American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the recommended induction treatment for cryptococcal meningitis in patients without HIV/AIDS or transplantation?

1. Oral fluconazole for 8 weeks

2. Amphotericin B and flucytosine for ≥4 weeks

3. Lipid formulation of amphotericin B only

4. Itraconazole

The correct answer is: Amphotericin B and flucytosine for ≥4 weeks

The recommended induction treatment for cryptococcal meningitis in patients without HIV/AIDS or transplantation is amphotericin B combined with flucytosine for a duration of at least four weeks. This combination therapy is effective due to the synergistic effects of both medications: amphotericin B works by disrupting fungal cell membrane integrity, while flucytosine inhibits fungal DNA and RNA synthesis. This dual approach is associated with better outcomes, including faster clearance of the cryptococcal organism from the cerebrospinal fluid and improved survival rates. Monotherapy with amphotericin B is often less effective alone for cryptococcal meningitis, and while lipid formulations of amphotericin B may be used in some cases, they are generally not the first-line treatment without the addition of flucytosine for this specific condition. Oral treatment options, such as fluconazole or itraconazole, are typically considered for maintenance therapy after successful induction rather than for initial management, especially in severe cases of cryptococcal meningitis. Thus, the combination of amphotericin B and flucytosine is the standard and most effective induction therapy for this serious infection, ensuring rapid intervention and appropriate management of the patient's condition.