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CASE REPORT
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 270-272

Successful resolution of skin ulceration by itraconazole in an immunocompetent elderly patient


Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Shangcheng Qu, Hangzhou, China

Date of Submission01-May-2019
Date of Acceptance31-Jul-2019
Date of Web Publication7-Feb-2020

Correspondence Address:
Dr. J Zhou
Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road No. 88, Shangcheng Qu, Hangzhou, 310009
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_245_19

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   Abstract 


A 63-year-old patient was presented with faciocervical erythema and ulcers of 3 months duration. Pathological examination showed infiltration of inflammatory cells. Pathogenic microorganism cultivation was negative. However, empirical therapy with itraconazole proved effective.

Keywords: Fungal infections, itraconazole, ulcer


How to cite this article:
Shen J Y, Ding H, Zhou J. Successful resolution of skin ulceration by itraconazole in an immunocompetent elderly patient. Niger J Clin Pract 2020;23:270-2

How to cite this URL:
Shen J Y, Ding H, Zhou J. Successful resolution of skin ulceration by itraconazole in an immunocompetent elderly patient. Niger J Clin Pract [serial online] 2020 [cited 2020 Feb 25];23:270-2. Available from: http://www.njcponline.com/text.asp?2020/23/2/270/277856




   Introduction Top


Primary cutaneous cryptococcosis (PCC) belongs to a family of systemic mycoses. Although once viewed as diseases that only immunocompromised patients were susceptible to, its incidence rate in immunocompetent individuals has increased.[1] PCC is mainly presented as ulcers, cellulitis, or molluscum contagiosum-like lesions in the exposed areas. Clinically, Triazole compounds are found effective.


   Case Report Top


A 63-year-old male was presented with faciocervical erythema and ulcers in our dermatological ward. Three months ago, the patient had developed scattered itchy pink macules on his face and neck after cleaning a ceiling without wearing a mask. The macules gradually developed into ulcerative lesions [Figure 1]. His physician diagnosed this as discoid lupus erythematosus and prescribed him hydroxychloroquine and tripterygium glycosides, which provided no relief. The patient reported no systemic complaints, no trauma, and no significant history of systemic medications. His family history was remarkable.
Figure 1: Dermatologic examination at the time of the initial presentation.Multiple oval or irregular ulcers scattered on the forehead and cheeks, with the diameters ranging from 0.3 to 1.5 cm. Four oval ulcers on the back of the patient's neck, with the diameters ranging from 5 to 2.5 mm. The depths of the ulcers ranged from 1 to 3 mm. Each ulcer had an intumescent edge and was surrounded by erythema. The surfaces of the ulcers were flat

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After admission, an intravenous Ceftriaxone was administered but that failed to resolve his symptoms. Further, chest computed tomography (CT) showed chronic bronchitis, emphysema, scattering focal proliferation, and calcification in both the lungs. A fungal smear test, fungal culture, test results of (1,3)-β-D-glucan, galactomannan, and cryptococcal capsular antigen were all negative. A deep incisional biopsy was taken from the ulcerous edges [Figure 2]. Histochemical stainings of periodic acid-schiff and periodic acid-silver metheramine, and immunohistochemical analysis of cytokeratin (AE1, AE3) were negative while immunohistochemical analysis of CD68 was positive.
Figure 2: Histopathological findings of the skin lesion. (a) Mild incrassation of the epidermis with ulcers and crusts (HE staining,×17). (b) Masses of granulomas consisting of mixed inflammatory cell infiltration in the middle and deep parts of the dermis; and capillary dilatation and congestion in the ulcer biopsy specimen. Capillary dilatation and congestion in the ulcer, with mixed inflammatory cell infiltration (HE staining, ×26). (c) A suspected cryptococcus in the deep section of the dermis (red arrow, HE staining, ×120). HE: Hematoxylin and eosin

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We took PCC into consideration. After obtaining consent from the patient on empirical therapy with itraconazole, the patient received oral itraconazole (200 mg/d). The ulcers improved during the following 3 weeks. Oral itraconazole was maintained until the 2nd-month follow-up and the skin lesions continued to improve. When the lesions were totally cicatrized, the oral itraconazole treatment was stopped. One month later, the skin lesions recurred. Following the resumption of itraconazole, the ulcers healed again.


