Critical Care Medicine-Infections and Immunologic Disease>>>>>Antimicrobial Therapy and Resistance
Question 2#

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
B. High-dose ketoconazole
C. Liposomal amphotercin B and flucytosine
D. Micafungin or caspofungin 150 mg daily

Correct Answer is C

Comment:

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.

References:

1. Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases Society of America. Clin Infect Dis. 2010;50:291-322.
2. WHO Guidelines Approved by the Guidelines Review Committee. Guidelines for The Diagnosis, Prevention and Management of Cryptococcal Disease in HIV-Infected Adults, Adolescents and Children: Supplement to the 2016 Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection. Geneva: World Health Organization; 2018.