Cutaneous Cryptococccosis Due to Cryptococcus gattii in Immunocompetent Hosts: Case Report and Review

Cutaneous cryptococcosis caused by C. gattii, in immunocompent patients is a rare manifestation of disease, and may be one of the first manifestations of disseminated cryptococcosis. We report a case of disseminated cryptococcosis caused by Cryptococcus gattii presenting as cutaneous lesions in an immunocompetent patient. Previously to our report, only five cases of cutaneous involvement by Cryptococcus gattii in immunocompetent patients have been reported in the literature. Risk factors for C. gattii infection included exposure to the eucalypt reservoirs in tropical and subtropical areas. Skin involvement corresponded to the disseminated form of cryptococcosis in the majority of patients, and commonly affected the face and neck with different morphologies including papules, pustules, plaques, ulcers, subcutaneous masses, cellulitis or acneiform lesions. Due to the severity of this infection and the life threatening condition that it represents, clinicians must be aware that cutaneous involvement may be one of the first manifestations of disseminated cryptococcosis caused by C. gattii especially in patients living and coming from endemic areas.     

Atypical Micromorphology and Uncommon Location of Cryptococcosis: A Histopathologic Study Using Special Histochemical Techniques (One Case Report)

Here we report an unusual case of disseminated cryptococcosis in a patient with AIDS. Although typical Cryptococcus neoformans micromorphology was observed in tongue biopsy, cervical lymph node examination revealed atypical histopathologic findings. These included pseudohyphae, chains of budding yeasts and structures resembling germ tubes. Cryptococcus neoformans infection in supraclavicular lymph nodes was also confirmed by culture. The importance of using special histochemical techniques—Mayer’s mucicarmine stain for mucicarminophilic capsule and Grocott’s silver stain—in the diagnosis of cryptococcosis is reinforced.     

Fatal disseminated Cryptococcus gattii infection in New Mexico

We report a case of fatal disseminated infection with Cryptococcus gattii in a patient from New Mexico. The patient had no history of recent travel to known C. gattii-endemic areas. Multilocus sequence typing revealed that the isolate belonged to the major molecular type VGIII. Virulence studies in a mouse pulmonary model of infection demonstrated that the strain was less virulent than other C. gattii strains. This represents the first documented case of C. gattii likely acquired in New Mexico.     

Disseminated Fusariosis Secondary to Neuroblastoma with Fatal Outcome

Disseminated fusariosis is an uncommon clinical condition in immunocompromised patients. We report a fatal case of disseminated fusariosis secondary to neuroblastoma in a male patient, 15 years old, who underwent a bone marrow transplant. The patient was admitted to the pediatric intensive care unit (PICU) of a public hospital in Recife-PE, Brazil, presenting bone marrow aplasia, severe leukopenia, and thrombocytopenia. After 15 days, the patient developed right knee effusion. Synovial fluid and blood samples were analyzed at the Medical Mycology Laboratory of the Federal University of Pernambuco. Mycological diagnosis was based on the presence of hyaline septate hyphae on direct examination and the isolation of Fusarium oxysporum in culture, confirming the case of disseminated fusariosis. In vitro, the isolate showed fluconazole resistance and sensitivity to amphotericin B, anidulafungin, and voriconazole. Therapy with voriconazole in combination with liposomal amphotericin B led to an improved clinical response; however, due to underlying disease complications, the patient progressed to death.     

肝移植后播散性隐球菌病1例及其实验研究

目的播散性隐球菌病临床及实验研究。方法患者女,47岁,肝移植术后2 d,面部、肩部、四肢皮肤出现多发溃疡,伴昏迷。通过脑计算机断层扫描、皮损组织病理检查、PAS染色、皮损组织真菌培养及激光俘获显微切割结合PCR扩增序列分析确诊,并对获得菌株进行尿素酶试验、API试验、PCR扩增测序等实验研究。结果皮损组织病理可见大量圆形和椭圆形菌体,PAS染色阳性。血液和脑脊液真菌镜检均为阴性。皮损组织真菌培养可见酵母样菌落生长,菌株尿素酶试验阳性,API试验鉴定为新生隐球菌。ITS区序列分析鉴定为新生隐球菌grub ii变种。激光俘获显微切割结合PCR扩增,序列分析与培养获得的菌株直接PCR扩增后序列分析结果一致。脑脊液特异性隐球菌抗原（＋＋）,血液特异性隐球菌抗原（＋＋＋＋）。脑CT显示为多发结节灶。依据临床及实验室检查确诊为播散性隐球菌病,致病菌为新生隐球菌grubii变种。结论通过对该病例的深入研究,为临床明确诊断播散性隐球菌病奠定基础,确立了显微切割技术在皮肤真菌感染中的应用价值。     

