A 36-year-old HIV-positive man with a CD4 count of 42 cells/µL and not on ART presents with fever, headache, and meningismus. CSF India ink preparation is positive. Serum cryptococcal antigen titre is 1:512. What is the recommended induction regimen for cryptococcal meningitis in this patient according to WHO 2022 guidelines?
- A Fluconazole 400 mg/day alone for 2 weeks
- B Voriconazole IV for 2 weeks
- C Amphotericin B deoxycholate plus fluconazole for 4 weeks
- D Liposomal amphotericin B plus flucytosine for 1 week followed by fluconazole ✓
Explanation
WHO 2022 guidelines updated the recommended induction regimen for HIV-associated cryptococcal meningitis to: liposomal amphotericin B (LAmB) 3–4 mg/kg/day plus flucytosine 100 mg/kg/day for 1 week (7-day induction), followed by fluconazole 1200 mg/day for 1 week (consolidation), and then maintenance fluconazole — based on the AMBITION-cm trial that showed single-dose LAmB plus 1 week of 5-FC was non-inferior to 2-week deoxycholate amB + 5-FC with fewer toxicities. Fluconazole monotherapy for induction is inferior. Voriconazole is not active against Cryptococcus neoformans at achievable concentrations.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.