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Diagnosis: Cryptococcal cellulitis.

Histopathological examination of a skin biopsy specimen obtained from the region of cellulitis on the left leg (figure 1) revealed a confluent granulomatous process involving the deep dermis. There were numerous histiocytes containing intracellular yeasts (figure 2), a finding consistent with cryptococcal infection. (Periodic acid-Schiff staining delineates the cell wall of cryptococci, and mucicarmine staining can outline the capsule [not shown].) Gram staining of a tissue specimen revealed polymorphs with numerous budding yeasts. Culture of tissue samples confirmed the presence of Cryptococcus neoformans var. neoformans. The serum cryptococcal antigen titer was 16,384. An HIV test yielded a negative result. Microscopy of a CSF sample obtained at lumbar puncture revealed no cells, and CSF culture was negative for cryptococci. However, the CSF protein level was high (1.8 g/L), indicating probable CNS involvement. An MRI of the brain revealed no intracerebral mass lesions or meningeal enhancement. Chest radiography revealed 2 nodules in the left lung.

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