa GJ, Kershmann R, Berger T. Cutaneous cryptococcus infection and AIDS. Report of 12 cases and review of literature. Arch Dermatol 1996;132:545-8. PubMed

3. Calista D, Stagno A, Landi C. Cutaneous lesions of disseminated cryptococcosis as the initial presentation of advanced HIV infection. J Eur Acad Dermatol 1997;8:140-44.

4. Van Griek SA, Dupont LJ, Van Raemdonck DE, Van Bleyenbergh P, Verleden GM. Primary cryptococcal cellulitis in a lung transplant recipient. J Heart Lung Transplant 2007;26:285-9. PubMed

5. Sarosi GA, Siberfarb PM, Tosh FE: Cutaneous cryptococcosis a sentinel of disseminated disease. Arch Dermatol 1971;104:1-3. PubMed

6. Sing Y, Ramdial PK. Cryptococcal inflammatory pseudotumors. Am J Surg Pathol 2007;31:1521-7. PubMed

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