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Cryptococcal IRIS LP Management — SCE Infectious Diseases MCQ

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ModerateCNS InfectionCryptococcal IRIS LP ManagementSCE Infectious Diseases

A 45-year-old man with HIV develops immune reconstitution syndrome manifesting as paradoxical worsening of a previously treated Cryptococcal meningitis infection. CSF opening pressure is 38 cmH2O. CSF culture is STERILE. He has worsening headache and papilloedema. What is the critical management?

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Correct answer: C — Serial therapeutic lumbar punctures to reduce intracranial pressure — this is the most important intervention; remove sufficient CSF to reduce OP to ≤20 cmH2O or by 50%

Raised ICP in cryptococcal IRIS is the primary cause of morbidity and mortality. With STERILE cultures confirming this is IRIS (not treatment failure), the management priority is pressure control through serial therapeutic LPs. Each LP should remove sufficient CSF to reduce OP to ≤20 cmH2O (or by 50% from baseline). Daily LPs may be needed for several days. Corticosteroids (Dexamethasone) are added for refractory IRIS not responding to LPs alone. Resuming antifungal induction is NOT indicated with sterile cultures. ART must be CONTINUED.

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