In a patient with AIDS (CD4 <50 cells/µL) presenting with headache, neck stiffness, and CSF showing India ink preparation with encapsulated yeast cells and opening pressure of 280 mm H2O, cryptococcal antigen (CrAg) is positive 1:2048. What is the recommended induction therapy?
- A Fluconazole 400 mg orally for 8 weeks
- B Amphotericin B deoxycholate 0.7 mg/kg/day IV + flucytosine 25 mg/kg QID for 2 weeks, then fluconazole consolidation ✓
- C Voriconazole 6 mg/kg BD IV for 4 weeks
- D Micafungin 150 mg IV daily for 2 weeks
Correct answer: B. Amphotericin B deoxycholate 0.7 mg/kg/day IV + flucytosine 25 mg/kg QID for 2 weeks, then fluconazole consolidation
Explanation
WHO guidelines for cryptococcal meningitis in HIV recommend a 2-week induction with amphotericin B deoxycholate (0.7-1 mg/kg/day) + flucytosine (25 mg/kg QID) as it achieves the fastest CSF sterilisation. This is followed by 8-week consolidation with fluconazole 400 mg/day, then 200 mg/day maintenance. Fluconazole monotherapy is inferior and used only when amphotericin B is unavailable. Echinocandins (micafungin, caspofungin) have no clinically relevant activity against Cryptococcus. The high opening pressure requires serial therapeutic lumbar punctures.
Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.