A 46-year-old man living with HIV presents to the emergency room with confusion and quickly becomes obtunded. Lumbar puncture is notable for elevated opening pressure and cerebrospinal fluid with 14 leukocytes/mL. India ink stain is positive.
Which of the following therapies is the BEST choice for management of his disease?A. High-dose fluconazole
Correct Answer: C
Cryptococcal meningitis is a common central nervous system infection in immunocompromised patients. It is usually diagnosed using India ink stain or detection of cryptococcal antigen in cerebrospinal fluid. When available, the most effective therapy for cryptococcal meningitis is combination liposomal amphotericin B plus flucytosine (Answer C). After an induction period of treatment with combination amphotericin B and flucytosine therapy, fluconazole is often given for six to eighteen more months (Answer A). Although ketoconazole (Answer B) penetrates brain tissue, it is not currently used as first-line therapy for cryptococcal meningitis. Micafungin and caspofungin (Answer D) do not penetrate the central nervous system and thus have no role in treating cryptococcal meningitis or other central nervous system infections.