Case Letter
Cutaneous and pulmonary cryptococcosis
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array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Pamella Paola Bezerra de" "apellidos" => "Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Daniela Mayumi" "apellidos" => "Takano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Idalina Inês Fonseca Nogueira" "apellidos" => "Cambuim" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Hospital Otávio de Freitas, Recife, PE, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Universidade Federal de Pernambuco, Recife, PE, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Mycology Laboratory, Hospital Otávio de Freitas, Recife, PE, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1032 "Ancho" => 2226 "Tamanyo" => 546123 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology. PAS (left) and Alcian blue (right) staining of cryptococci, ×400.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cryptococcus neoformans</span> is the etiological agent of cryptococcosis, an infectious disease that affects humans, domestic and wild animals. This pathogen is often found in pigeon excreta, possessing innumerable environmental sources.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnosis can be performed by analysis of cerebrospinal fluid (CSF), urine sediment, bronchoalveolar lavage fluid, wound exudates, floating node aspirate and suspected lesions biopsies.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Treatment of cryptococcosis in immunocompetent and immunocompromised humans, consists of amphotericin B in combination with 5-flucitosin in disseminated infections; or with fluconazole or itraconazole, as an alternative for the treatment of cutaneous infections.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A 36-year-old female patient presented an ulcerated plaque with hematic crust and erythematous infiltrated edges topped with pustules, measuring approximately 3<span class="elsevierStyleHsp" style=""></span>cm length in the posterior region of the left ear (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient related the lesion appeared 4 months before the appointment, accompanied by systemic symptoms such as intermittent fever, productive cough, and weight loss of approximately 5<span class="elsevierStyleHsp" style=""></span>kg in 15 days. Chest X-ray showed evidence of hypotransparency in the middle segment of the right lung lobe. Patient was insulin-dependent diabetic and had a history of kidney transplant performed three years ago and in use of azathioprine and prednisone. After dermatological evaluation, it was decided to perform lesional skin scrapings and mycological culture of the lesion's secretion and the sputum, as well as an incisional biopsy, with the removal of two fragments for mycological and histopathological study. Slides of direct secretion and sputum were prepared with addition of India ink upon which capsulated yeasts were observed. In the mycological culture of all the samples, there was a development of colonies of white to cream color of mucous aspect typical of <span class="elsevierStyleItalic">Cryptococcus</span> spp. The species identification and antifungal susceptibility were performed in the Vitek 2-Compact. The isolate was also identified by sequencing the D1/D2 domain of the rDNA using the primers NL1 and NL4 being identified as <span class="elsevierStyleItalic">Cryptococcus neoformans</span> (San Felice) Vuill (1901). Histopathology revealed numerous yeast fungal structures, best visualized by PAS staining (periodic acid-Schiff), with mucopolysaccharides capsules that stand out for Alcian Blue staining, with scarce inflammatory infiltrate in between (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patient was hospitalized and treated with amphotericin B associated with fluconazole. After significant clinical improvement, the patient was discharged on the use of fluconazol daily until complete resolution of the cutaneous condition (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">According to literature, this mycosis is commonly diagnosed in patients with cellular immunosuppression, such as HIV positive, being the most frequent systemic mycosis in this group of patients and the third cause of opportunistic Central Nervous System (CNS) disease.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4</span></a> In renal transplant patients, cryptococcosis occurs in 0.8–5% of them, depending on the type and intensity of immunosuppression.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Infection is usually observed in the late postoperative period, about four months after the introduction of immunosuppressive drugs.