Case of Disseminated Cryptococcosis Diagnosed in the Context of Left Lower Leg Cellulitis and where Voriconazole is Ineffective, Successfully Treated with Liposomal Amphotericin B and Flucytosine Therapy

We report a case of left lower leg cellulitis caused by disseminated cryptococcosis in a patient with RA. As blood culture tests misidentified it as Candida spp., antifungal treatment with caspofungin was initiated. Furthermore, the patient was switched to oral voriconazole to treat the Schedosporium apiospermum complex that was detected in an upper arm skin ulcer before admission. However, Cryptococcus neoformans was identified in the blood culture tests; therefore, disseminated cryptococcosis was diagnosed. Despite the high concentration of voriconazole in the blood (>4.0 μg/mL) due to the continuation of the treatment, the fungus was identified in the tissue culture from the left lower leg cellulitis and in multiple blood culture tests. Therefore, voriconazole was deemed ineffective and the treatment was changed to liposomal amphotericin B infusion and oral administration of flucytosine as induction therapy, similar to meningitis treatment. Consolidation therapy with fosfluconazole injections and oral fluconazole was followed by oral fluconazole maintenance therapy. The patient recovered and was transferred to another hospital. In rare cases of cellulitis caused by disseminated cryptococcosis, antifungal therapy similar to that used to treat meningitis is considered useful when voriconazole is ineffective.