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Cryptococcal Disease — SCE Infectious Diseases MCQ

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HardHIV MedicineCryptococcal DiseaseSCE Infectious Diseases

A 31-year-old man with newly diagnosed HIV has a CD4 count of 45 cells/µL, viral load 620,000 copies/mL, and a positive serum cryptococcal antigen (CrAg) at a titre of 1:128. He is asymptomatic with no headache or neck stiffness. Lumbar puncture shows normal opening pressure, no WCC, and negative CSF CrAg. What is the most appropriate management?

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Correct answer: B — Start Fluconazole 800 mg daily for 2 weeks then 400 mg daily, and defer ART for 4–5 weeks

Asymptomatic CrAg positivity with negative CSF CrAg indicates subclinical cryptococcal antigenaemia without meningitis. WHO 2022 guidelines recommend pre-emptive antifungal therapy with Fluconazole 800 mg daily for 2 weeks, then 400 mg daily for 8 weeks, then 200 mg daily maintenance. ART should be deferred for 4–5 weeks to reduce the risk of cryptococcal IRIS. Full induction with Amphotericin B/Flucytosine is reserved for confirmed cryptococcal meningitis.

Reference: WHO 2022 – Guidelines on cryptococcal disease in people living with HIV; BHIVA 2022 – OI guidelines