The
n e w e ng l a n d j o u r na l
of
m e dic i n e
images in clinical medicine Lindsey R. Baden, M.D., Editor
Disseminated Cryptococcosis A
B
C
Guillaume Martin-Blondel, M.D. Loic Ysebaert, M.D., Ph.D. Toulouse University Hospital Toulouse, France [email protected]
50 µm
A
60-year-old man presented with a 4-week history of progressive skin lesions. For the past 6 years, he had been treated for chronic lymphocytic leukemia (CLL) with successive administration of a combination of rituximab, fludarabine, and cyclophosphamide, a combination of alemtuzumab and dexamethasone, and a combination of rituximab, bendamustine, and methylprednisolone, to which he had had a partial response. His blood CD4+ T-cell count was 20 per cubic millimeter (1%). The physical examination revealed multiple papules of various sizes that were sometimes umbilicated and were located mainly on his face but also on his shoulders, arms, and legs (Panels A and B). The patient also had polyadenopathy related to the CLL. He was otherwise asymptomatic and, in particular, did not present with fever, a decline in general health, or neurologic signs such as headaches, altered mental status, or neck stiffness. The biopsy of one papule revealed numerous encapsulated yeast forms (Panel C, arrowheads; hematoxylin and eosin). Cryptococcus neoformans was cultured from cerebrospinal fluid, blood, urine, and skin, and a test for serum cryptococcal antigen was positive at a titer of 1:400. Amphotericin B plus flucytosine was administered for 3 weeks before he was transitioned to fluconazole. The skin lesions gradually disappeared, with a decrease in the serum cryptococcal antigen titer. DOI: 10.1056/NEJMicm1309435 Copyright © 2014 Massachusetts Medical Society.
n engl j med 370;18
nejm.org
may 1, 2014
The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF GEORGIA on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
1741
n e w e ng l a n d j o u r na l
of
m e dic i n e
images in clinical medicine Lindsey R. Baden, M.D., Editor
Disseminated Cryptococcosis A
B
C
Guillaume Martin-Blondel, M.D. Loic Ysebaert, M.D., Ph.D. Toulouse University Hospital Toulouse, France [email protected]
50 µm
A
60-year-old man presented with a 4-week history of progressive skin lesions. For the past 6 years, he had been treated for chronic lymphocytic leukemia (CLL) with successive administration of a combination of rituximab, fludarabine, and cyclophosphamide, a combination of alemtuzumab and dexamethasone, and a combination of rituximab, bendamustine, and methylprednisolone, to which he had had a partial response. His blood CD4+ T-cell count was 20 per cubic millimeter (1%). The physical examination revealed multiple papules of various sizes that were sometimes umbilicated and were located mainly on his face but also on his shoulders, arms, and legs (Panels A and B). The patient also had polyadenopathy related to the CLL. He was otherwise asymptomatic and, in particular, did not present with fever, a decline in general health, or neurologic signs such as headaches, altered mental status, or neck stiffness. The biopsy of one papule revealed numerous encapsulated yeast forms (Panel C, arrowheads; hematoxylin and eosin). Cryptococcus neoformans was cultured from cerebrospinal fluid, blood, urine, and skin, and a test for serum cryptococcal antigen was positive at a titer of 1:400. Amphotericin B plus flucytosine was administered for 3 weeks before he was transitioned to fluconazole. The skin lesions gradually disappeared, with a decrease in the serum cryptococcal antigen titer. DOI: 10.1056/NEJMicm1309435 Copyright © 2014 Massachusetts Medical Society.
n engl j med 370;18
nejm.org
may 1, 2014
The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF GEORGIA on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
1741
