Spider Bite John W. Baddley, MD, MSPH University of Alabama at Birmingham Birmingham VA Medical Cent er

Case 64-year-old man with ESRD secondary to polycystic kidney disease who had a deceased donor renal transplant in 1988 He was doing some plumbing work under his trailer (June, 2015) and was exposed to dirty water (kneeling in it). A few days later he developed a painful, erythematous area on right lateral leg He was seen by his local physician for a possible “spider bite” and prescribed trimethoprim-sulfa DS one twice daily. It did not improve after one week and he was changed to doxycycline 100mg twice daily. He was seen in UAB Renal Transplant clinic one week later. He had not improved and creatinie had increased. He was admitted and treated with vancomycin and ceftriaxone and a biopsy was performed. He was discharged to home and re-admitted after biopsy results returned.

Other History He did not have fevers or chills. He complained of right leg pain. He also noted “seeing people in the room that aren’t there” for 3 weeks. His wife described changes in the patient’s personality lately. No headaches, memory loss. Past Medical History: -HTN, CAD, RA, DVT, hyperlipidemia Relevant Medications: -Prednisone 10mg daily -Cyclosporine 150mg daily -Doxycycline 100mg twice daily Social History: -former mechanic; lives in rural Alabama -no substance abuse

Labs Neu 68% Lym 23%

Follow-up Lumbar puncture showed lymphocytic meningitis Serum CRAG 1:640; CSF CRAG 1:20 Leg biopsy grew C. neoformans; CSF culture negative Treated with lipid AMB plus flucytosine for 14 days weeks, followed by fluconazole Within one week, leg was much improved

Key Points: Spiders are colonized with C. neoformans (?) Not every skin lesion is a spider bite Multiple skin manifestations of cryptococcosis (cellulitis, pustules, papules, ulcers, plaques, necrosis) Be aggressive with skin biopsies in transplant recipients Mucicarmine staining is useful and is specific for the cryptococcal capsule Take a good history THANKS!