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Mixed Pneumocystis and Cryptococcus Cutaneous Infection Histologically Mimicking Xanthoma

Peña, Zachary G., BS, MS3*; Byers, Hugh R., MD, PhD; Lehmer, Larisa M., MA; Smith, Carolyn A., PA; Ragsdale, Bruce D., MD*

The American Journal of Dermatopathology: February 2013 - Volume 35 - Issue 1 - p e6–e10
doi: 10.1097/DAD.0b013e318266b59a
Extraordinary Case Report

Abstract: Cutaneous Pneumocystis jirovecii infection is rare. It is thought that the disease emerges from a latent infection delivered via hematogenous and/or lymphatic dissemination from a primary lung infection in immunocompromised individuals. A 32-year-old human immunodeficiency virus–positive male was admitted for headache and vomiting. He was diagnosed with meningitis due to Cryptococcus neoformans and sputum tested positive for Pneumocystis. Six months later, he presented with a slightly crusted yellowish brown plaque and 2 similar but smaller papules with telangiectasia near the right angle of the mouth. Biopsy of the area featured histiocytes expanded by foamy cytoplasm as in a xanthoma except that the vacuoles were coarser. Special stains ultimately demonstrated the characteristic disks of Pneumocystis accompanied by a minor component of budding yeasts (Cryptococcus) in the same fields. This case illustrates the utility of adequate special stains in recognizing a mixed cutaneous infection, particularly in human immunodeficiency virus–positive patients, when microscopy presents an odd xanthoma-like lesion.

*Creighton University School of Medicine, Omaha, NE

Western Dermatopathology Services, Central Coast Pathology, Inc., San Luis Obispo, CA

West Dermatology, San Luis Obispo, CA.

Reprints: Larisa M. Lehmer, MA, 3701 S. Higuera Street, Suite 200, San Luis Obispo, CA 93401 (e-mail:

No outside funding was received for the writing of this report.

The authors have no funding nor conflicts of interest to disclose.

© 2013 by Lippincott Williams & Wilkins.