European Journal of Internal Medicine 26 (2015) 363–364
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Multiple nodules on the bilateral lower extremities Hsin-Yu Fang a,1, Chia-Hung Chen b,c,1, Wei-Chih Liao b,c,⁎ a b c
Department of Dermatology, China Medical University Hospital, Taiwan Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taiwan Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
a r t i c l e
i n f o
Article history: Received 6 September 2014 Received in revised form 21 September 2014 Accepted 20 October 2014 Available online 30 October 2014 Keywords: Cutaneous cryptococcosis Erythematous nodules Corticosteroid
1. Introduction A 55-year-old female with a history of asthma, diabetes mellitus and hypertension presented with a 2-month history of multiple tender nodules on the bilateral lower extremities. She suffered from asthma and
had been treated with, on average, 10–20 mg prednisolone daily for years. Physical examination revealed multiple erythematous tender nodules, measuring 2–4 cm on the bilateral lower extremities (Fig. 1, Panel A). Ulceration and purulent discharge were found in the largest nodule on the right thigh (Fig. 1, Panel A). We performed a skin biopsy
Fig. 1. Panel A: Multiple erythematous tender nodules, measuring 2–4 cm on the bilateral lower extremities; and ulceration and purulent discharge were found from the largest nodule on the right thigh. Panel B: The pathology report of biopsy showed a dense suppurative granulomatous inflammation with numerous encapsulated yeast-like organisms. Panel C: Chest CT scan revealed diffuse nodules in bilateral lungs. ⁎ Corresponding author at: Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, No. 2, Yude Road, Taichung, Taiwan. Tel.: +886 4 22052121x3484; fax: +886 4 22038883. E-mail address: [email protected] (W.-C. Liao). 1 Both authors contributed equally to this article.
http://dx.doi.org/10.1016/j.ejim.2014.10.015 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
364
H.-Y. Fang et al. / European Journal of Internal Medicine 26 (2015) 363–364
on the right thigh nodular lesion (Fig. 1, Panel B). A chest computed tomography (CT) scan (Fig. 1, Panel C) was also arranged. What is the diagnosis?
verify, which can present as a non-specific lesion. It is crucial to include Cryptococcus in the differential diagnosis of cutaneous lesions in patients on long-term treatment with corticosteroids or other immunosuppressive patients.
2. Diagnosis
Contributorship
The skin biopsy showed a dense suppurative granulomatous inflammation with numerous encapsulated yeast-like organisms. Microbiological cultures of the biopsy specimen and pus grew Cryptococcus neoformans. The chest CT scan revealed diffuse nodules in bilateral lungs, which suggested hematogenous spread. Together with the serum, histopathologic and image findings, a diagnosis of disseminated cryptococcosis was made. The patient was hospitalized and treated with intravenous amphotericin B and flucytosine. After one month of treatment, the ulcers began to heal and the nodules decreased in size. C. neoformans is an opportunistic fungus, which primarily affects patients with immunological defects. In our patient, her history of diabetes mellitus and long-term use of corticosteroids both contributed to the immunological impairment and represented the main predisposing factors for cryptococcosis. Cutaneous involvement is rare in disseminated cryptococcosis. Many manifestations had been described, such as papules, pustules, ulcers, plaques and nodules [1,2]. Cutaneous cryptococcosis presenting as cellulitis, erythema nodosum and necrotizing fasciitis had also been reported [3]. Because of its various clinical morphologies, disseminated cutaneous cryptococcosis is very difficult to
Hsin-Yu Fang wrote the report. Chia-Hung Chen provided case details and planned the report. Wei-Chih Liao supervised the report. Funding information This report received no specific funding. Conflict of interests There are no competing interests. References [1] Pappas PG, Perfect JR, Cloud GA, Larsen RA, Pankey GA, Lancaster DJ, et al. Cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy. Clin Infect Dis 2001;33:690–9. [2] Pema K, Diaz J, Guerra LG, Nabhan D, Verghese A. Disseminated cutaneous cryptococcosis: comparison of clinical manifestations in the pre-AIDS and AIDS eras. Arch Intern Med 1994;154:1032–4. [3] Ni W, Huang Q, Cui J. Disseminated cryptococcosis initially presenting as cellulitis in a patient suffering from nephrotic syndrome. BMC Nephrol 2013;14.
