Cutaneous cryptococcosis associated with lepromatous leprosy

A 65-year-old Brazilian man presented with an erythematous nodular lesion on the left forearm (Fig. 1). The patient had been treated with multidrug therapy for 8 months for lepromatous leprosy. During therapy, he developed recurrent episodes of reactions which were treated with high doses of prednisone and thalidomide. The histopathology of the cutaneous nodular lesion showed a granulomatous inflammatory infiltrate; some histiocytes contained vacuolations and others demonstrated oval-like or coma-like structures (Fig. 2). The specimen was cultivated in Sabouraud agar at room temperature. The colonies were transferred to Petri dishes containing Niger Seed. Agar (NSA) (Fig. 3). The confirmed diagnosis was Cryptococcus neoformans var.. neoformans based on microscopy, and physiology, including the canavanine-glycine-bromothymol blue (CGB) medium (Lazera MS, Pires FDA, Camillo-Coura L, et al Natural habitat of Cryptococcus neoformans var. neoformans in decaying Wood forming hollows in living trees. J Med Vet Mycol 1996; 34:127-131). The liquor culture was negative. Hemoculture and urine culture were also negative. Latex agglutination test was blood positive and liquor negative. The patient's hemogram revealed normocytic anemia and normal, total and differential white blood count. The CD4 count was 189/m(3) and the CD8 count was 141/m(3). Serology for anti-human. immunodeficiency virus-1 (anti-HIV-1) antibodies was negative. The X-ray of the lungs showed an areolar image in the superior lobe of the right lung. Therapy with prednisone was suspended and fluconazole (300 mg/day) was prescribed. The nodular cutaneous lesion regressed completely after 90 days. The patient was submitted to a second skin biopsy for treatment control. The culture of the specimen taken was still positive and the histopathology showed the same picture as before treatment. After 5 months of continued therapy with fluconazole, another biopsy was performed but no fungus was recovered from the specimen.