Pulmonary cryptococcosis: A rare but emerging disease

Pulmonary cryptococcosis occurs primarily in immunocompromised hosts as an isolated infection or as a precursor to disseminated disease. Recent studies indicate that patients with isolated pulmonary cryptococcosis may be asymptomatic or, if symptomatic, will often have very low serum cryptococcal antigen, distinguishing them from patients with disseminated disease. Amphotericin B plus flucytosine is the initial treatment for disseminated cryptococcosis or severe symptomatic pulmonary cryptococcosis, followed by fluconazole once symptoms have improved. Fluconazole is recommended for asymptomatic or mild disease. Targeted immunotherapies and vaccines are being studied and offer exciting new prevention and treatment strategies.     

Primary Cutaneous Mucormycosis Presenting as a Giant Plaque: Uncommon Presentation of a Rare Mycosis

Mucormycosis is an uncommon opportunistic fungal infection caused by Zygomycetes. It usually affects immunocompromised, diabetic and trauma patients with infected wounds. We report a case of disseminated infection secondary to facial cutaneous mucormycosis caused by Saksenaea vasiformis in a diabetic patient who had a farming accident causing him severe head injury. The patient was treated with a combination of surgical debridement and antifungal therapy with liposomal amphotericin B, but he had a slow and fatal outcome. In cases of tissue necrosis following trauma involving wound contact with soil (i.e., potential fungal contamination), testing for the presence of Zygomycetes fungi such as S. vasiformis in both immunocompetent and immunocompromised patients is crucial. The reason is that this infection usually has a rapid progression and may be fatal if appropriate treatment is not administered.     

Disseminated <Emphasis Type="Italic">Histoplasma capsulatum</Emphasis> and <Emphasis Type="Italic">Cryptococcus neoformans</Emphasis> Co-Infection in Patients with AIDS

Histoplasmosis and cryptococcosis are the most prevalent systemic mycoses in HIV-infected patients. The authors report a 20-year-old Brazilian HIV-positive woman with concomitant disseminated histoplasmosis and cryptococcosis. In addition, we review the reported cases described in the medical literature.     

Simultaneous chronic pulmonary paracoccidiodomycosis and disseminated cryptococcosis in a non-HIV patient

An unusual case of chronic pulmonary paracoccidiodomycosis and disseminated cryptococcosis in a non-HIV infected patient is reported in a 72-year-old previously healthy man. A chest radiograph disclosed a bilateral diffused interstitial infiltrate involving middle and lower lung fields. Specimen samples taken from the tracheal tube revealed yeast-like organisms suggestive of Cryptococcus neoformans and Paracoccidiodes brasiliensis. Blood and cerebrospinal fluid culture was positive forC. neoformans and the immunodiffusion test against paracoccidiodin revealed a precipitation band. The patient died 24 days after the admission.     

播散性隐球菌病1例及其实验研究

目的 播散性隐球菌病1例临床及实验研究.方法 患者男,72岁,红皮病1年2个月,口服醋酸泼尼松治疗,双下肢出现结节、溃烂6个月.皮损组织病理、皮损组织真菌培养、尿素酶试验、PCR扩增测序比对明确诊断,同时做胸部及脑部CT.结果 皮损组织病理显示为感染肉芽肿改变,可见大量圆形和椭圆形酵母细胞.皮损组织真菌培养可见酵母样菌落生长,菌株尿素酶试验阳性,ITS区测序比对鉴定为新生隐球菌grubii变种.血清隐球菌荚膜多糖抗原乳胶凝集试验阳性(++++).胸部CT显示左下肺后基底段空洞性病灶.依据临床及实验室检查确诊为由新生隐球菌grubii变种引起的 播散性隐球菌病.给予患者静滴氟康唑400 mg/d治疗2周,之后改口服300 mg/d治疗,3个月后结节性皮损全部消退,胸片显示左肺陈旧性病变,血清隐球菌荚膜多糖抗原乳胶凝集试验阳性(++).治疗15个月后,血清隐球菌荚膜多糖抗原乳胶凝集试验仍阳性(++).结论 对该病例的临床和实验室研究为临床明确诊断和治疗提供了依据,确定菌种需要进行分子生物学研究.     

