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Cutaneous cryptococcosis in a patient on corticosteroid therapy for rheumatoid arthritis

Jorge Lobo’s disease (keloid blastomycosis) is an illness that catches the observer’s interest even though it is extremely infrequent. The reasons are its striking clinical features and enigmatic but interesting pathogenesis. Venezuela is one of the countries in which this ailment has been described. The authors supplied two additional cases and performed a fair review of the salient features of the disease and of conventional wisdom about its pathogenesis. Regretfully, Paniz-Mondolfi et al . failed to mention two papers that I coauthored that provide useful information. In the first, in 1961, Reyes et al . 2 described the third case of this condition in Venezuela, with probably the most extensive lesions ever reported. These were thick, hard lesions on the feet, legs, knees, hands, forearms, and elbows which progressed in a sporotrichoid fashion. The patient was aged 80 years and in good general health, and remembered clearly that the disease had started after trauma to the left sole 10 years before consultation. We also showed, for the first time, a distinct increase in serum γ -globulin. There was no evidence whatsoever of ill health or immune deficiency. Long-acting oral sulfonamides were tried, but the patient did not remain under control for long enough to judge the results of treatment. The second paper, in 1989, by Goihman-Yahr et al . 3 studied polymorphonuclear leukocyte function in the cells of another patient with Jorge Lobo’s disease. These were compared with cells from patients with diverse granulomatous diseases (including paracoccidioidomycosis and leishmaniasis), as well as healthy controls. The main objectives were as follows: (i) to determine whether there were any nonspecific deficiencies in neutrophil function; and (ii) to evaluate whether the specific inability of neutrophils from patients with paracoccidioidomycosis to digest in vitro Paracoccidioides brasiliensis was present or not in neutrophils from the patient with Jorge Lobo’s disease. The results were clear. Neutrophils from the patient with keloid blastomycosis phagocytosed and digested well Candida albicans and, most importantly, P. brasiliensis in vitro , and showed a normal myeloperoxidase reaction. The patient’s serum showed no antibodies against deep fungi, such as P. brasiliensis , Histoplasma capsulatum , C. albicans , Coccidioides immitis , or Aspergillus spp. In this way, the specificity of the digestive defect against P. brasiliensis by neutrophils from patients with paracoccidioidomycosis was confirmed, as well as the individuality of Jorge Lobo’s disease. The overall leukocyte function was basically normal in keloid blastomycosis. This occurred despite the fact that blood had to be flown from Ciudad Bolívar to Caracas airport, and from there driven to the laboratory to perform in vitro tests (normally, neutrophils are isolated from freshly drawn blood). I do feel that a review on Jorge Lobo’s disease in Venezuela (or elsewhere) should have mentioned these two papers. Interestingly, Paniz-Mondolfi et al . currently work in the same institution in which this writer headed the Section of Immunology for several decades. I would also like to stress that no ill will should be attributed to Paniz-Mondolfi et al . Indeed, the first author of the 1961 paper 2 was Dr Oscar Reyes-Flores, the father of Oscar Reyes-Jaimes, one of the coauthors of the paper by Paniz-Mondolfi et al . 1