Primary Cutaneous Cryptococcosis in a Patient with Chronic Lymphocytic Leukemia: A Case Report

Case Report

Ann Hematol Oncol. 2016; 3(3): 1082.

Primary Cutaneous Cryptococcosis in a Patient with Chronic Lymphocytic Leukemia: A Case Report

Ajam T¹, Hyun G², Blue BJ³ and Rajeh N³*

¹Department of Medicine, Saint Louis University School of Medicine, USA

²Medical Student, Saint Louis University School of Medicine, USA

³Division of Hematology, Saint Louis University School of Medicine, USA

*Corresponding author: Nabeel Rajeh, Division of Hematology, Saint Louis University School of Medicine, 3655 Vista Ave, West Pavilion, 3rd Floor, Saint Louis, MO 63110, USA

Received: March 11, 2016; Accepted: May 03, 2016; Published: June 06, 2016

Abstract

Cryptococcus neoformans is a fungal infection, which usually infects the lungs, however, certain subtypes can cause cutaneous infections. Primary Cutaneous Cryptococcosis is a rare presentation of cryptococcal infection and usually reserved for immunocompetent hosts. We present a case of a patient who develops a worsening skin lesion on her right forearm after planting vegetables and flowers in her garden. She suffers from relapsed chronic lymphocytic leukemia and is on ibrutinib. Culture of aspirate from the wound site revealed growth of Cryptococcus neoformans. She was started on fluconazole, and the patient achieved resolution of lesion on two month follow-up. The clinical and microbiological characteristics of primary cutaneous cryptococcosis are discussed.

Keywords: Cutaneous Cryptococcus; CLL; Ibrutinib; Cryptococcus

Abbreviations

PCC: Primary Cutaneous Cryptococcosis; CLL: Chronic Lymphocytic Leukemia

Introduction

Cryptococcus neoformans is yeast present in the environment and the main portal of entry for infecting particles is the respiratory tract [1]. C. neoformans has been recovered in soil contaminated with avian excreta, decaying wood, dust, vegetables, and fruit [2]. Primary cutaneous cryptococcosis (PCC) is a rare and clinically distinct mycosis caused by C. neoformans or C. gattii that usually presents as a unique skin lesion in the absence of disseminated disease [3].

This is the first reported case of PCC in a patient with chronic lymphocytic leukemia or a patient on ibrutinib. We report a 76-year old Caucasian woman with relapsed chronic lymphocytic leukemia on ibrutinib who presented with an ulcerated skin lesion on her right forearm. Subsequent skin biopsy and culture were positive for C. neoformans. Ibrutinib is an irreversible inhibitor of Bruton tyrosine kinase that blocks downstream B-cell receptor activation [4], and the most common adverse events include diarrhea, fatigue, and upper respiratory tract infections [5]. The case represents an uncommon presentation of cutaneous cryptococcosis in an immune compromised patient. Though clinicians are familiar with the presentation and management of systemic cryptococcal infection in patients with impaired immunity, primary cutaneous cryptococcosis is a rare presentation that should not be overlooked.

Case Presentation

A 76-year-old woman with relapsed chronic lymphocytic leukemia diagnosed in 2000 and an avid gardener on ibrutinib presented with a progressive worsening skin lesion. Significant past medical history includes a splenectomy in 2012. She had no history of recent travel, and she lived in the Mississippi river valley. In her garden she is exposed to soil, compost, rose thorns, and vegetables. Two weeks prior to presentation, she developed an erythematous papule without any conceivable cause that appeared on her right dorsal forearm, and was progressively increasing in size. At home she developed a fever of 101°F with associated fatigue. At first she used over-the-counter antibiotic ointments, and was later prescribed amoxicillin/clavulanic acidby her haematologist without clinical improvement. Upon general examination, she was a febrile and no involvement of other skin sites or organs. The skin manifestation was an erythematous 3 by 4 cm plaque with central irregular ulceration with pink fibrinous base (Figure 1) on the right dorsal forearm. There was no regional lymphadenopathy or any other cutaneous lesion. A sporotrichosis was suspected, itraconazole 100 mg/12 h was started, and a skin biopsy was performed for histopathological and microbiological studies.

Citation: Ajam T, Hyun G, Blue BJ and Rajeh N. Primary Cutaneous Cryptococcosis in a Patient with Chronic Lymphocytic Leukemia: A Case Report. Ann Hematol Oncol. 2016; 3(3): 1082. ISSN : 2375-7965