Cavitary pneumonia in an AIDS patient with cryptococcosis

Pulmonary cryptococcosis is an unusual fungal infection that is most often found in AIDS or in organ transplant recipients. Although in immunocompromised patients, cryptococcal infection often causes pulmonary infections, the diagnosis of lung involvement is generally difficult. The presentation of pulmonary cryptoccosis in HIV-infected patients appears to be more acute and severe than in other immunocompromised patients, probably related with the severe immunosuppression. Diffuse infiltrates, mediastinal and hilar lymph nodes enlargement are the most common radiological findings in AIDS-associated pulmonary cryptococcosis. Cavitation is a rare form of and includes only 10% to 15% of all cases. Only a few case reports or studies with small number of patients of pulmonary cryptococcosis have been published over the past two decades. We report a case of an AIDS patient who developed cavitary pneumonia as the only clinical expression of cryptococcosis.     

Tongue lesion due to Cryptococcus neoformans as the first finding in an HIV-positive patient

BackgroundCryptococcosis is a severe universally distributed mycosis which mainly affects immunocompromised hosts. This mycosis is caused by yeasts of two species complex of the genus Cryptococcus: Cryptococcus neoformans and Cryptococcus gattii. Meningeal cryptococcosis is the most frequent clinical presentation of this disseminated mycosis. The oral mucosa involvement is extremely unusual.Case reportWe present a case of cryptococcosis with an unusual clinical form. The patient was assisted because she had an ulcerated lesion on the lingual mucosa. Encapsulated yeasts compatible with Cryptococcus were found in microscopic exams of wet preparations from lingual ulcer clinical samples obtained for cytodiagnosis and mycological studies. Cryptococcus neoformans (C. neoformans var. grubii VNI) was isolated in culture. This patient did not know her condition of HIV seropositive before the appearance of the tongue lesion.ConclusionsThe involvement of the oral mucosa is uncommon in this fungal infection, but is important to include it in the differential diagnosis in HIV positive patients.     

Pulmonary nodules: An unusual onset of HIV infection belatedly diagnosed

BackgroundCryptococcosis is a generally systemic and potentially lethal fungal infection. Although HIV infection is a predisposing condition, especially if the CD₄₊ lymphocyte count is less than 100 cells/mm³, other forms of immunosuppression may be associated with this opportunistic fungal condition, such as prolonged steroid therapy or solid organ transplantation. Pulmonary presentation must be included in the differential diagnosis of pneumonia or pulmonary neoplasia in the immunosuppressed patient.Case reportWe report a case of pulmonary cryptococcosis in a non-diagnosed HIV patient. In a 44 year-old male suffering from dyspnea and chest pain the image of a pulmonary nodule was observed in a radiological finding. In the histopathological study, intracellular structures suggestive of fungal conidia, and morphologically compatible with Cryptococcus, were observed. HIV serology and cryptococcal antigen detection in serum were requested, given the possibility of cryptococcosis. Cryptococcus neoformans var. grubii was isolated from the culture of the pulmonary biopsy. The patient was finally diagnosed with pulmonary cryptococcosis and HIV-1 infection. With a proper antifungal treatment the patient evolved satisfactorily.ConclusionsThe best strategy to avoid opportunistic infections such as cryptococcosis in HIV-infected patients consists of an early diagnosis and a highly active antiretroviral treatment. In our case, the diagnosis of a pulmonary infection by C. neoformans var. grubii allowed a late diagnosis of HIV-1 infection.     

