A 35-year-old HIV-positive man (CD4 45 cells/μL, viral load 180,000 copies/mL) presents with severe headache, photophobia, and progressive confusion for 2 weeks. CSF analysis reveals India ink positivity, CSF glucose 30 mg/dL, protein 90 mg/dL, WBC 20 cells/mm³. Cryptococcal antigen is positive. What is the standard induction regimen per IDSA 2010 guidelines?
- A Liposomal amphotericin B (3–4 mg/kg/day) plus flucytosine (100 mg/kg/day) for 2 weeks ✓
- B Fluconazole 400 mg daily for 10–12 weeks
- C Itraconazole 200 mg twice daily for 6 weeks
- D Voriconazole 200 mg twice daily
Explanation
Cryptococcal meningitis in HIV-positive patients is treated with a 3-phase regimen per IDSA guidelines: Induction (2 weeks): liposomal amphotericin B (3–4 mg/kg/day) + flucytosine (100 mg/kg/day in 4 divided doses); Consolidation (8 weeks): fluconazole 400 mg/day; Maintenance (≥1 year): fluconazole 200 mg/day. The AmBisome + 5-FC combination achieves fungicidal activity and accelerates CSF sterilization. Therapeutic lumbar punctures (opening pressure drainage) are critical for raised ICP management. Fluconazole monotherapy is used only when amphotericin is unavailable and has inferior outcomes.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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