A 36-year-old man with HIV infection (CD4 count 45 cells/µL) on ART for 3 months presents with headache, fever, and neck stiffness. CSF shows elevated pressure (28 cmH2O), lymphocytic pleocytosis (85 cells), protein 85 mg/dL, and glucose 45 mg/dL. India ink preparation is positive and CSF cryptococcal antigen (CrAg) is strongly positive (1:2048). The ASTRO-CM and ACTA trial-based optimal induction regimen for cryptococcal meningitis in HIV is:
- A Amphotericin B deoxycholate + flucytosine for 2 weeks followed by fluconazole consolidation ✓
- B Amphotericin B deoxycholate alone for 4 weeks
- C Single high-dose liposomal amphotericin B (10 mg/kg) + flucytosine for 1 week (ASTRO-CM short-course)
- D Fluconazole 800 mg/day monotherapy for 2 weeks (induction) followed by 400 mg/day
Explanation
The IDSA 2010 guidelines and updated recommendations based on the ACTA trial (2018, NEJM) establish that the standard induction regimen for HIV-associated cryptococcal meningitis is amphotericin B deoxycholate (0.7–1 mg/kg/day IV) PLUS flucytosine (100 mg/kg/day divided q6h) for 2 weeks, followed by consolidation with fluconazole 400 mg/day for 8 weeks, then maintenance/secondary prophylaxis with fluconazole 200 mg/day. The ACTA trial showed that combining AmB + flucytosine gave 70% culture-negative CSF at 2 weeks vs 50% with fluconazole + flucytosine. Liposomal AmB single-dose (ASTRO-CM) showed non-inferiority in some settings but the flucytosine combination remains standard when available.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.