Rare Dermatologic Presentations in Immunocompromised Individuals: Case Series and Review

Edith Hailee^*
*Correspondence: Edith Hailee, Department of Dermatology and Venereology, University Hospital Consortium Polyclinic of Bari, Piazza G. Cesare 11, 70124 Bari, Italy, Email:

Introduction

The skin serves as a crucial barrier and an early indicator of systemic disease, particularly in individuals with compromised immune systems. In immunocompromised patients whether due to HIV infection, organ transplantation, chemotherapy, or immunosuppressive therapy dermatologic manifestations can present in atypical, severe, or disseminated forms. These manifestations may serve as the first sign of underlying opportunistic infections, malignancies, or drug reactions. Diagnosing and managing rare dermatologic conditions in such patients is often challenging, owing to the overlap of clinical features, rapid disease progression and altered immune responses. This case series and review aims to highlight uncommon cutaneous presentations encountered in immunocompromised individuals, discuss diagnostic complexities and provide insights into effective management strategies. A 45-year-old renal transplant recipient presented with painful, ulcerated nodules on the limbs, initially suspected to be bacterial abscesses. Biopsy and tissue culture revealed cutaneous cryptococcosis, an uncommon presentation of Cryptococcus neoformans in the skin without central nervous system involvement. The patient had been on tacrolimus and mycophenolate mofetil for several years. Amphotericin B induction followed by fluconazole maintenance therapy resulted in gradual lesion resolution. This case illustrates the deceptive appearance of fungal infections in immunosuppressed hosts, where the skin becomes a secondary site of systemic mycoses or, less commonly, the primary entry point [1].

Description

In another case, a 29-year-old male with advanced HIV infection presented with extensive verrucous plaques on the face and neck, mimicking hypertrophic warts or cutaneous malignancy. Histopathology and PCR confirmed disseminated histoplasmosis with cutaneous involvement, a rare presentation of a fungal infection endemic to certain regions. The cutaneous lesions responded to intravenous liposomal amphotericin B followed by itraconazole. This case emphasized the importance of considering systemic mycoses in patients with low CD4 counts, even when lesions appear localized to the skin. A third patient, a 38-year-old woman undergoing chemotherapy for acute leukemia, developed painful, hemorrhagic bullae and dusky plaques over her extremities. Differential diagnosis included Stevens-Johnson syndrome, vasculitis and neutrophilic dermatoses. Skin biopsy revealed dermal infiltration with atypical myeloid cells, consistent with leukemia cutis. This rare presentation highlights how hematologic malignancies can directly infiltrate the skin, masquerading as infectious or inflammatory dermatoses. Early dermatopathologic evaluation is essential, especially when the lesions deviate from expected chemotherapy-associated reactions [2].

Another rare but critical presentation involved a 54-year-old liver transplant recipient who developed multiple non-healing ulcers and nodules over the scalp and trunk. The clinical picture resembled pyoderma gangrenosum, but biopsy demonstrated atypical keratinocytes and viral inclusions. Immunohistochemistry and in situ hybridization confirmed cutaneous squamous cell carcinoma (SCC) with human papillomavirus (HPV) positivity. Immunosuppressed individuals, particularly transplant recipients, are at significantly increased risk for aggressive cutaneous malignancies, especially SCC, which tends to occur in multiple sites and with increased recurrence. This case reiterates the need for routine skin surveillance in chronically immunosuppressed patients and a high index of suspicion for malignancy when faced with atypical ulcers or nodules [1].

A particularly perplexing case involved a 62-year-old man with poorly controlled diabetes and chronic corticosteroid use for autoimmune disease who presented with targetoid lesions and mucosal erosions. The clinical suspicion was for erythema multiforme or drug reaction. However, subsequent biopsy revealed features of Kaposiâ??s sarcoma, confirmed by positive HHV-8 immunostaining. Although classically associated with HIV, Kaposiâ??s sarcoma may also occur in iatrogenically immunosuppressed individuals, such as organ transplant recipients or those with autoimmune diseases. The lesions regressed after tapering immunosuppressive therapy and initiating systemic treatment with pegylated liposomal doxorubicin. One of the rarest cases observed was a 26-year-old female with systemic lupus erythematosus on azathioprine therapy who developed chronic, ulcerative lesions over the genital region. While herpes simplex virus (HSV) was suspected, the ulcers were unusually large and persistent. Viral culture confirmed HSV-2 and she was treated successfully with prolonged antiviral therapy. This case illustrates how viral infections in immunocompromised patients can present in exaggerated forms, with chronicity and resistance to standard durations of therapy.

Conclusion

Rare dermatologic presentations in immunocompromised individuals are not merely cutaneous anomalies but often reflect deeper systemic pathologies or complications of underlying immunosuppression. They demand a comprehensive diagnostic approach and integrated care to ensure early identification and appropriate management. As the population of immunocompromised patients continues to rise with advances in transplantation, oncology and immunotherapy, clinicians must remain vigilant to the myriad ways skin disease may present in this vulnerable cohort. Continued documentation of unusual cases, along with clinical awareness and research, will be essential to improving diagnosis, treatment and long-term outcomes for these patients.

Acknowledgement

None.

Conflict of Interest

None.

References

1. Niu, Xiaokang, Nana Zhang, Shusen Li and Ning Li, et al. "Bifidobacterium animalis subsp. lactis MN-Gup protects mice against gut microbiota-related obesity and endotoxemia induced by a high fat diet." Frontiers in NutritionFront Nutr 9 (2022): 992947.

Google Scholar        Cross Ref                Indexed at

2. Bodke, Harsh and Sangita Jogdand. "Role of probiotics in human health." Cureus14 (2022).

Google Scholar        Cross Ref                Indexed at