American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the main treatment for cryptococcal meningitis during the induction phase in transplant recipients?

1. Lipid formulation of amphotericin B

2. Oral fluconazole

3. High-dose amphotericin B deoxycholate

4. Caspofungin

The correct answer is: Lipid formulation of amphotericin B

The main treatment for cryptococcal meningitis during the induction phase in transplant recipients is the lipid formulation of amphotericin B. This choice is optimal because the lipid formulations, such as liposomal amphotericin B, have significantly improved safety profiles compared to older formulations like amphotericin B deoxycholate. They are less nephrotoxic and allow for higher doses to be administered, which is crucial in treating cryptococcal meningitis effectively. In transplant recipients, who often have compromised immune systems, achieving a therapeutic concentration while minimizing toxicity is essential. Lipid formulations provide a means to achieve this balance, making them preferable during the induction phase of treatment. Oral fluconazole, while important in the treatment hierarchy for cryptococcal infections, is typically used in the consolidation and maintenance phases rather than the initial induction treatment, especially in cases of severe disease like meningitis. High-dose amphotericin B deoxycholate, although effective, has a higher risk of nephrotoxicity and infusion-related reactions compared to lipid formulations and is less favored in vulnerable populations such as transplant recipients. Caspofungin, an echinocandin antifungal, is not typically first-line for cryptococcal meningitis and is more commonly