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Cryptococcal cellulitis in a renal transplant patient.

A 54-year-old male patient was admitted due to fever and cellulitis of the left leg (Figure 1). Three years before, he had undergone renal transplantation, and his immunosuppressive regimen was cyclosporine (75mg b.i.d.) and prednisone (10mg q.d.). His other significant medical history included previous deep venous thrombosis affecting the left leg, and type 2 diabetes, controlled with diet. At admission, he appeared healthy, with no complaints but fever and local inflammatory signs on the left leg. No abscess was perceived. He was treated with ciprofloxacin, but no improvement was seen after 96 h of antimicrobial therapy. Two out of three blood culture sets revealed the growth of yeast-like organisms (Cryptococcus neoformans var. grubii), and amphotericin B desoxycholate was started (1mg/kg/day). Skin biopsies showed the presence of chronic panniculitis associated with round yeast forms (Figure 2), and culture of the fragments revealed C. neoformans var. grubii. The serum cryptococcal antigen titre was 1:32 768. Chest radiography and cerebrospinal fluid tests were negative, and there were no signs of intracranial hypertension. Renal function worsened after 20 days of amphotericin B deoxycholate treatment, and the antifungal therapy was changed to fluconazole (200mg b.i.d.). During this period, a positive cytomegalovirus antigenemia (46 positive cells/100 000 leukocytes) was treated with a 14-day course of intravenous ganciclovir. The patient was discharged with secondary prophylaxis with fluconazole (200mgq.d.). Skin lesions in patients with cryptococcosis are