Cryptococcal cellulitis in a patient with bullous pemphigoid.

Cryptococcosis is a rare, life-threatening fungal infection caused by the yeast-like encapsulated fungus Cryptococcus neoformans. It is considered an opportu-nistic infection as it affects mainly immunosuppressed individuals (1, 2). The disease is believed to be acquired mainly by inhalation of the infectious propagule from the environment. In humans, C. neoformans causes various kinds of clinical manifestations; meningoencephalitis, pneumonia, skin lesions, eye lesions, bone involvement, etc. (3). AIDS is the predisposing factor in approximately 90% of cryptococcal infections (4). Other defects in T-cell-mediated immunity are also predisposing factors of infection, such as haematological malignancies (4). We report here an elderly male patient with bullous pemphigoid (BP) who was complicated with cryptococ-cal cellulites. A 79-year-old man, living in a big city in Japan, presented with swelling, erythema and severe pain of the left arm. The skin lesions had developed rapidly. The patient reported an accidental injury of the left arm before the skin lesions. The patient had had BP for one year and had been treated with oral prednisolone at 17.5 mg daily from the onset of the lesion on the arm. The diagnosis of BP was based on skin manifestations of generalized multiple bullae (Fig. 1), histological features of subepidermal blisters with eosinophilic infiltration, deposition of IgG and C3 at the dermal basement membrane zone, and high-titre circulating anti-BP180 antibodies detected with BP180 enzyme-linked im-munoassay (ELISA) (MBL Intl. Corp., Nagoya, Japan). On examination, the left forearm exhibited swelling and ery-thema, suggesting cellulitis. The left axillary lymph nodes were palpable. The results of blood examination were as follows: white blood cell count of 11,600/µl (normal: 4,000–8,000/µl), C-reactive protein of 6.77 mg/dl (< 0.30 mg/dl), urea nitrogen of 30 mg/ dl (10–15 mg/dl), creatinine of 1.15 mg/dl (0.60–1.10 mg/dl), and lactate dehydrogenase of 315 U/l (125–225 U/l). Other data were within normal limits, including beta-D glucan of < 6.0 pg/ ml (< 11.0 pg/ml) and circulating antibodies to HIV of 0.1 S/CO (< 1.0 S/CO). Intravenous piperacillin 2 g × 2/day was initiated for 1 week as an empirical treatment for bacterial cellulitis. Pairs of blood cultures were negative. One week later, intravenous merope-nem at 0.5 g × 2/day was administered. However, no improvement in the cellulitis of the left arm was perceived. Finally, histopathological observations of a skin biopsy specimen from the cellulitis with haematoxylin-eosin stain, Grocott stain and periodic acid-Schiff stain revealed yeast-like microbes 2 weeks after the administration of antibiotics. …