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Drug resistance, when using fluconazole, is likely to occur during prolonged suppressive treatments as in cases of <span class="elsevierStyleItalic">C. neoformans</span> meningitis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> For the treatment of renal transplant patients using immunosuppressive drugs, drug interactions and side effects should be especially considered, particularly the intrinsic nephrotoxicity of amphotericin B.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> There is still no consensus regarding dose adjustment, time and duration of treatment, as well as the need of maintenance therapy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This report presents the medical history of a patient with cutaneous and pulmonary alterations, which allowed the diagnosis of cryptococcosis and the appropriate treatment for it. Through this report we could highlight the importance of the differential diagnosis of infectious conditions in renal transplant patients.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Deborah Lucena Markman: approval of the final version of the manuscript; elaboration and writing of the manuscript; effective participation in research orientation; critical review of the literature.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Pamella Paola Bezerra de Oliveira: elaboration and writing of the manuscript; critical review of the literature.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Daniela Mayumi Takano: approval of the final version of the manuscript; effective participation in research orientation; critical review of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Idalina Inês Fonseca Nogueira Cambuim: approval of the final version of the manuscript; effective participation in research orientation; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-05-27" "fechaAceptado" => "2019-07-04" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Markman DL, Oliveira PPB, Takano DM, Cambuim IIFM. Cutaneous and pulmonary cryptococcosis. An Bras Dermatol. 2020;95:394–6.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology of Hospital Otávio de Freitas, Recife, PE, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2099 "Ancho" => 1583 "Tamanyo" => 299684 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous lesion in the posterior region of the left ear.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1032 "Ancho" => 2226 "Tamanyo" => 546123 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology. PAS (left) and Alcian blue (right) staining of cryptococci, ×400.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2233 "Ancho" => 1417 "Tamanyo" => 179026 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Post-treatment cutaneous lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Criptococose-uma revisão bibliográfica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.P.A.F. Queiroz" 1 => "F.D.N. Sousa" 2 => "R.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 10 | 24 |
| 2024 October | 85 | 82 | 167 |
| 2024 September | 114 | 97 | 211 |
| 2024 August | 129 | 146 | 275 |
| 2024 July | 125 | 127 | 252 |
| 2024 June | 90 | 76 | 166 |
| 2024 May | 94 | 65 | 159 |
| 2024 April | 100 | 86 | 186 |
| 2024 March | 73 | 62 | 135 |
| 2024 February | 94 | 76 | 170 |
| 2024 January | 100 | 47 | 147 |
| 2023 December | 87 | 59 | 146 |
| 2023 November | 72 | 77 | 149 |
| 2023 October | 79 | 86 | 165 |
| 2023 September | 65 | 78 | 143 |
| 2023 August | 63 | 44 | 107 |
| 2023 July | 50 | 32 | 82 |
| 2023 June | 59 | 39 | 98 |
| 2023 May | 54 | 24 | 78 |
| 2023 April | 41 | 22 | 63 |
| 2023 March | 74 | 42 | 116 |
| 2023 February | 54 | 42 | 96 |
| 2023 January | 35 | 39 | 74 |
| 2022 December | 51 | 23 | 74 |
| 2022 November | 58 | 53 | 111 |
| 2022 October | 79 | 57 | 136 |
| 2022 September | 38 | 65 | 103 |
| 2022 August | 38 | 55 | 93 |
| 2022 July | 42 | 51 | 93 |
| 2022 June | 40 | 50 | 90 |
| 2022 May | 35 | 48 | 83 |
| 2022 April | 35 | 48 | 83 |
| 2022 March | 45 | 73 | 118 |
| 2022 February | 31 | 38 | 69 |
| 2022 January | 39 | 82 | 121 |
| 2021 December | 34 | 62 | 96 |
| 2021 November | 38 | 69 | 107 |
| 2021 October | 48 | 91 | 139 |
| 2021 September | 39 | 52 | 91 |
| 2021 August | 34 | 55 | 89 |
| 2021 July | 34 | 47 | 81 |
| 2021 June | 29 | 48 | 77 |
| 2021 May | 42 | 90 | 132 |
| 2021 April | 212 | 260 | 472 |
| 2021 March | 52 | 70 | 122 |
| 2021 February | 16 | 15 | 31 |
| 2021 January | 15 | 19 | 34 |
| 2020 December | 23 | 22 | 45 |
| 2020 November | 20 | 16 | 36 |
| 2020 October | 25 | 10 | 35 |
| 2020 September | 21 | 10 | 31 |
| 2020 August | 9 | 7 | 16 |
| 2020 July | 14 | 12 | 26 |
| 2020 June | 16 | 13 | 29 |
| 2020 May | 18 | 15 | 33 |
| 2020 April | 0 | 4 | 4 |
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