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    "textoCompleto" => "<p class="elsevierStylePara">Cutaneous cryptococcosis is a very uncommon disease&#46; It was initially described in 1928 by Buscke&#44;<span class="elsevierStyleSup">1</span> although the first to describe its impacts on the central nervous system &#40;CNS&#41; was Zenker in 1861&#46;<span class="elsevierStyleSup">2</span> This disease occurs most frequently in immunocompromised patients as an opportunistic infection&#44;<span class="elsevierStyleSup">3</span> with primary cutaneous infection in the absence of systemic involvement a very rare form of the disease&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Cryptococcus neoformans</span> is the most commonly found encapsulated fungus in humans&#46; It can produce pulmonary&#44; meningeal&#44; or cutaneous infection&#46;<span class="elsevierStyleSup">5</span> Three different species have been identified&#58; <span class="elsevierStyleItalic">C&#46; neoformans</span><span class="elsevierStyleItalic">gatti</span>&#44; <span class="elsevierStyleItalic">C&#46; neoformans grubii</span>&#44; <span class="elsevierStyleItalic">C&#46; neoformans neoformans&#44;</span> and 5 serotypes<span class="elsevierStyleItalic">&#46;</span><span class="elsevierStyleSup">6</span><span class="elsevierStyleItalic"> The </span>gatti is the most commonly found in immunocompromised patients&#44; and neoformans is the most commonly observed in immunodepressed patients&#46;<span class="elsevierStyleSup"><span class="elsevierStyleItalic">7</span></span> The natural habitat of these fungi is in the faeces of pigeons and other birds&#44; as well as in the floor contaminated by them&#46;<span class="elsevierStyleSup"><span class="elsevierStyleItalic">8</span></span></p><p class="elsevierStylePara">The infection is usually acquired by inhalation&#44; direct inoculation&#44; or through infection of a cutaneous lesion&#47;wound&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">Here we describe the cutaneous lesions produced by <span class="elsevierStyleItalic">Cryptococcus neoformans</span> in an immunocompromised patient with chronic kidney disease and on periodic haemodialysis&#46;&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case report</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our patient was a retired 53-year-old male who lived in a rural area&#46; He was diagnosed 10 years prior with inflammatory bowel disease&#44; which was under treatment with high doses of steroids&#46; Two years earlier&#44; he had been admitted to an intensive care unit due to intestinal sepsis with multi-organ failure&#59; since then&#44; the patient had been on periodic haemodialysis and had not recovered renal function&#46; A renal biopsy revealed tubulo-interstitial nephropathy&#46;</p><p class="elsevierStylePara">Since 1 month prior to hospitalisation&#44; the patient had suffered cutaneous erythematous lesions in indurated&#44; pruritic and painful areas&#58; the dorsal surface of the right foot and the internal surface of the thighs&#44; with a poor response to antibiotic treatment &#40;started empirically due to suspicion of cellulitis&#41; and that continued to evolve to desquamation and ulceration &#40;Figure 1&#41;&#46; We performed a cutaneous biopsy that revealed the presence of Cryptococcus &#40;Figure 2&#41;&#46; A direct examination with Indian ink and Gram stain revealed abundant large spherical yeasts that were encapsulated and had substantial budding&#46; A yeast cell culture was urease positive&#44; compatible with <span class="elsevierStyleItalic">Cryptococcus neoformans&#44; neoformans</span> variety&#46; Serum cryptolatex was also positive &#40;1&#47;2048&#41;&#46; We ruled out pulmonary and neurological involvement by computerised axial tomography and lumbar puncture&#46;</p><p class="elsevierStylePara">We started the patient on treatment with voriconazole at 200mg&#47;12 hours&#44; which produced a notable change in liver test results after 10 days of treatment &#40;total bilirubin&#58; 9&#46;59mg&#47;dl&#59; direct bilirubin&#58; 9&#46;41mg&#47;dl&#59; glutamic oxaloacetic transaminase &#91;GOT&#93;&#58; 176U&#47;l&#59; glutamic pyruvic transaminase &#91;GPT&#93;&#58; 226U&#47;l&#41;&#44; requiring replacement with amphotericin B at 100mg&#47;day&#46; In addition&#44; we decreased the dose of prednisone&#46; Under this treatment regimen&#44; the patient experienced a significant improvement in the cutaneous lesions after 2 weeks&#44; with an almost complete disappearance of ulcerations &#40;Figure 1&#41; and normalised liver test results&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Since the initial description provided by Buschke&#44; very few cases have been described of cutaneous cryptococcosis&#46;<span class="elsevierStyleSup">3</span> This infection is more common in males and in the elderly&#46; It is also frequently associated with organ transplants&#44; tumours&#44; human immunodeficiency virus&#44; and prolonged steroid use&#46;<span class="elsevierStyleSup">10-12</span> Vogelaers described in 1997 a case of primary lesions in Belgium in a male pigeon breeder who was on chronic steroid therapy due to chronic obstructive pulmonary disease&#46;<span class="elsevierStyleSup">13</span> This was similar to the case of our patient&#44; who suffered inflammatory bowel disease that required high doses of prednisone&#44; and who lived in a rural area in close proximity to fowls &#40;hens&#41;&#46;</p><p class="elsevierStylePara">The clinical spectrum of this infection varies widely&#59; it may produce papules&#44; nodules&#44; ulcers&#44; abscesses&#44; or pustules&#44;<span class="elsevierStyleSup">14</span> which can lead to confusion with other possible causal entities&#44; such as the suspicion of cellulitis in our patient&#46; Our differential diagnosis also considered pemphigus and pyoderma gangrenosum<span class="elsevierStyleSup">3</span> due to their association with inflammatory bowel disease&#46; The diagnosis is made by identifying the fungus through direct microscopic evaluation&#44; a histological analysis&#44; and microbiological culture&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">Azoles provide the treatment of choice for patients with pulmonary affectation and immunocompetent patients without CNS involvement&#46; Amphotericin B together with flucytosine is used to treat the most severe forms of meningeal infection as a primary induction therapy&#44; followed by fluconazole as a consolidation therapy&#44; according to the IDSA guidelines&#46;<span class="elsevierStyleSup">15</span> The use of voriconazole to treat this infection produces hepatic toxicity within a few days&#44; which is why we switched the treatment of our patient to amphotericin B&#44; which produced a notable improvement in 2-3 weeks&#46;</p><p class="elsevierStylePara">To conclude&#44; our patient had several risk factors for cryptococcosis&#58; chronic renal failure&#44; inflammatory bowel disease&#44; high doses of steroids&#44; and the epidemiological risk of living in a rural area&#46; The lesions resembled bacterial cellulitis&#44; necessitating a histological and microbiological analysis of tissue samples in order to confirm the diagnosis&#46;</p><p class="elsevierStylePara">Specific treatment must be maintained for a prolonged period&#44; no less than 6 months&#46;<span class="elsevierStyleSup">15</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11563&#95;16025&#95;35719&#95;en&#95;f111563&#46;jpg" class="elsevierStyleCrossRefs"><img src="11563_16025_35719_en_f111563.jpg" alt="Evolution of lesions"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Evolution of lesions</p><p class="elsevierStylePara"><a href="grande&#47;11563&#95;16025&#95;35720&#95;en&#95;f211563&#46;jpg" class="elsevierStyleCrossRefs"><img src="11563_16025_35720_en_f211563.jpg" alt="Cutaneous biopsy"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Cutaneous biopsy</p>"
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