Objective:

To describe a case of rapidly progressive primary cutaneous cryptococcosis with extensive tissue destruction despite no clinically apparent systemic dissemination.

Approach:

• Case: An 81-year-old man with transfusion-dependent myelodysplastic syndrome developed severe right middle-finger infection after a splinter injury.
• Assessment: The patient underwent surgical exploration, cultures, histopathology, and evaluation for systemic infection.
• Treatment and follow-up: Management included surgery and antifungal therapy, with clinical follow-up after treatment.

Key Findings:

• Fungal culture and histopathology identified Cryptococcus neoformans; routine bacterial cultures were negative.
• Operative findings suggested flexor tendon sheath involvement, but tendon-sheath specimens were not specifically collected for microbiological confirmation.
• Rapid progression led to amputation through the proximal interphalangeal joint, followed by further debridement and bone shortening.
• Blood cultures and serum cryptococcal antigen tests were negative, and chest radiography was normal; lumbar puncture and chest CT were not performed.
• After itraconazole was replaced with fluconazole, treatment was stopped after 9 weeks because of gastrointestinal adverse effects and clinical resolution. The wound was healed at 12 weeks, and the patient remained well 6 months after treatment.

Interpretation:

The authors report that primary cutaneous cryptococcosis can progress rapidly with severe local tissue destruction, even without clinically apparent systemic dissemination. They advise considering it in progressive cellulitis or suspected flexor tendon sheath infection that does not respond to antibacterial treatment, particularly after environmental trauma.

Limitations:

• Occult systemic dissemination was not definitively excluded because lumbar puncture and chest CT were not performed.
• Cryptococcal infection of the tendon sheath was not directly confirmed microbiologically.
• The contribution of myelodysplastic syndrome to disease severity was uncertain; immune function was not directly assessed.
• Because surgery and antifungal therapy were combined, their individual contributions to recovery could not be determined.

Conclusion:

The authors state that early deep-tissue sampling for fungal culture and histopathology, assessment for dissemination, and timely multidisciplinary management are important when extensive local involvement is suspected. Combined antifungal and surgical treatment may be appropriate in selected patients with extensive or progressive disease.

Sources:

• Cureus case report (source named in provided context)