A 35-year-old HIV-positive man with CD4 count 45 cells/µL presents with headache, fever, and confusion for 5 days. CSF shows opening pressure 280 mmH2O, glucose 35 mg/dL, protein 80 mg/dL, WBC 25 (lymphocytes), India ink stain positive, CSF cryptococcal antigen (CrAg) titer 1:1024. Per current WHO/IDSA guidelines, what is the preferred induction regimen?
- A Liposomal amphotericin B 3–4 mg/kg/day × 2 weeks
- B Fluconazole 800 mg/day × 2 weeks
- C Amphotericin B deoxycholate 0.7–1 mg/kg/day × 2 weeks + flucytosine ✓
- D Amphotericin B deoxycholate 0.7 mg/kg/day + fluconazole × 2 weeks
Explanation
Per IDSA 2010 (updated) and WHO 2022 guidelines, the induction regimen of choice for cryptococcal meningitis is amphotericin B deoxycholate 0.7–1 mg/kg/day combined with flucytosine (5-FC) 100 mg/kg/day for 2 weeks — this combination is superior to amphotericin B monotherapy (ACTA trial showed 28-day sterilization rates: 48% with AmB + 5-FC vs. 26% with AmB monotherapy). Fluconazole monotherapy has inferior fungicidal activity. Liposomal AmB (3–4 mg/kg) is equivalent in efficacy with reduced nephrotoxicity and is preferred when renal impairment exists. Therapeutic lumbar puncture (LP) for raised ICP >250 mmH2O is equally critical management.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.