A 35-year-old HIV-positive man has CD4 count 42 cells/µL. He presents with fever, headache, and photophobia for 5 days. CSF opening pressure is 280 mmH2O. CSF India ink preparation is positive. CSF cryptococcal antigen titre is 1:512. What is the induction treatment and how is raised intracranial pressure managed?
- A Fluconazole 400 mg/day orally — amphotericin B reserved for fluconazole failures
- B IV amphotericin B deoxycholate + dexamethasone 0.4 mg/kg/day for the first 6 weeks
- C Voriconazole + caspofungin combination as induction; mannitol for raised ICP
- D Liposomal amphotericin B (L-AmB) 3-4 mg/kg/day + flucytosine 100 mg/kg/day for 2 weeks induction; serial lumbar punctures to maintain opening pressure < 200 mmH2O ✓
Explanation
Cryptococcal meningitis in HIV requires induction therapy with liposomal amphotericin B (3-4 mg/kg/day) plus flucytosine (100 mg/kg/day in 4 divided doses) for at least 2 weeks — the AMBITION-cm and ACTA trials support this regimen. Raised ICP (> 250 mmH2O) is managed by daily therapeutic lumbar punctures removing 20-30 mL CSF until pressure is < 200 mmH2O, or placement of a lumbar drain if needed. Dexamethasone is CONTRAINDICATED in cryptococcal meningitis (increased mortality in C-GRIP trial). Fluconazole monotherapy is consolidation/maintenance phase only (after successful induction). Mannitol is not effective for raised ICP in meningitis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.