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CASE REPORT
Year : 1998  |  Volume : 64  |  Issue : 1  |  Page : 25-28

Cutaneous cryptococcosis and molluscum contagiosum occurring in the same lesion in a patient with AIDS




Correspondence Address:
D N Langewar


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PMID: 20921705

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  Abstract 

Patients with acquired immunodeficiency syndrome (AIDS) are susceptible to a wide range of pathogens due to profound defect in cell-mediated immunity. The co-existence of different diseases within the same lesion is a feature of human immunodeficiency virus (HIV) infection. We describe co-existent cutaneous cryptococcosis and molluscum contagiosum in the same lesion in a patient with the acquired immunodeficiency syndrome.



How to cite this article:
Langewar D N, Shroff H J, Kohli M A, Hira S K. Cutaneous cryptococcosis and molluscum contagiosum occurring in the same lesion in a patient with AIDS. Indian J Dermatol Venereol Leprol 1998;64:25-8

How to cite this URL:
Langewar D N, Shroff H J, Kohli M A, Hira S K. Cutaneous cryptococcosis and molluscum contagiosum occurring in the same lesion in a patient with AIDS. Indian J Dermatol Venereol Leprol [serial online] 1998 [cited 2019 Aug 26];64:25-8. Available from: http://www.ijdvl.com/text.asp?1998/64/1/25/4635



  Introduction Top


Increased incidence of molluscum contagiosum and cutaneous cryptococcosis has been observed among patients with acquired immunodeficiency syndrome. Several reports suggest that cutaneous lesions of cryptococcosis in these patients may resemble those of molluscum contagiosum. Since the clinical appearance of an infectious cutaneous lesion depends not only on the host response, but also on the organism involved, it is not surprising that these lesions may present with atypical appearance. We describe "molluscoid" skin lesions on the face of a patient with AIDS, the microscopy of which showed co-existing cutaneous cryptococcosis and molluscum contagiosum.


  Case Report Top


A 31-year-old man seropositive for HIV 1 on Western blot was evaluated as an in patient for scattered papular lesions. He had history of multiple heterosexual exposures. His AIDS defining illnesses included extragenital molluscum contagiosum, fever and profound weight loss, of one year duration. Clinically cutaneous lesions were present over both eyelids, face, chin and lips. These lesions were numerous, discrete, flesh -coloured, erythematous, umbilicated papules of 2mm to 20 mm in size. The left upper eyelid was the most affected with giant erythematous nodular lesions. A skin biopsy from one of the lesions on the face confirmed the diagnosis of molluscum contagiosum. After one month he developed meningitis, oropharyngeal candidiasis and watery diarrhoea. Laboratory investigations revealed a haemoglobin level of 9.6 gm/dl., white blood cell count of 3800/- cmm with 34% lymphocytes and 66% of polymorphonuclear leucocytes, an erythrocyte sedimentation rate of 50mm at the end of one hour. CD4 count was 30 cells/cmm. An India ink preparation and culture of CSF was positive for cryptococcus neoformans. A modified Ziehl-Neelsen stain on faecal smear showed acid fast oocysts of cryptosporidium species. Sputum examination showed acid fast bacilli. A western blot for HIV-1 was positive. Cryptococcal meningitis improved with oral fluconazole 200 mg/12 hrly. However inspite of clinical improvement repeated CSF examinations showed presence of cryptococci on India ink preparations.

Three months later a fresh lesion was observed on the face which was morphologically different from the earlier one.

It was a creamish, translucent papule of 5mm size, the biopsy of which revealed numerous large eosinophilic, hyaline intracytoplasmic inclusion bodies within the epidermal cells which were characteristic of molluscum contagiosum. In addition, the epidermis showed presence of yeast form of fungi ([Figure - 2] and [Figure - 3]).

