Mark Crislip, MD


December 07, 2012

Clinical Presentation:

A 55-year-old man presents with a chronic cheek ulcer. The lesion, a reddened nodule measuring 0.5 cm, had developed 2 months earlier. He was treated with cephalexin, followed by amoxicillin/clavulanate and then with moxifloxacin, but the lesion has not resolved. It ulcerated slowly, without pain, and the patient was eventually referred to the infectious diseases service.

History and Physical Examination

History. History revealed the following:

  • Medical history: hypertension

  • Medications: hydrochlorothiazide

  • Allergies: none

  • Habits: none

  • Pets: dog

  • Diet: regular

  • Travel: has traveled throughout the Pacific Northwest of the United States

  • Social: divorced; has a son ; heterosexual; no recent sexual contact

  • Immunizations: up to date

  • Sports/water exposure: hunting

  • Infectious disease exposure: none

Physical examination. The following were noted:

  • Vital signs: temperature, 99.4° F; pulse, 80 beats/min; respiratory rate, 16 breaths/min; blood pressure, 130/80 mm Hg

  • General: non-ill-appearing

  • HEENT: nickel-sized ulcer on cheek, slightly raised edges, nonpainful

  • Lungs: normal

  • Heart: normal

  • Abdomen: normal

  • Extremities/skin: normal

Diagnostic Evaluation

Laboratory results. The following values were obtained:

  • WBC count: 9200 cells/µL

  • Hemoglobin level: 11.2 g/dL

  • Differential: 8% lymphocytes; 2% monocytes; 90% polymorphonucleocytes

  • Culture: Cryptococcus gattii

  • Biopsy: yeast forms and granuloma

  • Serum cryptococcal antigen: negative

  • HIV: negative

  • CD4 count: 186 cells/µL