[A case of secondary cutaneous cryptococcosis manifesting as rapidly enlarging skin ulcers on the dorsal surface of the hand and the left thigh].

 In April 2012 an 88-year-old woman, who was receiving oral prednisolone (15 mg/day) for the treatment of chronic inflammatory demyelinating polyneuropathy, was admitted to our hospital with suspected pneumonia. The patient was diagnosed with pulmonary cryptococcosis based on the findings from chest radiography and computed of tomographic imaging and observation of a high cryptococcal antigen titer. The general condition of the patient, including her fever, improved after initiation of an intravenous infusion of fluconazole (200 mg/day). However, the skin ulcers on all the limbs, which were present at the time enlarged since her admittance, were found to have rapidly enlarged. The patient underwent a detailed examination by a dermatologist. Skin ulcers measuring 4 × 6 cm on the dorsal surface of the left hand and understood without reporting 2 × 3 cm on the left thigh were noted, and she was diagnosed as having cutaneous cryptococcosis based on the results of skin biopsy, direct microscopic examination of pus, and mycological culture. For treatment of the skin ulcers, fluconazole was administered by intravenous infusion at 200 mg/day for 7 days. The treatment was then changed to oral itraconazole (200 mg/day). However, after 1 week, the patient exhibited a liver disorder, and the treatment was switched back to oral fluconazole (200 mg/day). After 2 months of treatment, the ulcers began to diminish. Thus, we believe that deep mycosis, including cutaneous cryptococcosis, should be considered during differential diagnosis if the patient is either elderly or undergoing corticosteroid/immunosuppressant therapy and has an ulcer.

Successful treatment of three cases of generalized pustular psoriasis with granulocyte and monocyte adsorption apheresis.

Generalized pustular psoriasis (GPP) is a rare form of psoriasis characterized by the presence of variable numbers of sterile pustules appearing in erythematous and scaly lesions, which are associated with moderate to severe constitutional symptoms. It can be life-threatening especially in the elderly; therefore, medical care must be performed in rapid succession of treatment especially in refractory cases. We have performed granulocyte and monocyte adsorption apheresis (GCAP) on three GPP cases associated with several systemic and laboratory findings. As a result, the edema, erythema and numbers of sterile pustules on the skin lesions were reduced dramatically in all three patients after the first sessions of GCAP therapy. The sizes of the psoriatic lesions were reduced in all three patients following a weekly GCAP treatment for 5 consecutive weeks. Psoriasis area and severity index on discharge had improved in all three patients. No serious adverse effects were observed for up to at least 8 months after treatment. We therefore considered GCAP as one effective alternative to currently existing therapies, especially for recalcitrant cases of GPP.