Case Presentation: A 53 year-old woman with Type 2 Diabetes Mellitus presented with six days of painful rashes that began on her arms then spread to her face, scalp, and tongue. She reported fever of 38.8 °C, chills, nausea, emesis, and odynophagia. Her house was by a farm, but she did not tend animals.
Vitals signs were 166/77 mm Hg, PR 70 bpm, RR 16 bpm, and T 37.2 °C. Examination revealed thick, macerated white papules on the tongue; crusting of the lips and oral mucosa; and indurated, shiny, red papules on her arms, dorsal hands, cheeks, and scalp. She had no external genitourinary or rectal sloughing.

Hemoglobin was 5.9 g/dL and absolute lymphocyte count was reduced to 0.27 k/uL. She underwent endoscopy which showed multiple ulcers in the jejunum; but the biopsy was negative for infection. Autoimmune panel was negative. Infectious studies of the serum, urine, and cerebrospinal fluid were negative. Skin biopsy demonstrated pleomorphic yeasts that stained with the Grocott-Gömöri methenamine silver stain. Pathology showed a large amount of yeast with vacuolated spaces in the dermis with peripheral necrosis and degeneration; and the capsule walls accentuated with mucicarmine stain which was consistent with Primary Cutaneous Cryptococcosis.

Discussion: Fever with rash are commonly encountered by general internists, but Primary Cutaneous Cryptococcosis (PCC) is a rare cause. There are 21 reported cases as of 2015 systemic review of published reports. Cryptococcus neoformans is ubiquitous in soil contaminated with avian excreta. Patients with acquired immune deficiency syndrome, hematologic malignancy, solid organ transplant recipient on immunosuppressive agents, and chronic glucocorticoid therapy are at high risk for dissemination.

Conclusions: In this case, diabetes mellitus, which impairs proper macrophage function, likely increased her risk for this infection. Cryptococcus has tropism for the central nervous system (CNS) and skin lesions are sentinel for dissemination. Meningeal involvement leads to high mortality and morbidity and requires prolonged IV amphotericin. Therefore, it is critical to rule out CNS involvement before reaching the conclusion of PCC, which is treated with oral fluconazole and has a favorable prognosis for immunocompetent hosts.