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Cryptococcus neoformans:

Keywords (immunodeficiency): HIV, antiretroviral therapy, oropharyngeal thrush, hepatosplenomegaly, central umbilication, central necrosis, hemorrhagic crust.

  • Cryptococcus neoformans is an encapsulated yeast
  • Occurs in patients with advanced HIV (CD4<100/mm3)
  • The most common manifestation is meningoencephalitis
  • Pulmonary and/or disseminated disease may occur
  • Cutaneous cryptococcosis considered as a marker of disseminated disease
  • Rapid onset (2 weeks) of multiple widespread papular lesions with central umbilication
  • Diagnostic clue is the presence of a small area of central hemorrhage or necrosis
  • Resembles molluscum contagiosum
  • Most common areas affected are head and neck
  • Disseminated infections can affect liver, lymph nodes, peritoneum, adrenal gland, and eyes
  • Diagnosis
    • Biopsy of the lesion
    • Histopathological examination after staining (periodic acid-Schiff, Gomori methenamine silver nitrate)
    • Hyperplasia of the overlying dermis with underlying granulomas surrounding encapsulated yeasts
    • Fungal blood culture is often positive in severe disseminated cryptococcal disease but a biopsy is more sensitive and specific than blood culture (because untreated HIV patients have multiple ongoing opportunistic infections)
    • The most common wrong answer is skin scrapings with a microscopic evaluation which is used for the diagnosis of fungal infections as tinea or candidiasis.


  • Treatment:
    • >/= 2 weeks of IV amphotericin B plus oral flucytosine
    • Followed by a year of oral fluconazole (higher dose for 8 weeks, then maintenance)


DD:

  • Kaposi Sarcoma:
    • Primarily presents in homosexual men(men with HIV who are sexually active with other men)
    • Red or purple papules with no necrosis
  • Disseminated Mycobacterium avium complex:
    • Common opportunistic infection
    • Affects patients with advanced AIDS
    • Presents as fever, night sweats, abdominal pain, diarrhea, weight loss
    • Cutaneous lesions are uncommon and are usually nodular and ulcerating
  • Pyoderma gangrenosum:
    • Rare neutrophilic dermatitis
    • Associated with inflammatory bowel disease and inflammatory arthritides
    • Presents as a tender papule that degrades into a bluish, violaceous ulcer
  • Basal cell carcinoma
    • Single, pink, flesh-colored papules
    • Arise slowly