Response to the case report “Disseminated and cutaneous cryptococcosis by C. neoformans VNI in immunocompetent patient”: An insight on differential diagnoses

Resposta ao relato de caso “Criptococose disseminada e cutânea por C. neoformans VNI em paciente imunocompetente”: uma visão acerca de diagnósticos diferenciais

Laís C. Lima; João Pedro E. Gomes; Carlos Otávio Gonçalves
Universidade do Sul de Santa Catarina (UNISUL), Tubarão, Santa Catarina, Brazil
DOI: 10.5935/1676-2444.20210052

Dear editor,

The case report by Maranhão et al., published in 2020(1), addresses an immunocompetent adult individual with a clinical history of facial lesion and latent pneumonia, who was misdiagnosed with paracoccidioidomycosis. The patient was referred to a hospital complaining of facial lesions that appeared two months before, as well as persistent headache and night fever. According to his morbid history, he affirmed to work in a region with many pigeons, where he suffered a nose lesion with ceramic material. Ten years ago, he presented a wound that did not heal, constant cough and fever for a period of one month and 20 days(1). As the patient was initially misdiagnosed, it is essential to validate and understand the importance of differential diagnoses.

By analyzing the history of an individual with complaints of prolonged cough and fever for nearly two months in association with the current condition, it is possible to consider a differential diagnosis of tuberculosis, since Mycobacterium tuberculosis primarily affects the lung, and may progress to other organs such as the central nervous system and the skin. In the case reported(1), the patient sought a dermatologist for a skin complaint, who, based on his clinical condition, would reinforce the possibility of tuberculosis. However, cutaneous involvement by tuberculosis is a challenging diagnosis due to the great clinical, histopathological, and immunological variations and the difficulty in obtaining microbiological confirmation(2).

The patient’s dermatological lesions observed on physical examination are characterized as erythematous-papular lesions, with nodular and verrucous lesions distributed over the face, ears, and scalp. According to these characteristics, a cryptococcosis with skin lesion is considered a “molluscum-like” lesion(3). Thus, another possible differential diagnosis concerning the dermatological lesion presented in the case report is an infection with molluscum contagiosum. However, the absence of central umbilication and the association with other types of skin lesions make the diagnosis of this infection difficult(4). However, the other symptoms reported by the patient could not be justified only by the molluscum contagiosum infection, requiring exploring other causes for this symptomatology.

In such context, it is concluded that other hypotheses could be discussed given the initial clinical condition presented by the patient since tuberculosis and molluscum contagiosum infection are just some diagnostic possibilities for the clinical report. Therefore, it is essential to always attempt to the clinical investigation to collect important details for the development of differential diagnosis.

Key words: Molluscum contagiosum; Mycobacterium tuberculosis; Cryptococcus neoformans; differential diagnosis.