A 34-year-old HIV-positive man (CD4 80 cells/μL, not on ART) presents with headache, fever, and altered sensorium. CSF shows India ink positive encapsulated yeast, CSF opening pressure 32 cm H₂O, CSF cryptococcal antigen titre 1:512. Which management step is critical in the first 2 weeks beyond antifungal therapy?
- A Immediate ART initiation alongside amphotericin B
- B Therapeutic lumbar punctures daily or every other day to manage elevated intracranial pressure ✓
- C High-dose corticosteroids to reduce meningeal inflammation
- D IV fluconazole alone is sufficient for cryptococcal meningitis
Correct answer: B. Therapeutic lumbar punctures daily or every other day to manage elevated intracranial pressure
Explanation
Elevated intracranial pressure (ICP >25 cm H₂O) in cryptococcal meningitis is a major driver of early mortality and morbidity. Serial therapeutic lumbar punctures to maintain opening pressure <20 cm H₂O are critical in the first 2 weeks and should continue until pressure normalises; this is as important as antifungal therapy (amphotericin B + flucytosine induction). ART is deliberately delayed 4–6 weeks after starting antifungals to avoid IRIS. Corticosteroids worsen outcomes in cryptococcal meningitis. Fluconazole alone is inferior to amphotericin B for induction.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.