A 73-year-old White man presented to the dermatology office, referred by his primary care practitioner for evaluation of rapidly growing "skin cancers." The patient reported that these asymptomatic lesions had been developing over the past 2 weeks. This patient is retired but works daily on his small family farm and comes in contact with multiple animals, including horses, goats, chickens, and pigeons. He denies recent travel and any changes to soaps, detergents, shampoos, or colognes. The patient is in overall good health with no known malignancies or immunosuppression. His medical history is limited to controlled hypertension and an aortic valve replacement many years ago. Recent blood work ordered by his primary care practitioner included a complete blood count and comprehensive metabolic panel, the results of which were within normal limits.
On examination, firm, annular, pink and erythematous, smooth, and nonscaling nodules with centralized depressions were noted on the vertex scalp (Figure 1), right lower back (Figure 2), and lower posterior neck (Figure 3). The lesions ranged from 0.8 cm on the scalp to 2.6 cm on the right lower back. There was no evidence of bleeding, crusting, exudate, or ulceration and no central crusting, hyperkeratosis, or telangiectasia. No lymphadenopathy was noted on palpation of axillary, cervical, and inguinal nodes.
Basal Cell Carcinoma
Basal cell cancer is the most common skin malignancy. Nodular basal cell cancer typically presents as a slow growing, pearly, pink to flesh-colored papule or nodule with telangiectasia (Brooke, 2005). Large nodular basal cell cancers are sometimes called "rodent ulcers" and typically exhibit a central eroded depression. The patient's rapid simultaneous development of three individual lesions, lacking telangiectasia, with an erythematous (as opposed to pearly pink) appearance, makes this diagnosis unlikely.
Squamous Cell Carcinoma, Keratoacanthoma Type
This skin malignancy typically presents as a rapidly growing, erythematous crateriform nodule with central core of compact keratin (Sarabi, Selim, & Khachemoune, 2007). The rapid development of these lesions is consistent with this diagnosis, but the lack of the keratin-filled craters makes it less likely.
Molluscum contagiosum is of viral etiology and usually presents as 1- to 10-mm, pink, pearly, dome-shaped,umbilicated papules or nodules (McKenna & Benton, 2002). The size of the presenting lesions makes this diagnosis unlikely. Large lesions of molluscum contagiosum have been noted in immunosuppressed patients, such as those with AIDS, but this patient's immune system was uncompromised.
Lesions of granuloma annulare present as slightly erythematous to pink, annular 1- to 5-cm plaques with central regression (Wolff & Johnson, 2009). The rapid progression, the degree of erythema, and the nodular appearance of the patient's lesions make this diagnosis less likely.
Biopsies were taken of each of the lesions for histopathological examination. Histopathologically, there were multiple, variably sized and shaped yeasts surrounded by a gelatinous capsule. The results are consistent with cryptococcosis. This diagnosis was not considered in the differential at the time of the initial evaluation because of the unusual presentation.
Cryptococcosis is an infection most commonly caused by the Cryptococcus neoformans yeast. Less common forms also include Cryptococcus gattii, laurentil, and albidus. This yeast, which develops a capsule in tissue, is found in soil and in bird droppings, particularly those of pigeons (McAdam & Sharpe, 2005). Symptoms of the primary lung infection are similar to that of the common flu in the immunocompetent patient and include cough, fever, and general malaise. The annual incidence is 0.4 to 1.3 cases per 100,000 in the immunocompetent population and is highest among men older than 40 years. The largest proportion of cases are seen in those with AIDS because of their immunosuppressed status. The incidence in this group has ranged from 2 to 7 cases per 1,000 up to 100 cases per 1,000 annually (Centers for Disease Control, n.d.). Solid-organ transplant recipients on antirejection therapy, patients on systemic glucocorticoids, and those with sarcoidosis, lymphoma, and diabetes mellitus are at increased risk (Wolff & Johnson, 2009).
Infection is thought to be caused by inhalation of dust particles containing the spores. This causes a primary lung infection that tends to resolve without therapy in immunocompetent patients. If spontaneous remission does not occur, this disease can disseminate to the meninges, kidneys, and skin. Cutaneous involvement is seen in 10% to 15% of untreated patients with AIDS (Wolff & Johnson, 2009). It should be noted that cryptococcosis can present as multiple molluscum contagiosum-like lesions (Figure 3), occurring most commonly on the face and scalp, in patients with HIV/AIDS (Wolff & Johnson, 2009).
Treatment of cryptococcosis is dictated by the presence or absence of systemic involvement. Many HIV/AIDS clinics treat patients with low CD4 counts on prophylactic fluconazole to prevent disseminated disease. Upon diagnosis, if there is evidence of meningeal involvement without complication, amphotericin B is given by intravenous infusion for 2 to 4 weeks or for up to 6 weeks if there are complications (Wolff & Johnson, 2009). If the infection is localized to the skin, fluconazole dosed at 400 to 600 mg daily for 2 to 4 weeks is effective (Robles, 2002).
The patient was started on fluconazole 200 mg twice daily and referred to infectious disease for further evaluation and treatment. Chest x-rays, computed tomography (CT) scans, blood and sputum cultures, and lung biopsy were performed and revealed no evidence of systemic disease. The patient continued on oral fluconazole 400 mg daily for 1 month, then was reevaluated by infectious disease and dermatology. No cutaneous lesions were noted, and there continued to be no evidence of systemic disease on repeat chest x-ray and blood cultures.
This case appears to be either an isolated case of primary cutaneous cryptococcosis or a disseminated infection in which the pulmonary infection resolved spontaneously before our diagnostic testing. In either case, it is a very unusual presentation for an immunocompetent patient to have developed significant cutaneous involvement. Treatment was successful, although the cause is still not known. Working on a farm and having contact with birds, including pigeons, may have led to the patient's cutaneous infection, but this is only speculative.
Brooke, R. (2005). Basal cell carcinoma. Clinical Medicine
McAdams, A. J., &Sharpe, A. H. (2005). Infectious disease. In V. Kumar, A. K. Abbas, N. Fausto (Eds.), Robbins and Cotran pathologic basis of disease
(7th ed., 343-414). Philadelphia: Elsevier Saunders.
McKenna, D. B., &Benton, C. (2002). Molluscum contagiosum. In M. Lebwohl, W. Heymann, J. Berth-Jones, &I. Coulson (Eds.), Treatment of skin disease: Comprehensive therapeutic strategies
(pp. 398-400). New York: Mosby.
Robles, W. S. (2002). Cryptococcosis. In M. Lebwohl, W. Heyman, J. Berth-Jones, &I. Coulson (Eds.), Treatment of skin disease: Comprehensive therapeutic strategies
(pp. 128-130). New York: Mosby.
Sarabi, K., Selim, A., &Khachemoune, A. (2007). Sporadic and syndromic keratoacanthomas: Diagnosis and management. Dermatology Nursing
Wolff, K. & Johnson, R. A. (2009). Fitzpatrick's color atlas and synopsis of clinical dermatology
(6th ed.). New York: McGraw-Hill.
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