Primary Cutaneous mycosis in an Immunocompetent Parrot Keeper Due to Cryptococcus neoformans  

Dave  P.1 , Pal  M.2
1. Department of Skin, Welfare Hospital and Research Center, Bharauch-392001, Gujarat, India
2. Department of Microbiology, Immunology and Public Health, College of Veterinary Medicine and Agriculture, P.B.No.34, Debre Zeit, Ethiopia
Author    Correspondence author
Molecular Microbiology Research, 2015, Vol. 5, No. 4   doi: 10.5376/mmr.2015.05.0004
Received: 13 Jul., 2015    Accepted: 10 Aug., 2015    Published: 08 Oct., 2015
© 2015 BioPublisher Publishing Platform
This is an open access article published under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Preferred citation for this article:

Dave P. and Pal M., 2015, Primary Cutaneous mycosis in an Immunocompetent Parrot Keeper Due to Cryptococcus neoformans, Molecular Microbiology Research, Vol.5, No.4 1-3 (doi: 10.5376/mmr.2015.05.0004)

Abstract

The prime objective of this paper is to delineate the etiologic significance of Cryptococcus neoformans in primary cutaneous mycosis of a 34- year- old male immunocompetent person, who was occupationally exposed to the excreta of a caged parrot. The biopsy obtained from the cutaneous lesion of a parrot keeper was examined in Indian ink mount, and was cultured onto the plates of Pal’s sunflower seed medium. In addition, the urine and blood of patient was also inoculated on Pal’s sunflower seed medium to rule out the systemic infection. In order to establish the source of infection, samples of parrot droppings, and wooden box were examined on Pal’s sunflower seed medium. Microscopic examination of clinical specimen in India ink preparation revealed circular, wide, thickly encapsulated yeast cells of Cryptococcus neoformans. Numerous dark brown colored colonies of C. neoformans grew from biopsied tissue on Pal’s sunflower seed medium. The microscopic morphology of the fungal isolates was done in Narayan stain. There was no growth of C. neoformans from blood, and urine of the patient on Pal’s sunflower seed medium. The pathogen was easily recovered from the parrot droppings, and wooden box on Pal’s sunflower medium. These findings conclusively established that the patient acquired primary cutaneous cryptococcosis from his immediate environment as revealed by the presence of C. neoformans in the excreta, and wooden cage of the caged parrot.

Keywords
Cryptococcus neoformans; Cutaneous mycosis; Immunocompetent; Narayan stain; Parrot keeper; Pal medium

Introduction
Cutaneous mycosis is a disease of diverse fungal etiologies with cosmopolitan in distribution (Pal, 2007; Dave et al., 2015). The disease occurs in both sexes, and all age groups; and mostly in sporadic form, and causing significant morbidity (Pal, 2007).The infection may be primary in origin or secondary to haematogenous dissemination (Pal, 2007). Among several fungal cutaneous mycoses, cryptococcosis is one of the important diseases, and is reported from many countries of the world (Kamalam et al., 1977; Hay, 1985; Christianson et al., 2003; Joshi et al., 2004; Bauza et al.,2005; Chang et al., 2009; Kulkarni et al., 2012; Spiliopoulou et al., 2012). The disease is caused by the genus Cryptococcus, consisting of 37 species of which C. neoformans and C. gattii are more pathogenic, and are implicated in most cases of cryptococcosis (Pal, 2014). Cryptococcus is a eukaryotic, Gram positive, aerobic, non-motile fungus, which occurs as saprophytes in a wide variety of environmental materials, and the avian droppings, especially the pigeon excreta is recognized as the most important saprobic reservoir for C. neoformans (Pal,1997; Pal,2005; Pal et al., 2014 ; Pal, 2015). Globally, C. neoformans and C. gattii affect approximately 1000,000 individuals annually with over 620,000 fatalities, and accounts for about one third of all HIV/AIDS associated deaths, surpassing tuberculosis mortality in Africa (Park et al., 2009). The cutaneous cryptococcosis is primarily caused by C.neoformans, however, rare cases due to C. laurentii and C. gattii have also recorded (Kamalam et al., 1977; Baes and Van Cutsem, 1985; Perfect and Casadevell, 2002; Revenga et al., 2002; Kulkarni et al., 2012). The skin lesions occur on any part of the body such as face, neck, arms, trunk, leg, etc., and may be solitary or multiple, and painful or painless. Clinical manifestations of cutaneous cryptococcosis show papules, nodules, cellulitis, acniform lesions, subcutaneous abscesses, plaques, and non-healing ulcers (Hay, 1985; Bauza et al., 2005; Pal, 2007).The scarcity of information on cutaneous cryptococcosis from this region of India prompted us to put on record a case of primary cutaneous cryptococcosis due to C. neoformans in an apparently healthy pet bird keeper from Bharauch, Gujarat, India. 

