Cellulitis as First Clinical Presentation of Disseminated - PDF document

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/15342789 Cellulitis as First Clinical Presentation of Disseminated Cryptococcosis in Renal Transplant Recipients Article in Infectious Diseases · February 1994 DOI: 10.3109/00365549409011823 · Source: PubMed CITATIONS READS 29 140 4 authors , including: Alphons M Horrevorts Roland J J Koopman Canisius-Wilhelmina Ziekenhuis Bernhoven Hospital 108 PUBLICATIONS 2,269 CITATIONS 44 PUBLICATIONS 1,157 CITATIONS SEE PROFILE SEE PROFILE Jacques Meis Canisius-Wilhelmina Ziekenhuis 1,087 PUBLICATIONS 30,261 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: CryptoZim View project Molecular characterization, diagnosis, antifungal susceptibility pattern, pathogenicity and epidemiology of clinically relevant Fusarium species View project All content following this page was uploaded by Jacques Meis on 22 May 2014. The user has requested enhancement of the downloaded file.

623-626, 1994 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Scand J Infect Dis 26: zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA CASE REPORT ROLAND J. J. KOOPMAN) and JACQUES F. G. M. MEIS' zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Cellulitis as First Clinical Presentation of Disseminated From the Deparrmenls zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Cryptococcosis in Renal Transplant Recipients ALPHONS M. HORREVORTS, FRANS T. M. HWSMANS~, o f 'Medical Microbiology, 'Internal Medicine and 3Dermatology, with antifungal agents was successful. Disfeminated cryptococcal disease zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA University Hospital Nijmegen, The Netherlands Scand J Infect Dis Downloaded from informahealthcare.com by Radboud Universiteit Nijmegen on 12/09/12 diagnosis and appropriate therapy are therefore essential. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Two renal transplant recipients with cellulitis due to Cryptococcus neoformans are described. The A. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA patients were treated empirically for a presumed bacterial erysipelas, but without response. Examination of skin biopsies revealed C. neoformans as the causative organism. In both patients the cellulitis was the presenting clinical manifestation of disseminated cryptococcosis. Therapy occurs mainly in immunocompromized patients. When left untreated, it nearly always has a fatal course. Early coccosis zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA M . Horrevorts, MD, Department o f Medical Microbiology, University Hospital Nijmegen, P . O . Box 9101, 6500 HB Nijmegen, The Netherlands For personal use only. INTRODUCTION Disseminated infection by Cryptococcus neoformans is observed mainly in immunocompro- mized patients and cutaneous involvement occurs in 10- 15% of cases (1). Primary crypto- of the skin is very rare and cryptococcal skin disease should therefore be interpreted as a sign of systemic cryptococcal infection (2). Cryptococcal skin disease can manifest itself in a variety of ways, each of which is uncharacteristic for C. neoformans (3). Cellulitis is a very uncommon form (I). We describe 2 patients, both renal transplant recipients, with cellulitis caused by C. neoformans. CASE REPORTS Case 1 A 31-year-old woman was admitted to the hospital with fever and a lesion of the right lower leg that resembled erysipelas. The general practitioner had prescribed erythromycin, but without improvement. She had in the past had 2 unsuccessful renal transplants, followed by periods of long-term intermittent hemodialysis and peritoneal dialysis because of a terminal renal insufficiency due to an anti-GBM glomerulonephritis. She then underwent a third. successful renal transplantation. Her medication consisted of prednisone 10 mg and azathioprine 100 mg daily. Four days prior to admission she had felt feverish, without rigors, and had noticed a dry unproductive cough. On examination she appeared moderately ill with a pulse rate of 80 per min and a blood pressure of 120/90 mmHg. Her temperature was 39.0C. Examination of heart, lungs and abdomen was unremarkable. On the skin of the right lower leg, there were a few painful, slightly elevated, erythematous patches (Fig. I). Laboratory findings: hemoglobin 90 g/l; leukocyte count 5.2 x 109/1; platelet count 285 x 109/l; serum creatinine was stable at 86 pmol/l. The chest X-ray showed pleural fluid on the left side and 2 circular infiltrates, each with a mg/day intravenously. Follow-up cultures of zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA diameter of IScm, in the right upper lobe. Because the disorder on the right lower leg resembled erysipelas. erythromycin was changed to oral penicillin. The patient became subfebrile and started to complain of headache. A broncheoalveolar lavage and a skin biopsy were performed. Microscopic examination of both showed small yeast cells and cultures yielded C. neoformans. Cerebrospinal fluid (CSF) and urine cultures both grew C. neoformans, whereas blood cultures remained sterile. The cryptococcal antigen titres in the CSF and blood were 4 and 32, respectively. Combination therapy with amphotericin B and 5-fluorocytosine was started. However, as the isolate was resistant to 5-fluorocy- tosine in vitro, therapy was changed to fluconazole 400 0 1994 Scandinavian University Press. ISSN 0036-5548

