Disseminated cryptococcosis

A 42-year-old HIV-positive male patient with CD4 count 32 cells/mm³ on antiretroviral therapy presented with fever of 3 weeks duration, altered sensorium, aggressive behavior, and weakness of limbs and skin lesions of 1 week duration. On examination, the patient was drowsy, deep tendon reflexes were sluggish and there was neck stiffness with positive Kernig’s sign. Dermatological examination revealed multiple papules with central umbilication and crusting over forehead, cheeks, earlobes, and inner canthus of the left eye [Figures 1 and 2a-d]. Leishman stain of tissue smear revealed thick-walled yeasts. Gram stain of cerebrospinal fluid yielded Gram-positive budding rounded yeast cells surrounded by Gram-negative capsule [Figure 3]. Indian ink preparation was positive for Cryptococcus in cerebrospinal fluid. The patient succumbed to illness 2 weeks later.

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Figure 1:

Dome-shaped papule with central umbilication and crusting over the right ear lobe.

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Figure 2:

(a) Papule with central umbilication on the left side of forehead. (b) Erythematous papule with central erosion over medial epicanthal fold of the right eye. (c) Dome-shaped papule with central umbilication and crusting over the left ear. (d) Umbilicated papules over the right cheek.

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Figure 3:

Gram-positive rounded budding yeast cell surrounded by Gram-negative capsule in cerebrospinal fluid (Gram stain, ×400).

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Disseminated cryptococcosis is defined as cryptococcosis affecting two or more non-adjacent organs simultaneously. Disseminated cryptococcosis was diagnosed due to skin and central nervous system involvement. Gram stain of cerebrospinal fluid is a highly sensitive but simple and reliable method in the diagnosis of cryptococcal meningitis.