A 35-year-old patient with HIV (CD4 30 cells/μL) develops severe headache, fever, and neck stiffness. CSF analysis shows: lymphocytic pleocytosis, low glucose, high protein, and India ink preparation shows encapsulated yeast cells. Cryptococcal antigen (CrAg) titer in CSF is 1:1024. Which treatment regimen is recommended for induction therapy for cryptococcal meningoencephalitis in HIV patients (WHO/IDSA 2022)?

• A Fluconazole 400 mg/day monotherapy for 8 weeks (induction) in resource-limited settings
• B Amphotericin B liposomal + voriconazole for 2 weeks, followed by fluconazole maintenance
• C Single-dose amphotericin B 10 mg/kg with flucytosine for 2 weeks
• D Amphotericin B deoxycholate + flucytosine for 1 week (short-course induction), followed by fluconazole consolidation ✓

Explanation

WHO 2022 guidelines strongly recommend single-dose liposomal amphotericin B (10 mg/kg) plus 1 week of flucytosine as the preferred induction regimen for cryptococcal meningoencephalitis in HIV — this short-course induction has equivalent efficacy to 2-week regimens with better tolerability and lower nephrotoxicity. Alternatively, amphotericin B deoxycholate (0.7–1 mg/kg/day) + flucytosine (100 mg/kg/day) for 2 weeks (IDSA 2010 standard) is used where liposomal form is unavailable. Flucytosine (5-FC) is essential for the combination — it inhibits fungal DNA/RNA synthesis and prevents relapse. Fluconazole 400–800 mg/day follows as consolidation therapy (8 weeks) and then maintenance. Fluconazole monotherapy is inferior and not recommended as first-line induction.

Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.