Chief Complaint: “I have these strange skin bumps that won’t heal.”

History of Present Illness:
A 45-year-old male from a rural village in Sub-Saharan Africa presents to a local clinic with multiple painless, nodular skin lesions on his face, neck, and upper arms. The lesions started as small, firm bumps a month ago and have gradually increased in size, some developing ulceration and crusting. He also reports occasional low-grade fever and fatigue but denies any itching or significant pain.

His medical history includes untreated HIV, which was diagnosed two years ago. He has not been on antiretroviral therapy (ART) due to limited healthcare access. He works as a farmer and has frequent exposure to soil and bird droppings.

Physical Examination:

• Multiple dome-shaped, violaceous papules and nodules, some with central ulceration
• No tenderness or warmth over lesions
• Mild generalized lymphadenopathy
• No oral thrush or meningismus

Diagnosis:
Given the patient’s history of untreated HIV and characteristic skin lesions, a clinical suspicion of cutaneous cryptococcosis is made. A skin biopsy with fungal culture and India ink staining of cerebrospinal fluid (CSF) is ordered to rule out disseminated Cryptococcus neoformans infection, particularly cryptococcal meningitis.

Management Plan:

• Systemic antifungal therapy: Amphotericin B and fluconazole
• HIV management: Initiation of ART after stabilizing cryptococcal infection
• Patient education:
  • Cutaneous cryptococcosis often indicates systemic infection, requiring urgent treatment
  • Regular follow-up for monitoring response to therapy and managing HIV-related complications

The patient is referred to a regional hospital for further care, including CSF evaluation, as cryptococcal infections often involve the central nervous system in immunocompromised individuals