244.3 🩺 內科專科考前版

244.3.0.1 1⃣ AMBITION-cm Trial 2022

  • Single dose liposomal AmB 10 mg/kg alternative to 2-week induction
  • For HIV-related cryptococcal meningitis in resource-limited settings
  • Non-inferior to 7-day AmB + flucytosine in mortality
  • WHO 2022+ recommendation
  • Reduces drug requirements, hospital stay, cost
  • Game-changer for sub-Saharan Africa

244.3.0.2 2⃣ Sub-Saharan Africa Burden

  • 70%+ of global cryptococcal meningitis deaths
  • HIV-related primarily
  • Limited access to flucytosine + liposomal AmB
  • WHO + Gilead access programs improving
  • Mortality 30-40% with optimal Tx; up to 60-70% without

244.3.0.3 3⃣ Cryptococcal Meningitis IRIS

  • Paradoxical worsening with HIV + ART
  • More common with delayed ART (4-6 wk)
  • Headache + meningitis features recurrence
  • Repeat LP
  • Continue ART + cryptococcal Tx
  • Steroid for severe (controversial)

244.3.0.4 4⃣ Repeat LP — Procedure

  • Opening pressure measurement essential
  • Drain CSF to reduce ICP (often 20-30 mL)
  • Repeat daily or every-other-day
  • Continue until pressure normalized
  • Lumbar drain or VP shunt for refractory high ICP
  • Most institutions: protocol-based LP for high ICP

244.3.0.5 5⃣ Solid Organ Transplant + Cryptococcal

  • Reduced immunosuppression often beneficial
  • Treatment same as HIV
  • IRIS-like reaction possible with immune restoration
  • Variable maintenance duration

244.3.0.6 6⃣ C. gattii Cerebral Cryptococcomas

  • Mass lesions often
  • May need neurosurgical intervention
  • Surgery + antifungal
  • Long-term follow-up

244.3.0.7 7⃣ Resistance

  • Fluconazole resistance reported (especially after exposure)
  • Rare in C. neoformans + C. gattii overall
  • AmB + flucytosine resistance very rare
  • AST in failure cases

244.3.0.8 8⃣ 健保 / Taiwan

  • 通報 mandatory
  • 健保 AmB + flucytosine + fluconazole + voriconazole
  • ID + neurology + neurosurgery consultation
  • Sub-tropical Taiwan endemic; sporadic cases including in immunocompetent

244.3.0.9 9⃣ Future + Vaccines

  • Cryptococcal vaccine in research (subunit)
  • Newer antifungals
  • Encochleated AmB (oral) in development for cryptococcal meningitis (resource-limited)

244.3.0.10 10. Diagnostic Updates

  • Lateral flow immunoassay (LFA) for serum + CSF CrAg — POC
  • Rapid + sensitive + cheap
  • WHO-prequalified
  • Expanding access in resource-limited