Brenner, M.

Conen, A.

Flückiger, U.

Itin, P.

Vuichard, D.

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IMAGES IN INFECTIONBullous cellulitis with Cryptococcus neoformansD. Vuichard • A. Conen • M. Brenner •P. Itin • U. Flu¨ckigerReceived: 14 December 2010 / Accepted: 12 January 2011 / Published online: 8 February 2011 Urban & Vogel 2011A 79-year-old immunocompromised pigeon farmer pre-sented with a 2-week history of a well-demarcated rednessand swelling of his left hand spreading to the upper arm.His medical history was remarkable for untreated myelo-dysplastic syndrome. Despite antibiotic treatment forassumed bacterial cellulitis, he developed progressiveerythema, partial skin necrosis, and hemorrhagic epidermalbullae (Fig. 1a). Examination of deep skin biopsy speci-mens revealed granulomatous inflammation and encapsu-lated yeasts compatible with Cryptococcus neoformans(Fig. 1b, c), which was subsequently confirmed in micro-biological culture. Fluconazole therapy was initiated, andseveral surgical debridements were performed. The patientis currently receiving antifungal treatment on an outpatientbasis and is in good health.The skin is the third most common organ affected inC. neoformans infections, after the lung and central ner-vous system. Although direct inoculation has been descri-bed, cutaneous cryptococcal infection most commonlyresults from the hematogenous spread of inhaled organ-isms. Cryptococcal cellulitis may mimic bacterial infectionin both appearance and rapidity of onset. Thus, in cases ofsoft tissue infections not responding to broad-spectrumantibiotics, it is of utmost importance that the clinicianconsider the possibility of this yeast as causal agent,especially in immunocompromised patients. Obtaining skinbiopsies for culture and histopathologic examination andthe prompt administration of an antifungal agent is crucialto successful treatment. In a case involving immunosup-pression, a prolonged treatment course of 6–12 months hasto be considered, even in the absence of clinical ormicrobiological signs of dissemination.Conflict of interest None.D. Vuichard (&)Division of Infectious Diseases and Hospital Epidemiology,University Hospital Basel, Petersgraben 4, 4031 Basel,Switzerlande-mail: vuichardd@uhbs.chA. ConenDivision of Infectious Diseases and Hospital Epidemiology,Department of Internal Medicine, Cantonal Hospital Aarau,Aarau, SwitzerlandM. Brenner  P. ItinDepartment of Dermatology, University Hospital Basel,Basel, SwitzerlandU. Flu¨ckigerInfectious Diseases, Hirslanden Clinic Aarau,Aarau, SwitzerlandU. Flu¨ckigerFaculty of Medicine, University Basel, Basel, SwitzerlandInfection (2011) 39:181–182DOI 10.1007/s15010-011-0082-zFig. 1 a Left arm witherythematous, partially necroticskin and hemorrhagic bullae,b periodic acid–Schiff stain(940) of skin biopsy showingan encapsulated yeast (arrow),c multiple encapsulated yeastson Grocott stain (940) of atissue specimen182 D. Vuichard et al.

Bullous cellulitis with Cryptococcus neoformans

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Bullous cellulitis with Cryptococcus neoformans

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