Primary Cutaneous Cryptococcal Granuloma in a Child By T. Viswanatha
Rao, K. Sreenivasa Andhra
Rao, and C. V. Satyanarayana
Pradesh,
India
Primary cutaneous cryptococcosis is rare, and usually occurs in the form of acneform pustules, granuloma-like ulcers, deep seated abscesses or tumor-like lesions on the skin. These tumor-like lesions mimic ‘Myxomas’ and are formed of pure culture of cryptococcus neoformans. The first case of primary cutaneous form was reported by Rappaport and Kaplan.’ Of the five cases found in the literature up to 1972, four were in adults beyond 40 yr and one was a female of 29 yr.’ Our case is unique in that the lesion presented in a IO-yr-old girl. CASE
REPORT
F.C. (9 yr) was admitted into the Paediatric Surgical Unit, King George Hospital, Visakhapatnam in November 1974 with a complaint of a painless, gradually increasing swelling on the left popliteal fossa, of 44 mo duration. Flexion movement of knee joint became limited due to mechanical obstruction by the tumor. The swelling ulcerated a month prior to admission with foul smelling serous discharge. At this stage she had pain. There was no history of preceeding trauma, no cough, no fever. Bowels and micturition were normal.
Local Examination A large hemispherical brownish swelling, 4 inches in diameter, was present on the left popliteal fossa. There was ulceration on the surface with serous discharge. The floor was covered by slough. The swelling was firm, nontender, and mobile from side to side. Movements of the knee joint were painful and terminal degrees of flexion restricted. There were no visible veins or pulsations and no evidence of neurologic or vascular deficit. While under examination the swelling with overlying skin shelled out enmass leaving a big ulcer covered with unhealthy granulations. The edge of the ulcer was pigmented and indurated. Regional lymph nodes were not enlarged. Biopsy of the edge of the ulcer was done. The ulcer healed, following local dressings and systemic injections of streptomycin and penicillin for 3 weeks. The child has been followed-up for 4 mo with no evidence of local recurrence or dissemination. Grossly the tumor was 4 inches x 4 inches, oval and soft. The cut section was gelatinous and slippery with a myxomatous appearance characteristically described as gelatinous tumor. Microscopically it showed pure culture of Cryptococcus neoformans with gelatinous thick capsules around the fungus. In areas, budding of the fungus was clearly noted (Fig. I). As it was a pure culture-like growth with no inflammatory cell reaction, culture of the fungus was thought superfluous. Microscopically the skin showed hypertrophy with hyperplasia of Rete pegs with corium and islands of Cryptococcus neoformans fungus encircled by heavy infiltrations of polymorphs, plasma cells, lymphocytes,
and histiocytes
with a few giant cells.
DISCUSSION Noble and Jajardo’ have laid down certain criteria for the diagnosis of a primary cutaneous lesion. (I) The lesion is confined to skin and subcutis. (2) The diagnosis is confirmed by biopsy. (3) Culture of C.C. neoformans is positive. (4) There must have been no clinical evidence of systemic involvement during a minimum period of 4 wk. Direct inoculation through the skin has been accepted as the mode of entry by many authors. Cutaneous Cryptococcosis has been experimentally produced in the monkey by Weidman.3 Gelatinous tumor-like lesions simulating coagulated serum with no inflammatory reaction in the
0 1976 by Grune & Swatron,
Inc.
Journal of Pediatric Surgery, Vol. 11, No. 2 (April), 1976
267
CASE REPORTS
Fig. 1.
Primary cutaneous CrypYococal gmnuloma.
mass but consisting of pure culture of the fungus cryprococcus is a rare occurrence and few, if, any, symptoms are noted. This type of self-limiting, healing lesion is uncommon in comparison to severe devastating generalized fatal disease. Although the reasons for this difference in course are not fully understood, observations define two clinical situations, namely, infection of a host with apparently normal immune mechanism, and infection of a host with suppressed immune mechanism producing disseminated progressive fatal disease. Amphotericin-B is considered the drug of choice for Cryp~ococcus neoformans, but this drug was not available. The lesion in our patient healed with local wound care and daily penicillin and streptomycin.
REFERENCES I. Rappaport torula mycosis.
