Clinical Report: Cutaneous cryptococcosis mimicking cellulitis in a transplant patient

Background

Cryptococcus neoformans is a major opportunistic pathogen in immunocompromised hosts, with an increasing burden among solid organ transplant recipients. Although cryptococcosis is rare in this population, it is the third most common invasive fungal infection and is associated with substantial mortality, particularly with central nervous system (CNS) involvement or disseminated disease. Cutaneous involvement is uncommon but clinically important because it may mimic bacterial skin and soft tissue infections and can represent an early sign of disseminated infection.

Data Highlights

• The systematic review included 65 studies comprising 72 kidney transplant recipients; with the present case, 73 patients were analyzed.

• Disseminated cryptococcosis occurred in 49 of 73 patients (67.1%).

• Among patients with disseminated disease, cutaneous involvement was the initial manifestation in 34 of 49 cases (69.4%).

• Cellulitis-like lesions were the most common cutaneous presentation, occurring in 36 of 73 patients (49.3%).

• Overall, 60 of 73 patients (82.2%) achieved clinical recovery following antifungal therapy.

Key Findings

• Cutaneous cryptococcosis frequently presented with cellulitis- or erysipelas-like lesions that mimicked bacterial infection and could delay appropriate diagnosis and treatment.

• Among published cases, cutaneous involvement was more often associated with systemic infection than with isolated disease.

• The CNS, lungs, and bloodstream were the most frequently involved extracutaneous sites in disseminated cases.

• Skin biopsy, histopathology, culture, and cryptococcal antigen testing were important for diagnosis and staging.

• Identification of cutaneous cryptococcosis should prompt evaluation for CNS and bloodstream involvement, with systematic neurological evaluation, including lumbar puncture, supported by the high frequency of CNS disease.

Clinical Implications

Clinicians should maintain a high index of suspicion for cryptococcosis in kidney transplant recipients with atypical, nonhealing, or antibiotic-refractory skin lesions, particularly when systemic symptoms or recent intensification of immunosuppression are present. Prompt diagnostic evaluation is important because cutaneous disease may represent an early manifestation of disseminated cryptococcosis.

Conclusion

Cutaneous cryptococcosis is an uncommon but clinically significant manifestation in kidney transplant recipients and, among published cases, most commonly occurred in the setting of disseminated infection. Early recognition of atypical or nonresponsive cutaneous findings can prompt appropriate diagnostic evaluation and timely antifungal therapy.

Related Resources & Content

1. Pappas PG, Alexander BD, Andes DR, Hadley S, Kauffman CA, Freifeld A, et al. “Invasive fungal infections among organ transplant recipients: results of the Transplant-Associated Infection Surveillance Network (TRANSNET).” Clinical Infectious Diseases. 2010;50(8):1101–1111.

2. Meena P, Bhargava V, Singh K, Sethi J, Prabhakar A, Panda S. “Cryptococcosis in kidney transplant recipients: current understanding and practices.” World Journal of Nephrology. 2023;12(5):120–131.

3. Sun HY, Alexander BD, Lortholary O, Dromer F, Forrest GN, Lyon GM, et al. “Cutaneous cryptococcosis in solid organ transplant recipients.” Medical Mycology. 2010;48(6):785–791.

4. Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. “Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America.” Clinical Infectious Diseases. 2010;50(3):291–322.

5. Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, et al. “Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM.” The Lancet Infectious Diseases. 2024;24(8):e495–e512.