First Subungual Cryptococcosis Described in an HIV Patient with Disseminated Cryptococcosis

Cutaneous cryptococcosis occurs in 10-15% of patients with disseminated cryptococcosis. It typically presents as papulonodular molluscum-like lesions, but it can also produce a wide variety of lesions. Cryptococcal infection of the nail unit has never been reported.

A 28-year-old woman with a history of HIV with disseminated cryptococcosis in complete remission was referred to evaluate a subungual swelling of the right middle finger. Examination revealed an ulcero-burgeoning nodule over the right middle finger's subungual area with onycholysis, eschar, and erosion. An excisional biopsy was performed. Histopathological analysis demonstrated multiple histiocytic granulomas centered by encapsulated yeast cells. Culture grew Cryptococcus neoformans var. neoformans. After 9 months of follow-up, there was no recurrence of the lesion.

It is the first reported case of nail involvement in the course of cutaneous cryptococcosis. Definitive diagnosis required pathology and culture. Cryptococcal infection of the nail unit was recalcitrant to systemic therapy while the remaining infection cleared. Our case report suggests that surgical excision associated with systemic therapy is the best treatment approach for subungual cryptococcosis. Recognition of rare manifestations of cutaneous cryptococcosis, such as ours, is essential because HIV cases increase continuously.