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December 2004

Lower Extremity Ulceration in an Immunocompromised Patient—Diagnosis

Arch Dermatol. 2004;140(12):1531-1536. doi:10.1001/archderm.140.12.1531-b

Histologic examination revealed collections of yeast-form fungi with clear halos that had become confluent to form a large pool of mucin throughout the dermis. A diagnosis of cutaneous C neoformans infection was made.

Admission blood tests revealed a normal blood cell count except for a slight leukocytosis (white blood cell count, 11.1×103/μL; reference range [RR], 3.8-10.6×103/μL). Initial bacterial and fungal blood cultures were negative. A chest radiograph was also normal. Evaluation of a cerebrospinal fluid specimen revealed 83% neutrophils (RR, 0%-6%) and 17% lymphocytes (RR, 40%-80%), a glucose level of 44 mg/dL (2.4 mmol/L) (RR, 40-80 mg/dL [2.2-4.4 mmol/L]), a protein level of 58 mg/dL (RR, 15-55 mg/dL), and aggregates of budding yeast. Cryptococcal antigen was subsequently found in high titers in specimens of the patient’s blood (>1:2048; normal, negative) and cerebrospinal fluid (>1:1024; normal, negative). The patient was subsequently put on an intravenous regimen of amphotericin B. His hospital course was complicated by increasing confusion and gram-negative septicemia with Klebsiella oxytoca and Enterococcus faecalis. Prednisone and azathioprine therapy was continued to avoid a recurrence of autoimmune hepatitis. Finally, at the request of the family, treatment with antibiotics and amphotericin B was discontinued, and the patient was admitted to hospice care.