A 32-year-old HIV-positive man with CD4 count 45 cells/µL presents with progressive bilateral headache, fever, and confusion over 2 weeks. CSF analysis: opening pressure 28 cmH₂O, glucose 38 mg/dL, protein 68 mg/dL, lymphocytes 12/µL, India ink positive. Which component of initial management has the strongest evidence for reducing acute mortality?
- A Therapeutic lumbar puncture to relieve raised intracranial pressure combined with amphotericin B plus flucytosine ✓
- B Fluconazole 800 mg/day as primary induction therapy
- C Immediate highly active ART initiation to restore immune function
- D Dexamethasone 0.4 mg/kg/day to reduce meningeal inflammation
Explanation
Cryptococcal meningitis in AIDS requires: (1) amphotericin B deoxycholate or liposomal amphotericin B plus flucytosine as induction therapy (superior to fluconazole per ACTG 5164 and AMBITION-cm trials); (2) serial therapeutic lumbar punctures to maintain ICP <20 cmH₂O — raised ICP is the leading cause of early mortality in cryptococcal meningitis. The ACTA trial showed liposomal amphotericin + flucytosine with ICP management significantly reduced mortality. Immediate ART should be deferred for 4–6 weeks to prevent immune reconstitution inflammatory syndrome (IRIS). Dexamethasone worsened outcomes in the CRYPTOACT-MRC trial.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.