Cutaneous Cryptococcoma in a Patient on TNF-α Inhibition

Area of Science:

• Dermatology
• Infectious Diseases
• Rheumatology

Background:

• Disseminated fungal infections can present with diverse cutaneous manifestations.
• Patients with autoimmune diseases on immunosuppressive therapy are at increased risk.
• Rheumatoid arthritis (RA) and chronic kidney disease (CKD) can complicate diagnosis and treatment.

Purpose of the Study:

• To report a case of hematogenously disseminated fungal panniculitis caused by Cryptococcus neoformans.
• To discuss the diagnostic challenges and treatment outcomes in an immunocompromised patient.

Main Methods:

• Case presentation of an 87-year-old male with RA and CKD.
• Clinical evaluation including physical examination and laboratory markers of inflammation.
• Skin biopsy with fungal cultures and serum cryptococcal antigen testing.
• Treatment with oral antibiotics followed by fluconazole.

Main Results:

• The patient presented with left hand erythema, pain, tenderness, induration, edema, and axillary lymphadenopathy.
• Skin biopsy revealed fungal panniculitis with Cryptococcus neoformans identified in cultures.
• Initial fluconazole treatment led to gradual improvement over six months.
• The patient's condition eventually stagnated and reverted to initial presentation.

Conclusions:

• Cryptococcus neoformans panniculitis is a rare but serious manifestation of disseminated fungal infection.
• Immunocompromised status due to RA treatment (glucocorticoids, adalimumab) likely contributed to the infection.
• Recurrence of infection despite initial treatment underscores the need for careful monitoring and potentially prolonged or alternative antifungal therapies.