Fingolimod-Associated Primary Cutaneous Cryptococcosis: A Case Report and Scoping Review With a Focus on Immune Monitoring
Year: 2026
Type: article
Abstract: Fingolimod is an oral therapy for relapsing-remitting multiple sclerosis (RRMS) that suppresses inflammatory activity by binding to sphingosine-1-phosphate receptors, causing lymphocyte sequestration and relative peripheral lymphopenia. This increases susceptibility to opportunistic infections, including cryptococcosis. We report primary cutaneous cryptococcosis in a 34-year-old man with RRMS stable on fingolimod monotherapy for five years. He presented with a non-healing, indurated erythematous lesion with a warty surface on the left forehead without systemic symptoms. Histopathology and fungal culture confirmed Cryptococcus neoformans. Investigations revealed profound CD4 lymphopenia (32 cells/µL) in the absence of HIV infection or central nervous system involvement. The patient was successfully treated with oral fluconazole and fingolimod was discontinued with plans for alternative disease-modifying therapy. Based on our review of the published literature, we have not identified any previously reported cases of fingolimod-associated primary cutaneous cryptococcosis in the United Kingdom. A scoping review was conducted using PubMed, ScienceDirect, and Google Scholar to identify case reports of fingolimod-associated cryptococcal infection published from 2020 onward. A total of 21 cases met the inclusion criteria. Most infections occurred after prolonged fingolimod exposure (median: six years, range: 3.75-12 years), with central nervous system involvement predominating. Profound CD4 depletion (<100 cells/µL) emerged as the most consistent risk factor, whereas absolute lymphocyte counts were often preserved. Primary cutaneous cryptococcosis accounted for a small minority of cases. Among cases with available CD4 data, profound CD4 lymphopenia was frequently observed, suggesting a possible association between marked CD4 depletion and cryptococcal infection. Routine CD4 lymphocyte subset monitoring and heightened clinical vigilance may therefore lead to early diagnosis and timely intervention. Given the small number of cases observed, this requires confirmation in larger prospective studies.
Source: Cureus
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7222889175