Case Presentation: A 30-year-old man presented to the emergency department with dyspnea, dry cough, and skin lesions developed over the past two weeks. He is a man who has sex with men and immigrated from Thailand five years prior. He had not received primary care because of the lack of insurance and the COVID-19 pandemic. Physical examination was notable for umbilicated papules of the face, neck, and chest. Laboratory studies confirmed a new diagnosis of HIV-1 infection with a viral load of 207,000 copies per milliliter and CD4 cell counts of 13 cells per cubic millimeter. Cryptococcal antigen was detected in serum and cerebrospinal fluid with titers of 1:2,560 and 1:10, respectively. A computed tomographic scan of the chest showed bilateral centrilobular ground-glass opacities with subpleural sparing. The biopsy of the papule revealed budding yeasts on mucicarmine stain consistent with cryptococcosis. Grocott methenamine silver stain of bronchoalveolar lavage fluid also showed fungal organisms morphologically consistent with Cryptococcus species. A diagnosis of disseminated cryptococcosis was made. He completed a two-week course of liposomal amphotericin B and flucytosine and was transitioned to oral fluconazole. Antiretroviral therapy with bictegravir/emtricitabine/tenofovir alafenamide was started after he completed the induction therapy. At follow-up six weeks after initiating antifungal therapy, the dyspnea had resolved, and the skin lesions were fading.

Discussion: Cutaneous lesions are seen in up to 15 % of patients with disseminated cryptococcal infection, and the characteristic umbilicated papules resemble those due to molluscum contagiosum. As most cutaneous cryptococcal lesions represent disseminated infection, lumbar puncture to evaluate for meningoencephalitis and workup for pulmonary cryptococcosis are warranted in patients with skin lesions consistent with cutaneous cryptococcosis. Routine evaluation for central nervous system involvement is especially important because 1) symptoms of meningoencephalitis may develop indolently and the patients frequently lack headaches and meningeal signs, as seen in this patient, and 2) the treatment of cryptococcal meningoencephalitis requires an extended course of antifungal agents including induction therapy for two weeks, followed by consolidative therapy for eight weeks, and then suppressive therapy for a year. Antiretroviral therapy should be started at least two weeks after antifungal therapy has been initiated to reduce the risk of immune reconstitution inflammatory syndrome (IRIS).

Conclusions: Clinicians should have a high index of suspicion for disseminated cryptococcosis in patients with HIV/AIDS presenting with umbilicated skin papules resembling molluscum contagiosum. Evaluation for pulmonary infection with bronchoalveolar lavage and meningoencephalitis with lumbar puncture should be pursued.