Localized cutaneous Cryptococcus albidus infection in a 14-year-old boy on etanercept therapy

Immune-modulating medications, such as the tumor necrosis factor-alpha inhibitors, are establishing a niche in the dermatologic therapeutic armamentarium as novel, effective, and relatively safe alternatives in the treatment of numerous inflammatory dermatoses. The benefits of anti-tumor necrosis factor-alpha inhibitor therapy are well known. However, these agents are also associated with an increased risk of infectious complications--most commonly granulomatous infections with mycobacteria and fungi. We present a teenaged boy with localized, cutaneous Cryptococcus albidus infection on the scalp which occurred after he began etanercept for refractory psoriasis. The infection resolved after a course of fluconazole. This is the second report of localized, cutaneous C. albidus infection, but the first occurring in association with etanercept therapy. Our patient's findings remind us that extra vigilance is imperative in monitoring patients on immunosuppressive regimens and that any persistent, nonhealing lesion in these patients should prompt evaluation for potential infection, not only from common and typical pathogens but also from more unusual, atypical ones.