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Asymptomatic CrAg Positivity — SCE Infectious Diseases MCQ

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ModerateHIV MedicineAsymptomatic CrAg PositivitySCE Infectious Diseases

A 45-year-old HIV-positive man (CD4 150, not yet on ART) has a positive serum cryptococcal antigen (CrAg) detected by reflex screening. He is asymptomatic. Lumbar puncture shows: opening pressure 18 cmH2O, WCC 2/µL, protein 0.4 g/L, glucose 3.5 mmol/L, CSF CrAg negative, CSF culture negative. What is this called?

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Correct answer: B — Cryptococcal antigenaemia without meningitis (subclinical/asymptomatic CrAg positivity)

Serum CrAg screening in patients with CD4 <100 (or <200 in some protocols) can detect subclinical cryptococcal antigenaemia before clinical meningitis develops. This patient has a positive serum CrAg but normal CSF parameters and negative CSF CrAg — this is asymptomatic antigenaemia. WHO recommends pre-emptive Fluconazole therapy (800 mg daily for 2 weeks, then 400 mg daily for 8 weeks, then 200 mg maintenance) and deferring ART for 4–5 weeks to reduce IRIS risk. Without pre-emptive treatment, ~25% progress to meningitis.

Reference: WHO 2022 – Cryptococcal screening guidelines; BHIVA 2022 – OI guidelines