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Cirrhotic ascites — USMLE Step 3 MCQ

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HardInternal Medicine (Chronic Management)Cirrhotic ascitesUSMLE Step 3

A 38-year-old man with advanced HIV begins liposomal amphotericin B plus flucytosine for cryptococcal meningitis. Opening pressure was 38 cm H2O and 25 mL of cerebrospinal fluid was removed. The next day, headache, vomiting, and diplopia recur; CT shows no mass lesion or obstructive hydrocephalus. Which intervention is most appropriate now?

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Correct answer: C — Repeat lumbar puncture and drain CSF to reduce opening pressure

The best answer is “Repeat lumbar puncture and drain CSF to reduce opening pressure”. Recurrent symptoms after an initially elevated opening pressure indicate recurrent cryptococcal intracranial hypertension. Daily or more frequent therapeutic lumbar punctures are performed until pressure and symptoms remain controlled. Acetazolamide and mannitol have not improved outcomes, antifungal dose escalation does not acutely relieve pressure, and permanent shunting is reserved for pressure refractory to repeated drainage.

Reference: IDSA Guideline: Cryptococcal Disease: https://www.idsociety.org/practice-guideline/cryptococcal-disease/