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| Cryptococcus neoformans:
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| Keywords (immunodeficiency): HIV, antiretroviral therapy, oropharyngeal thrush, hepatosplenomegaly, central umbilication, central necrosis, hemorrhagic crust.
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| *Cryptococcus neoformans is an encapsulated yeast
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| *Occurs in patients with advanced HIV (CD4<100/mm3)
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| *The most common manifestation is meningoencephalitis
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| *Pulmonary and/or disseminated disease may occur
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| *Cutaneous cryptococcosis considered as a marker of disseminated disease
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| *Rapid onset (2 weeks) of multiple widespread papular lesions with central umbilication
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| *Diagnostic clue is the presence of a small area of central hemorrhage or necrosis
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| *Resembles molluscum contagiosum
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| *Most common areas affected are head and neck
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| *Disseminated infections can affect liver, lymph nodes, peritoneum, adrenal gland, and eyes
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| *Diagnosis
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| **Biopsy of the lesion
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| **Histopathological examination after staining (periodic acid-Schiff, Gomori methenamine silver nitrate)
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| **Hyperplasia of the overlying dermis with underlying granulomas surrounding encapsulated yeasts
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| **Fungal blood culture is often positive in severe disseminated cryptococcal disease but a biopsy is more sensitive and specific than blood culture (because untreated HIV patients have multiple ongoing opportunistic infections)
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| **The most common wrong answer is skin scrapings with a microscopic evaluation which is used for the diagnosis of fungal infections as tinea or candidiasis.
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| *Treatment:
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| **>/= 2 weeks of IV amphotericin B plus oral flucytosine
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| **Followed by a year of oral fluconazole (higher dose for 8 weeks, then maintenance)
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| DD:
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| *Kaposi Sarcoma:
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| **Primarily presents in homosexual men(men with HIV who are sexually active with other men)
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| **Red or purple papules with no necrosis
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| *Disseminated Mycobacterium avium complex:
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| **Common opportunistic infection
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| **Affects patients with advanced AIDS
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| **Presents as fever, night sweats, abdominal pain, diarrhea, weight loss
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| **Cutaneous lesions are uncommon and are usually nodular and ulcerating
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| *Pyoderma gangrenosum:
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| **Rare neutrophilic dermatitis
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| **Associated with inflammatory bowel disease and inflammatory arthritides
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| **Presents as a tender papule that degrades into a bluish, violaceous ulcer
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| *Basal cell carcinoma
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| **Single, pink, flesh-colored papules
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| **Arise slowly
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