A 34-year-old HIV-positive man with CD4 count 48 cells/μL presents with headache, fever, and meningism. CSF India ink preparation is positive. Cryptococcal antigen titre is 1:512. The MOST appropriate initial treatment is:
- A Fluconazole 400 mg/day for 8 weeks
- B Liposomal amphotericin B monotherapy for 4 weeks
- C Amphotericin B deoxycholate + flucytosine (5-FC) for 2 weeks, then fluconazole consolidation ✓
- D Immediate ART initiation with cryptococcal prophylaxis
Explanation
Cryptococcal meningitis in HIV requires a 3-phase approach per WHO 2022/IDSA guidelines: Induction (2 weeks) — amphotericin B deoxycholate 0.7-1 mg/kg/day + flucytosine 100 mg/kg/day (ACTA trial confirmed superior fungicidal activity vs. AmB alone); Consolidation (8 weeks) — fluconazole 400 mg/day; Maintenance — fluconazole 200 mg/day until CD4 >100 for 3+ months on ART. ART should be deferred 4-6 weeks after starting antifungal therapy to avoid immune reconstitution inflammatory syndrome (IRIS), which worsens outcomes in cryptococcal meningitis. Fluconazole monotherapy induction is inferior (ACTA, AMBITION trials).
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.