Primary cutaneous cryptococcosis (PCC) is acquired through direct inoculation of Cryptococcus neoformans into wounds or damaged skin, typically resulting in a localized infection confined to a single cutaneous site. Progression of PCC to disseminated cryptococcosis is extremely rare. The purpose of this case report is to describe an unusual instance of PCC progressing into disseminated disease in an immunosuppressed older patient and to highlight the importance of considering cryptococcosis as a differential diagnosis of cutaneous lesions unresponsive to antimicrobial therapy. We report the case of an 88-year-old woman with Evans syndrome receiving oral prednisolone (17.5 mg/day) who also had diabetes mellitus and engaged in home gardening. She developed redness, swelling, and induration of the right forearm 18 days before admission and was treated with cefazolin for presumed cellulitis. Subsequently, yeast-like fungi were detected from the wound and blood cultures on hospital day 7, and C. neoformans was identified on hospital day 8, leading to the diagnosis of disseminated cryptococcosis. Antifungal therapy with amphotericin B (150 mg/day) and flucytosine (2.5 mg/day) was initiated the same day. C. neoformans was later isolated from cerebrospinal fluid. Despite antifungal treatment, her condition progressively deteriorated, and she died. This case illustrates an exceptionally rare progression of PCC to disseminated disease in an older immunosuppressed patient. It highlights the need for heightened clinical suspicion of cryptococcosis when cutaneous lesions fail to respond to antimicrobial therapy, particularly in individuals receiving corticosteroids or with additional risk factors such as diabetes or soil exposure. Early recognition and appropriate antifungal management are essential to prevent fatal outcomes.
Maruta et al. (Thu,) studied this question.