A 38-year-old HIV-positive man with CD4 count 45 cells/µL presents with fever, headache, and neck stiffness. CSF: opening pressure 340 mm H₂O, protein 60 mg/dL, glucose 28 mg/dL (serum 90), WBC 20 cells/µL (lymphocytes). India ink stain positive. Cryptococcal antigen (CrAg) titre 1:2048. The induction regimen of choice per WHO 2022 HIV guidelines is:
- A Fluconazole 400 mg/day alone for 14 days
- B Voriconazole + caspofungin combination
- C Intrathecal amphotericin B
- D Liposomal amphotericin B 3 mg/kg/day + flucytosine 25 mg/kg 6-hourly for 7 days ✓
Explanation
WHO 2022 guidelines recommend a shortened 7-day induction with liposomal amphotericin B (3 mg/kg/day) plus flucytosine (25 mg/kg every 6 hours) as the preferred induction regimen for HIV-associated cryptococcal meningitis, based on the ACTA trial demonstrating superiority over fluconazole-based regimens and acceptable toxicity. This is followed by consolidation with fluconazole 400 mg/day for 8 weeks, then maintenance. Fluconazole monotherapy is inferior for induction in this context. Voriconazole has poor CNS penetration for Cryptococcus. Intrathecal amphotericin is not part of standard protocol.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.