Aspergillus myositis in a patient with a myelodysplastic syndrome

We present the case of an elderly man who, while being treated with corticosteroids for a myelodysplastic syndrome, developed myositis of the calf due to Aspergillus fumigatus. Despite therapy with amphotericin B the myositis failed to resolve and he died. At autopsy, a localized necrotizing myositis of the right calf was found with no evidence of disseminated Aspergillus infection. Myositis in the setting of disseminated candidiasis or cryptococcosis has been previously reported. This case is unique in that it is the first reported case of localized fungal myositis and of myositis caused by Aspergillus.     

Disseminated infection with Conidiobolus incongruus

The first fatal case of disseminated infection due to Conidiobolus incongruus is reported. The patient presented with a subcutaneous mass, febrility, weight loss, cough and hemoptysis. Histological examination of skin and subcutaneous tissue, lung, lymph nodes, esophagus, liver and jejunum showed a granulomatous reaction with bright eosinophilic amorphous material and broad hyphae. A fungus cultured from skin and subcutaneous tissue was identified as Conidiobolus incongruus.     

Fatal septicemia due to Clostridium hathewayi and Campylobacter hominis

Clostridium hathewayi and Campylobacter hominis have not been previously reported in infection. We report a fatal case of septicemia, massive intravascular hemolysis, shock, and disseminated intravascular coagulation; both of these organisms were recovered on blood culture, although it seems likely that the C. hathewayi was responsible for the clinical picture and that the C. hominis was an incidental finding.     

Intra-abdominal Cryptococcosis by Cryptococcus gattii: Case Report and Review

Although abdominal cryptococcomas and visceral cryptococcal lymphadenitis as part of disseminated fungal infection have been reported mostly in HIV-infected patients, localized intra-abdominal involvement due to Cryptococcus gattii has not been previously described in non-HIV-infected patients. In general, a smaller proportion of cryptococcosis is caused by C. gattii. We report here on a type II diabetic HIV-negative patient who presented with a localized intra-abdominal cryptococcal mass due to C. gattii. In addition, we review the general aspects of intra-abdominal and gastrointestinal involvement by Cryptococcus neoformans in the literature and discuss the importance of identifying the C. neoformans varieties and C. gattii in routine laboratories.     

Disseminated Emergomyces pasteurianus Infection in India: A Case Report and a Review

Mycopathologia - We report here a case of disseminated Emergomyces pasteurianus infection from India in a patient with AIDS. The patient presented with weight loss, dyspnoea and multiple non-tender...     

Insights on the Genotype Distribution Among Cryptococcus neoformans and C. gattii Portuguese Clinical Isolates

This study provides a comprehensive picture of the C. neoformans/C. gattii molecular types most often associated with human cryptococcosis in Portugal and assesses the impact of C. gattii in these infections. One hundred and twenty-two clinical isolates, from distinct patients, were identified as C. neoformans and genotyped by URA5-RFLP, with the molecular types VNI (45.5 %) and VNIII (30.9 %) being the most commonly found ones. The molecular types VNII (11.4 %) and VNIV (11.4 %) were less abundant. One patient was found to be infected with a VGII isolate. This patient exhibited unusual clinical symptoms of cryptococcosis, reinforcing the suspicion for the presence of a different genotypic pattern, as determined afterwards. This case was detected in 2007 and is the first report of a potential autochthonous C. gattii infection case in Portugal, as the patient revealed no historical record of travelling outside the country.     

Disseminated Zygomycosis Caused by Cunninghamella bertholletiae in Patient with Hematological Malignancy and Review of Published Case Reports

Cunninghamella bertholletiae is an unusual opportunistic pathogen belonging to the class Zygomycetes, order Mucorales, and the family Cunninghamellaceae. It has been identified with increased frequency in immunocompromised patients, especially those with hematological malignancy. Clinical infection by this fungus is almost always devastating. We report a fatal case of disseminated zygomycosis due to Cunninghamella bertholletiae in an acute myeloid leukemia patient without chemotherapy. We also reviewed the cases of Cunninghamella bertholletiae infection reported in these 20 years. These cases highlight the high mortality rate and rapid progression associated with this opportunistic fungal infection in immunocompromised patients.