Figure 1070

Cutaneous cryptococcosis, multiple lesions on the arm. Cryptococcus neoformans is an encapsulated yeast that exists worldwide, predominately in the soil contaminated by bird and other animal droppings. Infection is through inhalation with dissemination to the central nervous system (CNS), skin, mucous membranes, bone, bone marrow, and genitourinary tract. Infection has also occurred through the renal allograft. The most common disease site is the

CNS, where patients present with headache, fever, mental confusion, seizures, papilledema, long tract signs, or, uncommonly, meningismus. The onset of infection is anywhere from 6 months to years following transplantation. The onset may be very insidious, with nausea and headache occurring for weeks to months before the fever develops. Pulmonary involvement presents asymp-tomatically or with dyspnea and cough. The chest radiograph shows wide variability in that circumscribed pulmonary nodules, alveolar infiltrates, interstitial infiltrates with or without effusions, and cavitation may be seen. Cutaneous disease may be the first sign of dissemination in up to 30% of cases. Diagnosis is made by the identification of the yeast in the cerebrospinal fluid (CSF) or pulmonary secretions, the detection of cryptococcal antigen in the CSF or blood, or culture. Amphotericin B is the most common agent used for treatment, with some also favoring the use of flucy-tosine and perhaps azole therapy for maintenance to prevent relapse. Specific patients may be treated with fluconazole alone. Serial determinations of the serum cryptococcal antigen, which is positive in over 95% of patients with cryptococcal meningitis, may help to follow and modify the course of therapy. Patients should be treated until the cryptococcal antigen is negative, and then for another 2 to 4 weeks for added safety.

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