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Arch Ophthalmol. 1999;117:271-272.

Cutaneous cryptococcosis is a rare infection caused by Cryptococcus neoformans an encapsulated saprophytic yeast. It is 4 to 8 µm in diameter and is surrounded by a polysaccharide capsule that lives especially well in dust and soil contaminated by the excreta of pigeons.¹ The initial site of infection is usually the lung, where cryptococcosis occurs without symptoms and persists in a latent stage for a long time.² Hematogenous dissemination of the yeast may involve any organ of the body, principally the brain (70%-90% of the cases) with a meningoencephalitis or a subacute meningitis and, to a lesser extent, the skeleton, eyes, and skin.² We describe a man affected by acquired immunodeficiency syndrome in whom disseminated infection with C neoformans started with a nodule on the border of his right eye.

Report of a Case.
A 37-year-old man with acquired immunodeficiency syndrome had a 3-week history of a papular lesion on the border of the right side of his upper eyelid (Figure 1). The clinical suspicion was of either a molluscum contagiosum or a neoplasm derived from the meibomian glands. The lesion was surgically removed. The patient's immunologic test results were as follows: total leukocyte count, 5 x10⁹/L; CD4⁺ cells, 0.019 x10⁹/L; CD8⁺ cells, 0.039 x10⁹/L; and the CD4⁺/CD8⁺ ratio, 0.05 (normal ratio, 1-2). The patient was taking antiretroviral therapy with indinavir (800 mg, 3 times daily), stavudine (40 mg, 2 times daily), and lamivudine (150 mg, 2 times daily).

View larger version (122K): [in this window] [in a new window] Figure 1. Small papular lesion on the border of the right eyelid.

Histopathologic examination showed numerous cryptococcal organisms with large polysaccharide capsules, surrounded by a granulomatous inflammation inside the superficial and mid dermis (Figure 2). Cryptococcal antigen was detectable in serum (titer 1:8192) and cerebrospinal fluid (titer 1:512). A chest x-ray film showed interstitial thickening, but a bone scan, a computed tomographic scan of the cranium, and an ophthalmoscopic examination showed no abnormalities. Therapy with amphotericin B, 1 mg/kg per day, and flucytosine, 150 mg/kg per day, was started but after 15 days additional multiple dome-shaped, flesh-colored, umbilicated papules, and ulcerated nodules appeared on the face, arms, and the dorsal aspect of the hands. The complete clinical remission lasted 5 weeks after therapy.

View larger version (102K): [in this window] [in a new window] Figure 2. Numerous cryptococci organisms surrounded by gelatinous capsules (periodic acid–Schiff, original magnification x1000).

Comment.
Human cryptococcal disease is a potentially fatal infection that develops mainly in predisposed individuals with defective cell-mediated immunity.^{1, 3} Since the advent of acquired immunodeficiency syndrome, cryptococcosis has become more frequent, involving from 5% to 10% of patients during their life, 10% to 15% of whom had cutaneous involvement.⁴ Most prominent on the face and neck, less frequently located on the trunk and extremities, the typical clinical cutaneous manifestations are umbelicated papules with a tiny, central hemorrhagic crust quite similar to molluscum contagiosum.¹ Less often, violaceous papules, vesicles in a varicelliform pattern, crusted plaques, subcutaneous nodules, or cellulitis have been reported.⁴ The most frequent ophthalmic manifestations of infection with C neoformans involve the posterior segment of the eye with papilledema, optic nerve atrophy, endophthalmitis, and choroiditis.⁵ One existing report describes limbal and choroidal mass and another iris inflammatory mass in patients with acquired immunodeficiency syndrome.^6-7

The prognosis depends on the degree of the patient's immunodepression, the involvement of C neoformans, and the prompt start of therapy.^3-4 The patient we observed is interesting because he showed a single nondiagnostic lesion on the upper border of the eyelid as a sentinel lesion that preceded the spreading of the cryptococcal infection by 5 weeks. A rapid diagnosis permitted the prompt start of appropriate therapy. Notwithstanding this, our patient experienced an initial spread of cryptococcal lesions on his skin although then serum and the colony-stimulating factors titer of cryptococcal antigens were decreasing slowly. Now, after a 22-month follow-up, the patient is well. Occasional relapses of the opportunistic infection have been controlled with amphotericin B.

AUTHOR INFORMATION

Loriana Coccia, MD; Donato Calista, MD; Antonio Boschini, MD
Rimini, Italy

Corresponding author: Donato Calista, MD, San Patrignano Medical Center, San Patrignano, 47037 Rimini, Italy (e-mail: bufalini{at}cessn.unibo.it).

REFERENCES
1. Murakawa GJ, Kershmann R, Berger T. Cutaneous cryptococcus infection and AIDS: report of 12 cases and review of the literature. Arch Dermatol. 1996;132:545-548. FREE FULL TEXT 2. Wai FN, Ka TL. Cutaneous cryptococosis-primary versus secondary disease: report of two cases and review of literature. Am J Dermatopathol. 1993;15:372-377. WEB OF SCIENCE | PUBMED 3. Sarosi GA, Siberfarb PM, Tosh FE. Cutaneous cryptococcosis: a sentinel of disseminated disease. Arch Dermatol. 1971;104:1-3. FREE FULL TEXT 4. Calista D, Stagno A, Landi C. Cutaneous lesions of disseminated cryptococcosis as the initial presentation of advanced HIV infection. J Eur Acad Dermatol. 1997;8:140-144. FULL TEXT 5. Kestelyn P, Taelman H, Bogaerts J, et al. Ophthalmic manifestations of infection with Cryptococcus neoformans in patients with the acquired immunodeficiency syndrome. Am J Ophthalmol. 1993;116:721-727. WEB OF SCIENCE | PUBMED 6. Muccioli C, Belfort Junior R, Neves R, Rao N. Limbal and choroidal Cryptococcus infection in the acquired immunodeficiency syndrome. Am J Ophthalmol. 1995;120:539-540. WEB OF SCIENCE | PUBMED 7. Charles NC, Boxrud CA, Small EA. Cryptococcosis of the anterior segment in acquired immunodeficiency syndrome. Ophthalmology. 1992;99:813-816. WEB OF SCIENCE | PUBMED

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