RETROAURICULAR ULCER IN A PATIENT WITH A HISTORY OF MULTIPLE SKIN CANCERS Tony Nakhla, D.O.,* Helia Eragi, OMS IV,** Mark K. Horowitz, D.O.,*** David C. Horowitz, D.O., F.A.A.D., F.A.O.C.D.**** *3rd-year Dermatology Resident, Western University/Pacific Hospital of Long Beach, CA **4th-year Medical Student, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA ***Assistant Program Director, Western University/Pacific Hospital of Long Beach, CA ****Program Director, Western University/Pacific Hospital of Long Beach, CA ABSTRACT Cutaneous cryptococcosis may result from primary inoculation by the opportunistic mycosis Cryptococcus neoformans or from pulmonary dissemination. The latter form of cutaneous cryptococcosis commonly results from inhalation of pigeon droppings; and although it may occur in immunocompetent hosts, it is more common in immunocompromised patients, especially those with AIDS. We report a case of a 55-year-old male with a cutaneous cryptococcosis lesion presenting as a painful sore on the right postauricular region.
Case Report: A 55-year-old Caucasian male presented to our clinic with a two-week history of a painful sore on the right postauricular region. The patient had a past medical history of multiple non-melanoma skin cancers including five squamous-cell carcinomas and six basal-cell carcinomas, three of which required Mohs. He reported no other significant past medical history and was on no medications. He smoked approximately one pack per day. Physical examination revealed a cachectic, 55-year-old white male with poor hygiene. A large (approx 4.3x3.5 cm), tender, ulcerated, erythematous plaque with impetiginized crusts and purulent drainage was present around and within the right retroauricular sulcus (Figure 1). The differential diagnosis included squamous-cell carcinoma, basal-cell carcinoma, pyoderma gangrenosum and infectious, traumatic, and factitial causes. The patient had no medical insurance and was concerned with procedural costs. He was willing to pay for a complete excision but did not want to pay for a biopsy, since due to his history he was convinced it was another skin cancer that needed to be removed. After counseling the patient, he still refused a biopsy but agreed to be treated medically with oral antibiotics and topical corticosteroids in order to minimize medical expenses. He was instructed to return to the clinic in a week, when a biopsy would be needed if no improvement had occurred. The patient returned in a week with a clinically larger, more fulminant lesion, at which point he eagerly requested that an excision of the entire lesion be performed. Contrary to the patient’s adamant plea for a complete excision, and after lengthy counseling regarding the importance of obtaining a diagnosis prior to treatment, a deep shave biopsy was performed.
Figure 2
Figure 1
Microscopic examination revealed a dome-shaped, granulomatous infiltrate of foreign-body giant cells, lymphocytes, and macrophages (Figure 2). Numerous encapsulated, round-to-ovoid spores were present within macrophages and giant cells as well as in free spaces (Figure 3). A 0!3 STAIN was performed, which highlighted the spores (Figure 4). A MUCICARMINE STAIN was positive, confirming the diagnosis of cutaneous cryptococcosis (Figure 5).
Figure 3-4
Discussion: Cryptococcosis is caused by the opportunistic mycosis cryptococcus neoformans.1 Cutaneous cryptococcosis may result from primary inoculation or from pulmonary dissemination. The latter, secondary form of cutaneous cryptococcosis commonly results from inhalation of pigeon droppings and, although it may occur in immunocompetent hosts, is more common in immunocompromised patients, particularly those with AIDS. The diagnosis of
Figure 5
36 RETROAURICULAR ULCER IN A PATIENT WITH A HISTORY OF MULTIPLE SKIN CANCERS
primary cutaneous cryptococcosis should be made only after a thorough workup for systemic disease.1-2 Cutaneous features vary from ulcerations to cellulitis, as well as molluscum contagiosum-like lesions.2 Diagnosis is made by histopathologic evaluation of lesions that demonstrate characteristic capsulated yeasts. Mucicarmine or Alcian blue are used to highlight the capsule, and India ink is used to evaluate CSF preparations in cases of cryptococcal meningitis.2-3 The treatment for primary cutaneous cryptococcosis is oral antifungal medication, most commonly fluconazole, which is also used as prophylaxis in immunocompromised patients.2-3 Surgical excision of small, localized lesions may also be performed in conjunction with antifungal treatment.4 Disseminated disease carries a poor prognosis and is frequently fatal. Amphotericin B as well as the newer, less toxic systemic antifungals (itraconazole, caspofungin, and variconazole) are used and should be started promptly due to the poor prognosis associated with treatment delay.3,5,6
Conclusion: The suspicion for cutaneous cryptococcosis in this particular case was low when taking into account the close clinical resemblance to and the patient’s strong history of non-melanoma skin cancers. It would have been reasonable to assume the patient had a BCC or SCC and to perform a wide excision or Mohs rather than begin the correct treatment with oral antifungals. This case demonstrates the importance of preventing patient demands from taking precedent over proper diagnostic and treatment plans. Even though we must take into account patients’ financial and social needs, we must not deviate from the standard of care. Although indicated and highly suspicious in this case, our patient refused an immunocompromise workup as well a workup for systemic cryptococcosis. References: 1.
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Christianson JC, Engber W, Andes D. Primary cutaneous cryptococcosis in immunocompetent and immunocompromised hosts. Medical Mycology. 41(3):177-88, 2003 Jun. Revenga F, Paricio JF, Merino FJ, Nebreda T, Ramirez T, Martinez AM. Primary cutaneous cryptococcosis in an immunocompetent host: case report and review of the literature. Dermatology. 204(2):145-9, 2002. Micalizzi C, Persi A, Parodi A. Case reports. Primary cutaneous cryptococcosis in an immunocompetent pigeon keeper. Clinical & Experimental Dermatology. 22(4):195-7, 1997 Jul. Hontanilla B, Ruiz de Erenchun R, Toledo G, Idoate M. Case report. Primary cutaneous Cryptococcosis in an immunocompetent patient: surgical management. Annals of Plastic Surgery. 47(6):683-4, 2001 Dec. Vijaya D, et al. Case report. Disseminated cutaneous cryptococcosis in an immunocompetent host. Mycoses 2001;44:113. Yao Z, et al. Management of cryptococcosis in non-HIVrelated patients. Med Mycol 2005;43:245.
NAKHLA, ERAGI, HOROWITZ, HOROWITZ
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