A 34-year-old HIV-positive man with CD4 count 48 cells/µL and viral load 180,000 copies/mL presents with progressive headache, fever and altered consciousness. CSF shows opening pressure 280 mmHg, WBC 12 cells/µL (predominantly lymphocytes), protein 85 mg/dL, glucose 30 mg/dL (serum glucose 90 mg/dL). India ink preparation shows encapsulated yeast. The treatment of choice for induction is:
- A Fluconazole 400 mg daily alone
- B Voriconazole 6 mg/kg IV loading then 4 mg/kg BD
- C Liposomal amphotericin B 3 mg/kg/day + flucytosine 25 mg/kg QID for 2 weeks ✓
- D Caspofungin 70 mg loading then 50 mg daily
Correct answer: C. Liposomal amphotericin B 3 mg/kg/day + flucytosine 25 mg/kg QID for 2 weeks
Explanation
Cryptococcal meningitis in HIV (CD4 <100) is treated per IDSA 2010 guidelines with induction: liposomal amphotericin B (3 mg/kg/day) plus flucytosine (25 mg/kg QID) for 2 weeks, followed by consolidation with fluconazole 400 mg/day for 8 weeks, then maintenance fluconazole 200 mg/day. Flucytosine synergizes with amphotericin B, significantly improving CSF sterilization rates (ACTA trial). The elevated opening pressure requires therapeutic lumbar puncture to reduce ICP and prevent blindness/death. Fluconazole monotherapy is inferior for induction in severe disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.