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Cryptococcal IRIS Pressure Management — SCE Infectious Diseases MCQ

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ModerateCNS InfectionCryptococcal IRIS Pressure ManagementSCE Infectious Diseases

A 30-year-old man with HIV develops immune reconstitution inflammatory syndrome affecting the brain (CNS-IRIS). He had previously been treated for cryptococcal meningitis and then started ART 4 weeks ago. His CSF now shows rising opening pressure (35 cmH2O) with worsening headache but sterile CSF cultures. What is the critical management step?

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Correct answer: E — Therapeutic lumbar puncture (LP) to reduce opening pressure — raised ICP in cryptococcal IRIS is managed with serial LPs; corticosteroids may also be needed

Cryptococcal IRIS manifests as worsening symptoms (headache, confusion) after ART initiation with raised CSF opening pressure but STERILE cultures (distinguishing it from treatment failure). The critical management is pressure management: therapeutic LPs removing sufficient CSF to halve the opening pressure (or to ≤20 cmH2O). Serial daily LPs may be needed. Corticosteroids (Dexamethasone) are used for severe CNS-IRIS not responding to pressure management. ART should generally be CONTINUED (stopping risks further OIs). VP shunt is reserved for refractory raised ICP.

Reference: BHIVA 2022 – OI guidelines; WHO 2022 – Cryptococcal disease; Lancet ID 2019