Cryptococcal Disease Presenting With Cellulitis in Kidney Transplant Recipients

We would like to make some comments on the interesting article by Yokose et al describing a case of cryptococcal meningitis presenting with lower leg cellulitis in a recipient of a kidney transplant.1 The authors state that their case “highlights a good example of an anchoring bias,” but, in our opinion, it could be better defined as an example of overlooked and delayed diagnosis of cryptococcosis for the following reasons: 1) the patient was an immunocompromised host (a solid organ transplant [SOT] recipient receiving immunosuppressive treatment), and the failure of empiric antibiotic treatment should have suggested a search for opportunistic pathogens, including fungi; 2) cryptococcosis is the third-most frequent invasive fungal infection in SOT recipients,2 and those with kidney transplants are involved in 50%-95.6% of the cryptococcosis cases described in this context (Table 1); 3) cellulitis of the lower limbs is the second-most frequent manifestation of cutaneous cryptococcosis and a well-known manifestation of cryptococcosis in SOT recipients;3-5 4) mild headache or negative central nervous system imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) cannot rule out a clinical picture of cryptococcal meningitis, per se,6 especially in the presence of other signs of infection.

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