Horreuorts et al. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 624 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA A . zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA M. %and J Infect Dis 26 Scand J Infect Dis Downloaded from informahealthcare.com by Radboud Universiteit Nijmegen on 12/09/12 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA renal transplant recipient. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 1. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA was stopped (cumulative dose 1.6 g), but fluconazole was continued in a dose of zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA F i g . Cutaneous skin lesion in a T h e biopsy revealed Cryptococcus For personal use only. neoformans. CSF, urine and skin biopsies remained sterile, although cryptococci were still visible in smears of skin biopsies even after 5 weeks of treatment. Combination therapy was given for 7.5 weeks after which amphotericin B 100 mg orally twice daily for 6 months. 11 weeks after admission, the patient was discharged in good condition with healed skin lesions. Cryptocmal antigen titres in CSF and blood had become negative. However, the abnormalities on the pulmonary X-ray were unchanged. Three months after stopping medication, a control pulmonary X-ray showed that the infiltrates i n the upper right side of the lung had progressed. Therefore blood CSF, urine and bronchoalveolar lavage were taken for culture, but none yielded C. neoformans. Eventually a dorsal segment of the upper lobe of the right lung was removed. Histopathological examination revealed no abnormalities other than fibrotic consolidation and cultures proved negative for C. neoformans. Case 2 A 66-year-old woman was admitted to the hospital because of repeated episodes of high fever. A few months prior to admission she had been given antibiotics repeatedly by her general practitioner for an skin lesion on erysipelas-like the left lower leg. Several weeks prior to admission she had begun to complain of headache. During the last days, vomiting and fever > 39°C developed. Her medical history recorded a double-sided hydronephrosis due to junctura stenosis for which she underwent nephrectomy in 1939 (left) and again in 1982 (right). In 1982 a period of long-term, intermittent hemodialysis followed. In 1985 she received a cadaveric renal transplant. She was receiving maintenance immunosuppressive therapy with prednisone 10 mg and azathioprine 150 mg daily. She also suffered from diabetes mellitus type 11. On physical examination, a moderately ill, slightly somnolent and dehydrated patient was seen with a temperature of 38.4"C, a pulse rate of 108 per min and a blood pressure of 14/85 m H g . Meningeal signs were absent and fundoscopic examination showed no papilledema. The skin of the left lower leg displayed erythema (5 by 5 an). Laboratory findings: hemoglobin 152 g/l; leukocyte count 10.6 x 109/l; platelet count 392 x I09/l; serum creatinine was stable at 84 pmolfl. The pulmonary X-ray showed no abnormalities. Blood, CSF, urine and skin biopsies were taken for culture. CSF examination revealed a leukocyte count of 800 x 106/1, an increased albumin concentration of 3 g/l, and a decreased glucose concentration of 3.8 mmol/l (blood glucose of 14.6 mmol/l). An India ink preparation of the CSF proved positive for yeasts and C. neoformans was isolated from CSF, skin biopsies and urine, while blood and and 512, respectively. sputum remained negative. Cryptococcal antigen titres in CSF and blood were 64