A 34-year-old man with HIV (CD4 count 58 cells/µL, not on ART) develops fever, headache, and neck stiffness. CSF: opening pressure 380 mmH₂O, lymphocytic pleocytosis, low glucose, high protein. India ink preparation is positive. What is the treatment protocol?
- A Fluconazole 400 mg/day monotherapy for 8 weeks
- B IV voriconazole for 2 weeks then oral itraconazole
- C Caspofungin plus fluconazole for 4 weeks
- D Induction with amphotericin B deoxycholate plus flucytosine for 2 weeks, then consolidation with fluconazole ✓
Explanation
Cryptococcal meningoencephalitis in HIV requires a three-phase treatment approach per WHO 2022 and IDSA guidelines. Induction phase: amphotericin B deoxycholate (0.7–1 mg/kg/day) plus flucytosine (100 mg/kg/day in 4 doses) for at least 2 weeks — the ACTA trial demonstrated superiority of this combination over fluconazole-based regimens in 10-week mortality. Consolidation phase: fluconazole 400 mg/day for 8 weeks. Maintenance: fluconazole 200 mg/day until immune reconstitution. Liposomal amphotericin B is preferred when available for reduced nephrotoxicity. Therapeutic lumbar punctures are also performed to manage raised ICP.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.