Sexually Transmitted Diseases:
Primary Cutaneous Cryptococcosis of the Penis
Narváez-Moreno, Basilio MD*; Bernabeu-Wittel, José PhD*; Zulueta-Dorado, Teresa MD†; Conejo-Mir, Julián PhD*; Lissen, Eduardo PhD‡
From the Departments of *Dermatology, †Pathology, and ‡Internal Medicine, Virgen del Rocio, University Hospital, Seville, Spain.
Conflicts of interest and sources of funding: none declared.
Correspondence: Basilio Narváez-Moreno, MD, Virgen del Rocío University Hospitals, Sevilla, Spain. E-mail: email@example.com.
Abstract: Primary cutaneous cryptococcosis is characterized by skin lesions confined to one body region, without evidence of simultaneous dissemination. Skin lesions frequently occur in immunocompromised patients. We report a case of primary cutaneous cryptococcosis in an immunocompetent patient affecting genital area successfully treated with oral itraconazole.
A 66-year-old man presented 3 nontender white nodules of 0.5 cm in diameter, one with superficial ulceration, affecting the glans, coronal sulcus, and dorsal penile without other symptoms (Fig. 1A). No locoregional lymph nodes were detected on physical examination. He suffered from diabetes mellitus and had a regular and unique sexual partner. For years, he had been using topical steroids in genital areas, as he suffered from seborrheic dermatitis. He travelled to Central America 1 month earlier where he had unprotected oral sex with a nonregular partner. He denied other sexual risk behavior. Our clinical suspicions were molluscum contagiosum or possible carcinoma, because the lesions had a firm palpation. Histopathological examination of the biopsy specimen showed numerous small budding yeasts stained with Giemsa scattered individually throughout a diffuse granulomatous inflammatory infiltrate in the corium, which is typical of cryptococcal infection (Figs. 2A, B). Complete blood, biochemical and chest radiograph examinations resulted in findings within normal range. Serological tests for syphilis and human immunodeficiency virus were negative. Although the fungal culture would have been ideal to confirm the diagnosis, we thought it was not necessary to make a new biopsy because the lesions were located in an area that would increase patient morbidity. We performed no polymerase chain reaction for herpes simplex virus, as the lesions were solid and firm, and the patient presented no vesicles. He was diagnosed of primary cutaneous cryptococcosis.
Cutaneous cryptococcosis usually occurs by secondary spread from a primary focus in 10% to 20% of immunosuppressed patients.1 Primary cutaneous cryptococcosis is defined by the identification of Cryptococcus in the skin biopsy or by culture and either clinical or histologic criteria lesion confined to the skin together with the absence of dissemination.2 Primary cutaneous cryptococcosis is believed to be occurred due to self inoculation from environment. There are only 3 reported cases of cutaneous cryptococcosis involving genital areas.3–5
There are no previously reported cases of sexually transmitted cryptococcosis, hence we think it is highly improbable that our patient acquired this infection because of a risky sexual behavior. Local irritant dermatitis together with chronic application of corticosteroids could damage the penis skin. He lived in a rural area where there were different types of birds including pigeons and a lack of hygiene probably caused the self inoculation of Cryptococcus in the penis.
Although fluconazole is widely recommended as the main treatment for primary cutaneous cryptococcosis,6 in dermatology practices, there has been considerable experience in successful treatment with itraconazole, with which the patient was treated in a dose of 400 mg daily for 3 months. The penile lesions had cleared completely by the end of treatment, and at 2 years of follow-up, there was no evidence of relapse or systemic dissemination.
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