A 30-year-old HIV-positive man not on antiretroviral therapy presents with 3 weeks of fever, headache, and neck stiffness. His CD4 count is 68 cells/µL. CSF analysis shows: opening pressure 320 mmHg, glucose 32 mg/dL (serum 96 mg/dL), protein 75 mg/dL, WBC 8 cells/µL (lymphocytes), and India ink stain positive for encapsulated yeast. What is the treatment of choice?
- A Liposomal amphotericin B plus flucytosine for induction (at least 2 weeks) ✓
- B Fluconazole 400 mg daily as sole induction therapy
- C Voriconazole for induction followed by itraconazole maintenance
- D Intravenous acyclovir pending further workup
Explanation
Cryptococcal meningitis in HIV-infected patients (CD4 < 100) is treated with a 3-phase approach per IDSA guidelines. Induction therapy is liposomal amphotericin B (3–4 mg/kg/day IV) plus flucytosine (100 mg/kg/day) for at least 2 weeks, which achieves faster CSF sterilization than amphotericin alone and reduces early mortality. This is followed by fluconazole 400 mg/day consolidation (8 weeks) and then maintenance/secondary prophylaxis with fluconazole 200 mg/day until CD4 > 200. Fluconazole monotherapy as induction is inferior (slower fungicidal activity) and is reserved for resource-limited settings. Voriconazole has no role in cryptococcal meningitis. Acyclovir is for herpes simplex/varicella-zoster encephalitis, not cryptococcosis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.