A 35-year-old HIV-positive man (CD4 count 55 cells/µL, not on ART) presents with 3 weeks of headache, fever, and neck stiffness. CSF analysis shows: opening pressure 28 cmH2O, glucose 30 mg/dL, protein 95 mg/dL, WBC 8 cells/µL (lymphocytes). India ink stain is positive and CSF cryptococcal antigen (CrAg) titre is 1:1024. The initial induction regimen per WHO/IDSA guidelines is:

• A Fluconazole 400 mg/day alone for 6 weeks
• B Voriconazole as the preferred antifungal
• C Start ART immediately and defer antifungal until immune reconstitution
• D Liposomal amphotericin B (3–4 mg/kg/day) plus flucytosine for 2 weeks, then fluconazole consolidation ✓

Explanation

Cryptococcal meningitis in AIDS requires induction, consolidation, and maintenance phases. The 2022 WHO and IDSA guidelines recommend liposomal amphotericin B (3–4 mg/kg/day) plus flucytosine 100 mg/kg/day for 2 weeks as the preferred induction regimen based on the ACTA trial demonstrating superior fungicidal activity and reduced mortality. This is followed by fluconazole 400 mg/day for 8 weeks (consolidation) then 200 mg/day maintenance. ART is deferred 2–4 weeks post-antifungal initiation to avoid IRIS.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.