India ink preparation of CSF in an HIV patient with CD4 = 30 shows encapsulated yeast cells. Cryptococcal antigen (CrAg) is 1:1024. The treatment protocol recommended by WHO for cryptococcal meningitis includes:

• A Amphotericin B deoxycholate 0.7–1 mg/kg/day + flucytosine 25 mg/kg QID for 2 weeks (induction), then fluconazole consolidation/maintenance ✓
• B Fluconazole 400 mg/day for 2 weeks (induction), then maintenance
• C Liposomal amphotericin B 3–4 mg/kg/day + flucytosine for 1 week (induction), then fluconazole consolidation
• D Voriconazole 6 mg/kg BD loading then 4 mg/kg BD as induction

Explanation

WHO 2022 guidelines recommend amphotericin B deoxycholate (0.7–1 mg/kg/day) plus flucytosine (25 mg/kg QID) for 2 weeks as induction therapy for HIV-associated cryptococcal meningitis, followed by fluconazole 400 mg/day for 8 weeks (consolidation) then 200 mg/day maintenance; this combination achieves fungicidal cerebrospinal fluid sterilization. Liposomal amphotericin B 3–4 mg/kg/day + flucytosine for 1 week is an alternative (shorter course). Fluconazole monotherapy is fungistatic and has higher mortality as induction. Voriconazole has limited activity against Cryptococcus.

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

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Written and medically reviewed by the StethoPrep medical team.