The dermis and subcutaneous tissue also showed colonisation by yeast cells. The yeast cells stained positively with PAS stain and Gomori's silver methanamine (GMS) stain. Mucicarmine stain showed carminophilic capsular stain of the yeast cells, consistent with the diagnosis of cryptococcosis. Despite continued aggressive therapy, the skin lesions progressively increased in size and numbers, his CNS symptoms worsened and he died within a month. At autopsy there was widespread cryptococcal infection involving lymphnode, lung, spleen, gastrointestinal tract, kidney, thyroid, heart and brain. A single greyish white nodular lesion in liver showed histomorphology of liver cell carcinoma.


  Discussion Top


Molluscum contagiosum is a clinical disease caused by pox virus and is an important cutaneous marker of immunosuppression in HIV infected patients.[1] The prevalence of molluscum contagiosum in HIV infected persons ranges from 5% to 18%. In the presence of HIV infection molluscum contagiosum has an atypical presentation and course. The lesions are giant, hypertrophic especially in patients with extremely low CD4 counts.[1]

Cryptococcus neoformans is a ubiquitous encapsulated yeast found in soil, pigeon's excreta and some species of the eucalylptus tree in Australia. In immunocompromised patients wide spread organ involvement by cryptococcus neoformans is reported, of these 10% to 20% of patients have cutaneons involvement.[2] The cutaneous manifestations of cryptococcosis are varied, lesions may appear as subcutaneous nodules, ulcers, cellulitis, palpable purpura, pyoderma gangrenosum - like ulcers, herpetiform lesions, KAPOSI's sarcoma-like lesions, molluscum contagiosum-like lesions and occasionally as basal cell carcinoma.

Cutaneous manifestations of cryptococcosis may occur before or after the onset of clinical CNS disease.[3-5] In this case cutaneous cryptococcosis presented as a late manifestation and was a part of disseminated disease. Rare reports of co-existent lesions of cutaneous cryptococcosis and kaposi's sarcoma have been documented.[6], [7] However in the case presented here co-existent cutaneous cryptococcosis and molluscum contagiosum in the same biopsy is being documented for the first time. In some respect the histopathological findings identified in our case are different from the observations reported from other parts of the world. The microscopy of previously reported cases of cutaneous cryptococcosis showed presence of cryptococci in dermis and subcutaneous tissue without involvement of epidermis. However in our case cryptococci were demonstrated in the epidermis as well as in the dermis. Due to wide variety of skin lesions observed in patients with AIDS, a clinical diagnosis based strictly on cutaneous findings is almost impossible, hence study of cutaneous lesions by histopathology is warranted.



 
  References Top

1.Schwartz JJ, Myskowski PL. Molluscum contagiosum in patients with human immunodeflciency virus infection, J Am Acad Dermatol 1992; 27:583-588.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Radentz W. Elewski BE. Opportunistic myscosis. In: Cutaneous Fungal Infections, Edited Elewski BE, Igaku Shoin Medical Publishers, New York 1992; 191-192, 203-205.  Back to cited text no. 2    
3.Gauder JP. Cryptococcal cellulitis. JAMA 1977; 237: 672-673.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Hernandez AD. Cutaneous cryptococcosis. Dermatol Clin 1989; 7:269-274.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Shuttlewoth D, Philpot CM. Knight AG. Cutuneous cryptococcosis: Treatment with fluconazole. Br J Dermatol 1989; 120:683-687.  Back to cited text no. 5    
6.Libow LF, Dobert D. Sibulkin D. Co-existent cutaneous cryptococcosis and kaposi's sarcoma in a patient with the acquired immunodeficiency syndrome. Cutis 1988;41:159 - 162.  Back to cited text no. 6    
7.Glassman SJ. Hale MJ. Cutaneous cryptococcosis and kaposi's sarcoma occurring in the same lesions in a patient with the acquired immunodeficiency syndrome, Clin Exp Dermatol 1995;20:480-486.  Back to cited text no. 7    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3]



 

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