BRIEF ARTICLE Primary Cutaneous Cryptococcosis Caused by Cryptococcus Neoformans in an Immunocompetent Patient

Cryptococcosis is a fungal infection caused by Cryptococcus species, most commonly affecting immunocompromised individuals, while very few cases of the infection in immunocompetent hosts are available in the literature. In this manuscript, we present a case of primary cutaneous cryptococcosis caused by Cryptococcus neoformans in an immunocompetent patient. While cutaneous manifestation is usually a secondary sign of the disseminated disease, our patient presented with primary cutaneous cryptococcosis. Additionally, reports on cryptococcosis cases suggest that immunocompetent hosts are typically infected by C. gattii . However, culture of the discharge from our immunocompetent patient showed heavy growth of C. neoformans . This case highlights the importance of considering cutaneous cryptococcosis as differential diagnosis of ulcerated skin lesions in patients with an exposure to bird droppings, regardless of their immune status and systemic manifestations.

Cutaneous cryptococcosis can present with a variety of skin manifestations.6][7][8] Primary cutaneous cryptococcosis typically presents with solitary skin lesions (often nodules that ulcerate) in exposed body areas. 567-year-old woman presented with a 6month history of localized papules and

ABSTRACT
Cryptococcosis is a fungal infection caused by Cryptococcus species, most commonly affecting immunocompromised individuals, while very few cases of the infection in immunocompetent hosts are available in the literature.In this manuscript, we present a case of primary cutaneous cryptococcosis caused by Cryptococcus neoformans in an immunocompetent patient.While cutaneous manifestation is usually a secondary sign of the disseminated disease, our patient presented with primary cutaneous cryptococcosis.Additionally, reports on cryptococcosis cases suggest that immunocompetent hosts are typically infected by C. gattii.However, culture of the discharge from our immunocompetent patient showed heavy growth of C. neoformans.This case highlights the importance of considering cutaneous cryptococcosis as differential diagnosis of ulcerated skin lesions in patients with an exposure to bird droppings, regardless of their immune status and systemic manifestations.

INTRODUCTION CASE REPORT
plaques on her back.Upon review of systems, there was no fever, night sweats, pain, or cough.Her past medical history was unremarkable and she had no known history of malignancy, immunodeficiency, or immunosuppression.A more detailed history led to the revelation of exposure to pigeon droppings as she fed pigeons inside her New York home about one year prior to the onset of her skin lesions.In addition, a previous roommate several years prior had kept pet birds inside the patient's home.The physical examination revealed four ulcerated papules and plaques, some of which drained a purulent discharge on her left lower back (Figure 1).No similar lesions were found on other parts of the body.No relevant underlying disease was noted during physical examination.A shave biopsy of the ulcer margin was obtained and the histopathologic examination revealed variably-sized yeast-like organisms surrounded by clear capsules and granulomatous infiltrate (Figures 2 and 3).The organisms stained with PAS-D, GMS, Fontana-Masson, and a mucicarmine.Histologic findings were consistent with cryptococcosis.Culture of the discharge showed heavy growth of Cryptococcus neoformans.
Given an absence of systemic signs and symptoms and a negative chest X-ray, the diagnosis of primary cutaneous cryptococcosis was made.The patient was treated with oral fluconazole with complete resolution of her skin lesions.There was no recurrence of lesions or evidence of dissemination during the four months of follow-up.
Cryptococcosis most commonly affects pulmonary and central nervous systems, manifesting as pneumonia and meningoencephalitis. 3,9 Patients generally become infected with pulmonary cryptococcosis after inhaling the yeast basidiospores, usually from contaminated soil, bird or bat droppings. 7,9Meningoencephalitis may occur with secondary spread of the infection to the central nervous system. 47]10 Primary cutaneous infection may be caused by direct inoculation of the fungus into the skin by a contaminated object and is characterized by skin lesions with positive culture in the absence of systemic disease. 4,5,10In our case, the cutaneous manifestation of localized lesions, histopathological findings, positive culture  results, absence of fever, negative systemic workup, and excellent response to antifungal therapy support the diagnosis of primary cutaneous cryptococcosis, which is a rare condition recognized as a distinct clinical entity. 7,8ports on cryptococcosis cases suggest that C. neoformans commonly causes infection mainly in immunocompromised patients, while C. gattii variant usually affects immunocompetent hosts.Therefore, physicians should consider cutaneous cryptococcosis in their differential diagnosis of ulcerated skin lesions in patients with an exposure to bird droppings, regardless of their immune status.

Figure 1 .
Figure 1.Clinical photograph of ulcerated papules on the left lower back.

DISCUSSIONFigure 2 .
Figure 2. Hematoxylin-eosin-stained biopsy specimen of ulcer margin showing variably sized yeast-like organisms surrounded by clear capsules and granulomatous infiltrate within the dermis.