Primary cutaneous cryptococcosis presenting as a whitlow.

443 Letters to the Editor Sir, Cryptococcosis, an opportunistic yeast infection with Cryptococcus neoformans, remains the most common systemic fungal infection in immunosuppressed patients. Cutaneous cryptococcosis is usually secondary to haema-togenous dissemination. Primary cutaneous cryptococ-cosis (PCC) is characterized by skin lesions confined to one body region, positive culture for C. neoformans, and no evidence of simultaneous dissemination (1). We describe here a rare case of PCC in a male with normal cell-mediated immunity. CASe rePort A previously healthy 71-year-old man presented to our accident and emergency department the day after suddenly developing a painful, erythematous and oedematous skin lesion on the pulp of the thumb of the right hand and pyrexia of 38°C. A small pustular area was noted and culture was performed. He denied trauma at the site of the whitlow or contact with bird excreta, but careful questioning evidenced handling of clothing in very poor hygienic conditions whilst working for an aid organization. General physical examination was otherwise unremarkable. Cloxacillin was given orally, but 7 days after initial presentation there was a lack of clinical response and the whitlow became haemorrhagic (Fig. 1). Culture of the pustule yielded C. neoformans var. neoformans. A full battery of biochemical tests, including urea and electrolytes, liver, bone, protein and thyroid function test, tumour markers, t-cell subset analysis, serum and urinary electrophoresis were within reference ranges. Human immunodeficiency virus (HIV) serology, serum cryp-tococcal antigen testing, urine and blood cultures were negative. Chest radiograph showed no abnormalities and Mantoux test produced 25 mm of induration. the patient refused lumbar puncture and was given oral fluconazole at a dose of 400 mg per day for one month, achieving complete lesion clearance, and 200 mg/day for a further 2 months. Neither skin recurrence nor systemic dissemination has appeared during outpatient follow-up for 3 years. DISCUSSIoN C. neoformans is found worldwide as a soil organism affecting patients with impaired cell-mediated immunity (infection with HIV, complication of solid organ transplantation, lymphoma or corticosteroid therapy) but also immunocompetent individuals. C. neoformans is encapsulated yeast with 4 distinguishable serotypes: serotype A (C. neoformans var. grubii) has a worldwide distribution; serotype D (C. neoformans var. neofor-mans) is found mostly in europe; and serotypes B and C (C. neoformans var. gattii) are limited to tropical and subtropical areas (1). Although the exact mechanism of infection is unknown, the airway is thought to be the main portal of entry, with subsequent spread …