BZ, Kaplan B: Generalized Arch Pathol 1:720, 1926
2. Robert
Luis F, Jajardo:
C Noble,
Primary
cutaneous
cryptococcosis,
review
and
morpho-
logic study. Am J Clin Pathol57: 13-22, 1972 3. Weidmann FD: Cutaneous torulosis in a monkey. Arch Dermatol Syph 27:720, 1933
Rao, K. Sreenivasa Andhra
Rao, and C. V. Satyanarayana
Pradesh,
India
Primary cutaneous cryptococcosis is rare, and usually occurs in the form of acneform pustules, granuloma-like ulcers, deep seated abscesses or tumor-like lesions on the skin. These tumor-like lesions mimic ‘Myxomas’ and are formed of pure culture of cryptococcus neoformans. The first case of primary cutaneous form was reported by Rappaport and Kaplan.’ Of the five cases found in the literature up to 1972, four were in adults beyond 40 yr and one was a female of 29 yr.’ Our case is unique in that the lesion presented in a IO-yr-old girl. CASE
REPORT
F.C. (9 yr) was admitted into the Paediatric Surgical Unit, King George Hospital, Visakhapatnam in November 1974 with a complaint of a painless, gradually increasing swelling on the left popliteal fossa, of 44 mo duration. Flexion movement of knee joint became limited due to mechanical obstruction by the tumor. The swelling ulcerated a month prior to admission with foul smelling serous discharge. At this stage she had pain. There was no history of preceeding trauma, no cough, no fever. Bowels and micturition were normal.
Local Examination A large hemispherical brownish swelling, 4 inches in diameter, was present on the left popliteal fossa. There was ulceration on the surface with serous discharge. The floor was covered by slough. The swelling was firm, nontender, and mobile from side to side. Movements of the knee joint were painful and terminal degrees of flexion restricted. There were no visible veins or pulsations and no evidence of neurologic or vascular deficit. While under examination the swelling with overlying skin shelled out enmass leaving a big ulcer covered with unhealthy granulations. The edge of the ulcer was pigmented and indurated. Regional lymph nodes were not enlarged. Biopsy of the edge of the ulcer was done. The ulcer healed, following local dressings and systemic injections of streptomycin and penicillin for 3 weeks. The child has been followed-up for 4 mo with no evidence of local recurrence or dissemination. Grossly the tumor was 4 inches x 4 inches, oval and soft. The cut section was gelatinous and slippery with a myxomatous appearance characteristically described as gelatinous tumor. Microscopically it showed pure culture of Cryptococcus neoformans with gelatinous thick capsules around the fungus. In areas, budding of the fungus was clearly noted (Fig. I). As it was a pure culture-like growth with no inflammatory cell reaction, culture of the fungus was thought superfluous. Microscopically the skin showed hypertrophy with hyperplasia of Rete pegs with corium and islands of Cryptococcus neoformans fungus encircled by heavy infiltrations of polymorphs, plasma cells, lymphocytes,
and histiocytes
with a few giant cells.
DISCUSSION Noble and Jajardo’ have laid down certain criteria for the diagnosis of a primary cutaneous lesion. (I) The lesion is confined to skin and subcutis. (2) The diagnosis is confirmed by biopsy. (3) Culture of C.C. neoformans is positive. (4) There must have been no clinical evidence of systemic involvement during a minimum period of 4 wk. Direct inoculation through the skin has been accepted as the mode of entry by many authors. Cutaneous Cryptococcosis has been experimentally produced in the monkey by Weidman.3 Gelatinous tumor-like lesions simulating coagulated serum with no inflammatory reaction in the
0 1976 by Grune & Swatron,
Inc.
Journal of Pediatric Surgery, Vol. 11, No. 2 (April), 1976
267
CASE REPORTS
Fig. 1.
Primary cutaneous CrypYococal gmnuloma.
mass but consisting of pure culture of the fungus cryprococcus is a rare occurrence and few, if, any, symptoms are noted. This type of self-limiting, healing lesion is uncommon in comparison to severe devastating generalized fatal disease. Although the reasons for this difference in course are not fully understood, observations define two clinical situations, namely, infection of a host with apparently normal immune mechanism, and infection of a host with suppressed immune mechanism producing disseminated progressive fatal disease. Amphotericin-B is considered the drug of choice for Cryp~ococcus neoformans, but this drug was not available. The lesion in our patient healed with local wound care and daily penicillin and streptomycin.
REFERENCES I. Rappaport torula mycosis.
BZ, Kaplan B: Generalized Arch Pathol 1:720, 1926
2. Robert
Luis F, Jajardo:
C Noble,
Primary
cutaneous
cryptococcosis,
review
and
morpho-
logic study. Am J Clin Pathol57: 13-22, 1972 3. Weidmann FD: Cutaneous torulosis in a monkey. Arch Dermatol Syph 27:720, 1933
