A case of combined infection of cutaneous cryptococcosis and multiple other bacteria including MRSA manifesting as multiple abscesses and ulcer formation on the extremities

A 77-year-old man had received corticosteroid substitution therapy for secondary adrenocortical insufficiency caused by frequent oral administration of prednisolone for his repeated bronchial asthma attacks and had acquired steroid-induced diabetes mellitus due to the corticosteroid treatments. He had rubefaction, swelling, and local heat on the right ring finger and dorsal hand, and was diagnosed with cellulitis when he was hospitalized for an acute exacerbation of his chronic heart failure. Despite antibiotic treatment, similar skin lesions appeared on his right upper arm, left hand, and left leg. Skin biopsies of the lesions showed histological findings of erythema nodosum and loxoprofen, a nonsteroidal anti-inflammatory drug, was given orally. However, the treatment had to be terminated due to an exacerbation of his bronchial asthma attacks. In the meantime, his skin lesions further deteriorated, forming multiple abscesses and ulcers that required surgical debridement. Cryptococcus neoformans and Micrococcus species were then cultured from the subcutaneous abscesses and/or ulcers on his right hand and right upper arm. Further, methicillin-resistant Staphylococcus aureus (MRSA) and Citrobacter koseri were cultured from the skin abscesses and ulcers on his left leg. Cryptococcus fungus bodies were confirmed in the previous skin biopsy specimen after reexamination. The intravenous administration of fluconazole, doripenem, and vancomycin was ineffective, but switching from fluconazole to amphotericin B significantly improved his skin lesions. Orally administered itraconazole was also effective after his discharge and during follow-up.