Cryptococcal meningitis — DTM&H MCQ

Correct answer: D — Amphotericin-based induction with flucytosine and serial therapeutic lumbar punctures

The correct answer is D, amphotericin-based induction with flucytosine and serial therapeutic lumbar punctures. This patient has HIV-associated cryptococcal meningitis with a markedly raised opening pressure (36 cmH2O), a combination that carries a very high early mortality if untreated aggressively. Current guidance recommends liposomal amphotericin B combined with flucytosine as induction therapy for HIV-associated cryptococcal meningitis, because this combination clears CSF fungal burden faster and reduces mortality compared with fluconazole-based regimens. Repeated therapeutic lumbar puncture to bring the opening pressure down (target under 20 cmH2O or a 50 percent reduction) is an essential, independently life-saving intervention because raised intracranial pressure from impaired CSF outflow, not fungal burden alone, drives early death and blindness in this condition. Amphotericin plus flucytosine and pressure-directed lumbar punctures together address both the infective and mechanical drivers of mortality. Why the other options are wrong: E. Fluconazole prophylaxis dose and outpatient review: this dose is for maintenance or primary prophylaxis in less unwell patients, not induction therapy, and this patient has active meningitis with dangerously raised pressure requiring urgent inpatient treatment, not outpatient follow up. C. Immediate ART before antifungal therapy: starting ART before controlling the fungal burden risks unmasking or paradoxical cryptococcal immune reconstitution inflammatory syndrome, and ART initiation should be deferred for several weeks after starting antifungal induction. A. Ceftriaxone alone for bacterial meningitis: the CSF cryptococcal antigen is positive, confirming a fungal rather than bacterial cause, so an antibacterial agent alone will not treat the underlying infection. B. Albendazole with corticosteroids: albendazole is an anthelmintic used for conditions such as neurocysticercosis, not fungal meningitis, and has no role here. Key point: in HIV-associated cryptococcal meningitis, both antifungal induction (amphotericin plus flucytosine) and aggressive management of raised opening pressure with serial lumbar punctures are required, and ART must be deferred to avoid IRIS.

Reference: BHIVA Guidelines for the Treatment of Opportunistic Infection in HIV-seropositive Individuals 2011 (Central Nervous System Opportunistic Infections), HIV Medicine 2011;12(Suppl 2):8-24, https://bhiva.org/wp-content/uploads/2024/11/-file-SwhaEzgXmAGOt-hiv_v12_is2_Iss2Press_Text.pdf