A Case of Primary Cutaneous Cryptococcosis in the Setting of Tofacitinib Therapy for Rheumatoid Arthritis

Primary cutaneous cryptococcosis is a rare manifestation of Cryptococcus infection, which can present with diverse clinical manifestations, ranging from solitary nodules or papules to ulcerative lesions or cellulitis-like erythema. A 49-year-old female, a known case of rheumatoid arthritis who was on daily 4 mg of methyl prednisolone and 10 mg of tofacitinib, presented with painful, rapidly progressing ulcers over the right flank for 15 days. A differential diagnosis of pyoderma gangrenosum was considered since patient had rheumatoid arthritis. Histopathological examination of the skin biopsy from the edge of the ulcer showed granulomatous infiltrate with budding yeast forms surrounded by a thick capsule, suggestive of Cryptococcus neoformans . Fungal culture showed milky and creamy colonies on Sabouraud dextrose agar. Patient was initiated on oral Fluconazole 200 mg daily for three months. The ulcers healed completely after three months of treatment. To conclude, in patients with rapidly progressing ulcers, a differential diagnosis of cutaneous cryptococcosis must also be considered.