A 47-year-old man comes to a homeless shelter clinic due to 2 weeks of skin rash. The patient was recently hospitalized and treated for an infection, but he is unsure of the details. He was diagnosed with HIV 10 months ago and is not on antiretroviral therapy. He also has a history of chronic kidney disease and hypertension. He takes no medication regularly. The patient drinks 1-2 cans of beer daily and does not use tobacco. Temperature is 37.2 C (99.0 F) , blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 14/min. BMI is 17 kg/m². Oropharyngeal thrush is present. Cardiopulmonary auscultation reveals clear lung fields, and normal first and second heart sounds without murmur or gallop. The abdomen is soft and nontender. The liver is palpable 3 cm below the costal margin, and mild splenomegaly is present. Neurological examination shows no abnormalities. Multiple small papules with central umbilication are present on the face, neck, trunk, and upper thighs. Some of the lesions have central necrosis and are covered with a hemorrhagic crust.
Which of the following is the most likely diagnosis for this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient with untreated HIV has widespread skin papules with umbilication, suggesting cutaneous cryptococcosis. Cryptococcus neoformans is an encapsulated yeast that primarily affects patients who are significantly immunocompromised, particularly those with AIDS with CD4 counts <100/mm³. Although meningoencephalitis is the most common manifestation, pulmonary and/or disseminated disease may occur. encapsulated yeast Cutaneous cryptococcosis is usually a manifestation of disseminated infection. Lesions tend to arise quickly with the head and neck preferentially affected. Although appearance may vary, the most common form is papules with central umbilication that resemble molluscum contagiosum. A small area of central hemorrhage or necrosis is an important diagnostic clue. papules with central umbilication Disseminated infections also often affect the liver, lymph nodes, peritoneum, adrenal glands, and eyes. (Choice A) Cryptococcal skin infections occasionally resemble basal cell carcinoma (pink, flesh-colored papules). However, this patient has multiple lesions (not a single lesion) that arose quickly (not slowly), making basal cell carcinoma unlikely. basal cell carcinoma (Choice C) Disseminated Mycobacterium avium complex is a common opportunistic infection in patients with advanced AIDS that usually manifests with fever, night sweats, abdominal pain, diarrhea, and weight loss. Cutaneous lesions are uncommon and are usually nodular and ulcerating. (Choice D) Kaposi sarcoma is seen primarily in men with HIV who are sexually active with other men. Lesions are typically red or purple papules with no necrosis. purple papules (Choice E) Pyoderma gangrenosum is a rare neutrophilic dermatitis associated with inflammatory bowel disease and inflammatory arthritides, typically manifesting with a tender papule that degrades into a bluish, violaceous ulcer. This patient with untreated HIV and rapid-onset papular lesions with central umbilication is more likely to have disseminated Cryptococcus. ulcer Educational objective: Cutaneous cryptococcosis can occur in patients with advanced HIV (CD4 count <100/mm³) and is typically a marker of disseminated disease. Manifestations most commonly include the rapid onset of multiple papular lesions with central umbilication and central hemorrhage/necrosis.

A 47-Year-Old Man Comes to a Homeless Shelter Clinic Due