53-year-old male, retired, living in a rural area. He was diagnosed 10 years ago with inflammatory bowel disease, which is controlled only with high doses of steroids. Two years earlier he had been admitted to the Intensive Care Unit for sepsis of intestinal origin with multi-organ failure; since then he has been on periodic haemodialysis due to lack of functional recovery. Renal biopsy showed tubulointerstitial nephropathy.
Since one month before admission, she had presented erythematous skin lesions, on indurated, pruritic and painful areas on the dorsum of the right foot and inner thighs, with poor response to antibiotic treatment (started empirically due to suspicion of cellulitis), which progressively evolved towards desquamation and subsequent ulceration. A skin biopsy was performed and reported as cryptococcosis. Direct examination with India ink and Gram stain revealed abundant large, spherical yeasts with marked twinning and encapsulation. Culture showed a yeast-like fungus, urease positive, compatible with cryptococcus neoformans, variety neoformans. Serum cryptolatex positive 1/2048. Pulmonary and neurological involvement was ruled out by computerised axial tomography and lumbar puncture.

We started treatment with voriconazole 200 mg/12 hours, and after 10 days there was a marked alteration in liver tests (total bilirubin: 9.59 mg/dl; direct bilirubin: 9.41 mg/dl; glutamic-oxaloacetic transaminase [GOT] 176 U/l; glutamic-pyruvic transaminase [GPT]: 226 U/l), which made it necessary to replace it with amphotericin B at a dose of 100 mg/day. In addition to this, the prednisone dose was reduced. Thus, after 2 weeks he presented a marked improvement of the lesions with almost complete disappearance of the ulcerations and normalisation of the liver tests.