   Discussion Top


Although PCC was once viewed as diseases affecting only immunocompromised patients, there are no statistically significant differences between their incidence in immunocompromised and immunocompetent groups.[2] The main channel of cryptococcal infections is the airway, which makes systemic dissemination available for cryptococcus.[3] Trauma is another causative factor of PCC, wherein the infection originates in the wound.[4]

The upper extremities were the most common sites of infection (69.8%), followed by the face/head (16.4%).[4] The manifestations of PCC are diversiform, including ulcers, cellulitis, molluscum contagiosum-like lesions, and whitlow.[5] However, PCC cannot be diagnosed based only on these manifestations. Instead, the diagnosis is based on positive pathogenic microorganism findings. Furthermore, fluconazole and itraconazole are both effective treatment options.[6]

Our patient was an immunocompetent host, whose skin lesions manifested as ulcers localized within faciocervical area. Dust was suspected to have spread pathogens to his respiratory tract.[7] The histology pointed to cryptococcus in the deep section of the dermis and indicated a possible diagnosis of PCC. The ulcers resolved following oral itraconazole intake, and they relapsed following discontinuation of the medication. Thus, itraconazole appeared to be effective in the present case as consistent with the previous findings.[6]

In the present case, the final diagnosis was PCC. The infection was likely confined because of the patient's immunocompetent status. Due to the negative pathogenic microorganism findings in pathological slices and microorganism cultivation, the diagnosis of PCC lacks decisive evidence. Hence, the patient continues to be followed-up.

In conclusion, a diagnosis of PCC should be kept in mind not only for immunosuppressed patients but for immunocompetent patients. In cases of a negative pathogenic microorganism test results where the clinical assessment raises suspicion of PCC and the lesions fail to resolve spontaneously, itraconazole can be started except in those with contraindications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient has understood that his name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

This research was supported by the grants from the National Natural Science Foundation of China (NSFC) (81402594), 2018CMA-L'OREAL China Skin/Hair Grant (S2018-012).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Pappas PG. Cryptococcal infections in non-HIV-infected patients. Trans Am Clin Climatol Assoc 2013;124:61-79.  Back to cited text no. 1
    
2.
Brizendine KD, Baddley JW, Pappas PG. Predictors of mortality and differences in clinical features among patients with cryptococcosis according to immune status. PLoS One 2013;8:e60431.  Back to cited text no. 2
    
3.
Singh N, Dromer F, Perfect JR, Lortholary O. Cryptococcosis in solid organ transplant recipients: Current state of the science. Clin Infect Dis 2008;47:1321-7.  Back to cited text no. 3
    
4.
Christianson JC, Engber W, Andes D. Primary cutaneous cryptococcosis in immunocompetent and immunocompromised hosts. Med Mycol 2003;41:177-88.  Back to cited text no. 4
    
5.
Neuville S, Dromer F, Morin O, Dupont B, Ronin O, Lortholary O, et al. Primary cutaneous cryptococcosis: A distinct clinical entity. Clin Infect Dis 2003;36:337-47.  Back to cited text no. 5
    
6.
Du L, Yang Y, Gu J, Chen J, Liao W, Zhu Y. Systemic review of published reports on primary cutaneous cryptococcosis in immunocompetent patients. Mycopathologia 2015;180:19-25.  Back to cited text no. 6
    
7.
Hanson B, Zhou Y, Bautista EJ, Urch B, Speck M, Silverman F, et al. Characterization of the bacterial and fungal microbiome in indoor dust and outdoor air samples: A pilot study. Environ Sci Process Impacts 2016;18:713-24.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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