A 34-year-old man is brought to the emergency department due to 3 weeks of intermittent fever, headache, malaise, and night sweats. Over the last few days, his headaches have worsened, and he has had blurry and double vision. The patient uses injection drugs and was treated for staphylococcal endocarditis 4 years ago. Temperature is 38.1 C (100.6 F), blood pressure is 150/100 mm Hg, pulse is 66/min, and respirations are 18/min. BMI is 18.4 kg/m². The patient is ill in appearance and somnolent but easily arousable and oriented. There are white plaques on the oropharyngeal mucosa and several skin lesions resembling molluscum contagiosum. There is increased resistance to passive neck flexion. Neurologic examination reveals leftward gaze restriction in the left eye but no other focal weakness or sensory loss. Funduscopy reveals bilateral papilledema. A noncontrast CT scan of the head shows no abnormalities. The patient receives a lumbar puncture; results of the spinal fluid analysis are as follows: Two weeks after the treatment is started, the patient's symptoms improve and a repeat spinal fluid culture is negative. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

Explanation: Patients with HIV who have cryptococcal meningitis require treatment in 3 stages as follows: Induction - amphotericin B and flucytosine for >2 weeks (until symptoms abate and CSF is sterilized) Consolidation - high-dose oral fluconazole for 8 weeks Maintenance - lower-dose oral fluconazole for >1 year to prevent recurrence After 2 weeks of induction therapy, this patient has negative CSF cultures and no further symptoms; he can now be transitioned to oral fluconazole consolidation therapy. (Choices A and C) This patient does not need continued intravenous medications due to symptom improvement and negative CSF cultures; he now requires several months of oral fluconazole to prevent recurrence. (Choice B) Patients with cryptococcal meningitis who are initiated on antiretroviral therapy must continue oral fluconazole for at least a year. Fluconazole can be discontinued after a year if CD4 count is >100/mm³ and viral load is undetectable for >3 months. (Choice D) Acyclovir is an antiviral medication that is often used for herpes simplex virus; it is not effective against Cryptococcus. Educational objective: Patients with HIV who have cryptococcal meningitis are treated with amphotericin B and flucytosine for >2 weeks. Once symptoms abate and CSF is sterilized, patients are transitioned to 8 weeks of consolidative treatment with high-dose fluconazole followed by a year or more of maintenance therapy with lower-dose fluconazole. Antiretroviral treatment should generally be initiated 2-10 weeks after beginning treatment for meningitis. References: Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. (http://www.ncbi.nlm.nih.gov/pubmed/24963568) Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/20047480)

A 34-Year-Old Man Is Brought to the Emergency Department Due