Clinical Scorecard: Cryptococcal cellulitis may lead to amputation

At a Glance

Key Highlights

• An 81-year-old man with transfusion-dependent myelodysplastic syndrome developed severe right middle-finger infection after a splinter injury.
• The infection progressed despite empiric intravenous antibiotics, leading to amputation through the proximal interphalangeal joint and further procedures for persistent inflammation and poor wound healing.
• Fungal culture and histopathology supported C. neoformans infection; direct microbiological confirmation of tendon-sheath infection was unavailable.
• Negative serum cryptococcal antigen tests and absence of systemic symptoms supported localized infection, but lumbar puncture and chest CT were not performed.
• The patient received surgery and antifungal therapy; treatment was stopped after 9 weeks because of gastrointestinal adverse effects, and the wound was healed at 12 weeks.

Guideline-Based Recommendations

Diagnosis

• Consider primary cutaneous cryptococcosis in progressive cellulitis or suspected flexor tendon sheath infection that fails to respond to conventional antibacterial treatment, particularly after environmental trauma.
• Obtain early deep-tissue samples for fungal culture and histopathology when cryptococcal infection is suspected.
• Assess for systemic dissemination; in this case, negative serum cryptococcal antigen tests and absent systemic symptoms supported localized infection, but occult dissemination was not definitively excluded.

Management

• The authors emphasized timely multidisciplinary management when extensive local tissue involvement is suspected.
• Combined antifungal and surgical treatment may be appropriate in selected patients with extensive or progressive local disease, according to the study authors.
• In this case, initial itraconazole was changed to fluconazole 800 mg daily after C. neoformans identification and susceptibility testing; after 7 weeks, the dose was reduced to 400 mg daily for 2 weeks.

Monitoring & Follow-up

• Follow clinical progression and wound healing; this patient required additional debridement and bone shortening after amputation because of persistent inflammation and poor wound healing.
• At 12 weeks, the wound had healed with scarring and no signs of active infection; the patient remained well 6 months after treatment.

Risks

• The reported infection caused extensive tissue destruction, digital arterial thrombosis, and amputation.
• The patient experienced intolerable gastrointestinal adverse effects during fluconazole treatment, leading to discontinuation after 9 weeks.
• The authors noted that myelodysplastic syndrome may have contributed to the aggressive presentation, but immune function was not directly assessed.

Patient & Prescribing Data

Single case: an 81-year-old man with transfusion-dependent myelodysplastic syndrome, type 2 diabetes, hypertension, and actinic keratosis; he was not receiving chemotherapy, corticosteroids, or immunosuppressive therapy.

Oral itraconazole 200 mg every 12 hours was given for 2 weeks while fungal identification was pending. After C. neoformans confirmation and susceptibility testing, treatment changed to oral fluconazole 800 mg daily for 7 weeks, then 400 mg daily for 2 weeks. Therapy ended because of intolerable gastrointestinal effects and clinical resolution. Surgery and antifungal therapy were used together, so their independent contributions could not be determined.

Clinical Best Practices

• Consider fungal infection when cellulitis progresses despite antibacterial treatment, especially after environmental trauma.
• Obtain deep-tissue fungal cultures and histopathology early when cryptococcosis is suspected.
• Evaluate for systemic dissemination while recognizing that negative serum antigen testing and absent symptoms did not definitively exclude occult disease in this case.
• Coordinate surgical and antifungal management when local disease is extensive or progressive.

Related Resources & Content

• Cureus case report (source article)