1 Materials and Methods
A 34-year-male bird enthusiast presented with dermatological disorder at the Skin Outpatient Department (OPD) of Welfare Hospital and Research Center, Bharauch, India constituted the material for this investigation. The punch biopsy from the cutaneous lesion was performed under sterile conditions to obtain the sample for cultural isolation. The detailed clinical, biochemical (blood and urine), and radiological examination of the patient was done. A small piece of the skin biopsy was examined directly under microscope as wet mount preparation in India ink (Pal, 2007). The skin biopsy, blood, and urine were also cultured on Pal’s sunflower seed medium, and the inoculated plates were incubated at 25℃. In addition, droppings and scrapings of wooden cage were also streaked on to the plates of Pal medium (Pal, 2007). Microscopic morphology of the isolates was undertaken in Narayan stain (Pal, 2004).The patient was advised to take fluconazole 200 mg daily for fourteen weeks. In addition, vitamin B complex, liver tonic, and antacid were also prescribed. In case of any complications, the patient was asked to report to the hospital. The patient was directed to decontaminate the excreta and wooden cage of his pet bird by spraying 5% formalin.

2 Results
The clinical examination of the patient showed one erythematous, ulcerative, and nodular lesion on the left forearm. The patient narrated that this skin lesion occurred after receiving injury with wooden cage during the act of cleaning. The patient’s body temperature was 38.2℃, respiration rate 21 breaths per minute, and pulse rate 78 beats per minute. The test for HIV, and TB were negative. The blood profile showed WBC 12,500 /mm3, Hb 12.8 gm, blood urea nitrogen 21.5 mg/dl, and creatinine 1.1 mg/dl. The urine was negative for glucose and protein. Radiograph of chest did not reveal any abnormality. Microscopic examination of biopsied tissue in India ink showed round, wide, thickly encapsulated budding yeast cells morphologically simulating to C. neoformans. The culture of biopsy tissue from the lesion yielded many smooth, brown coloured colonies of C. neoformans on Pal’s sunflower seed medium after 3 days of incubation at 25℃. Interestingly, the pathogen was not isolated from the blood, and urine of the patient suggesting the absence of systemic involvement. The parrot excreta, and wooden scrapings from parrot cage also showed innumerable numbers of brown coloured and smooth colonies of C. neoformans on Pal’s sunflower seed medium. All the fungal isolates revealed many circular, thinly encapsulated yeast cells with and without budding in Narayan stain. We could not isolate the fungus from droppings and wooden cage after formalin treatment. The patient showed good clinical response with fluconazole, without any side effects of the drug.

3 Discussion
The clinical presentation, mycological observation, and chemotherapeutic response conclusively proved that our 34- year-old male immunocompetent patient was suffering with primary cutaneous cryptococcosis due to C. neoformans. This observation is consistent with the findings of Spiliopoulou and co-investigators (2012) who described primary cutaneous cryptococcosis in immunocompetent host. However, primary cutaneous cryptococcosis has also been recorded in immunoco- mpromised hosts (Vasanthi et al., 2002; Christianson et al., 2003; Yodella and Rao, 2011). Direct inoculation is considered as the possible mode of entry of the pathogen. A history of trauma is most frequently reported risk factor in primary cutaneous cryptococcosis (Revenga et al., 2002; Bauza et al., 2005; Pal, 2007). Our patient also gave the history of the skin injury while cleaning the wooden cage of the caged pet parrot. Furthermore, we proved the presence of C. neoformans in the dropping and wooden cage of parrot by conducing retrospective epidemiological investigation to establish the source of infection. We advised the patient to decontaminate the saprobic environment by spraying 5 % solution of formalin. The fungus could not be recovered from the excreta and wooden scrapings of the bird’s cage after decontamination with formalin.

It is pertinent to mention that the skin and brain are the primary sites following haematogenous dissem- ination of infection from the lungs (Chang et al., 2009). Moreover, cutaneous cryptococcosis occurs in 10 to 20 % of cases of disseminated disease (Pal et al., 2014). In this context, Yodalla and Rao (2011) mentioned that cutaneous cryptococcosis serves as a marker of life threatening disseminated disease in HIV/AIDS. Hence, it is emphasized that an early diagnosis is necessary to start specific antifungal therapy because disseminated cryptococcosis without treatment has a grave prognosis. As clinical manifestations of cutaneous cryptococcosis are protean and may mimic other cutaneous diseases, it is therefore, highly imperative to employ mycological techniques to confirm an unequivocal diagnosis of disease.
 
Acknowledgements
We thank the patient for his cooperation, and also the staff of Welfare Hospital and Research Center, Bharauch, Gujarat, India for their technical assistance.

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