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Multiple nodules on the bilateral lower extremities Hsin-Yu Fang a,1, Chia-Hung Chen b,c,1, Wei-Chih Liao b,c,⁎ a b c
Department of Dermatology, China Medical University Hospital, Taiwan Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taiwan Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
a r t i c l e
i n f o
Article history: Received 6 September 2014 Received in revised form 21 September 2014 Accepted 20 October 2014 Available online 30 October 2014 Keywords: Cutaneous cryptococcosis Erythematous nodules Corticosteroid
1. Introduction A 55-year-old female with a history of asthma, diabetes mellitus and hypertension presented with a 2-month history of multiple tender nodules on the bilateral lower extremities. She suffered from asthma and
had been treated with, on average, 10–20 mg prednisolone daily for years. Physical examination revealed multiple erythematous tender nodules, measuring 2–4 cm on the bilateral lower extremities (Fig. 1, Panel A). Ulceration and purulent discharge were found in the largest nodule on the right thigh (Fig. 1, Panel A). We performed a skin biopsy
Fig. 1. Panel A: Multiple erythematous tender nodules, measuring 2–4 cm on the bilateral lower extremities; and ulceration and purulent discharge were found from the largest nodule on the right thigh. Panel B: The pathology report of biopsy showed a dense suppurative granulomatous inflammation with numerous encapsulated yeast-like organisms. Panel C: Chest CT scan revealed diffuse nodules in bilateral lungs. ⁎ Corresponding author at: Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, No. 2, Yude Road, Taichung, Taiwan. Tel.: +886 4 22052121x3484; fax: +886 4 22038883. E-mail address: [email protected] (W.-C. Liao). 1 Both authors contributed equally to this article.
http://dx.doi.org/10.1016/j.ejim.2014.10.015 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
364
H.-Y. Fang et al. / European Journal of Internal Medicine 26 (2015) 363–364
on the right thigh nodular lesion (Fig. 1, Panel B). A chest computed tomography (CT) scan (Fig. 1, Panel C) was also arranged. What is the diagnosis?
verify, which can present as a non-specific lesion. It is crucial to include Cryptococcus in the differential diagnosis of cutaneous lesions in patients on long-term treatment with corticosteroids or other immunosuppressive patients.
2. Diagnosis
Contributorship
The skin biopsy showed a dense suppurative granulomatous inflammation with numerous encapsulated yeast-like organisms. Microbiological cultures of the biopsy specimen and pus grew Cryptococcus neoformans. The chest CT scan revealed diffuse nodules in bilateral lungs, which suggested hematogenous spread. Together with the serum, histopathologic and image findings, a diagnosis of disseminated cryptococcosis was made. The patient was hospitalized and treated with intravenous amphotericin B and flucytosine. After one month of treatment, the ulcers began to heal and the nodules decreased in size. C. neoformans is an opportunistic fungus, which primarily affects patients with immunological defects. In our patient, her history of diabetes mellitus and long-term use of corticosteroids both contributed to the immunological impairment and represented the main predisposing factors for cryptococcosis. Cutaneous involvement is rare in disseminated cryptococcosis. Many manifestations had been described, such as papules, pustules, ulcers, plaques and nodules [1,2]. Cutaneous cryptococcosis presenting as cellulitis, erythema nodosum and necrotizing fasciitis had also been reported [3]. Because of its various clinical morphologies, disseminated cutaneous cryptococcosis is very difficult to
Hsin-Yu Fang wrote the report. Chia-Hung Chen provided case details and planned the report. Wei-Chih Liao supervised the report. Funding information This report received no specific funding. Conflict of interests There are no competing interests. References [1] Pappas PG, Perfect JR, Cloud GA, Larsen RA, Pankey GA, Lancaster DJ, et al. Cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy. Clin Infect Dis 2001;33:690–9. [2] Pema K, Diaz J, Guerra LG, Nabhan D, Verghese A. Disseminated cutaneous cryptococcosis: comparison of clinical manifestations in the pre-AIDS and AIDS eras. Arch Intern Med 1994;154:1032–4. [3] Ni W, Huang Q, Cui J. Disseminated cryptococcosis initially presenting as cellulitis in a patient suffering from nephrotic syndrome. BMC Nephrol 2013;14.
