Case 4. Under Pressure: Cryptococcus, ART Initiation, and the Threat of IRIS

After brief mention of an HIV vaccine, the hosts turn to the challenges of treating cryptococcal meningitis in a 46-year-old woman with profound immune suppression after being off ART for 6-12 months. Emphasizing the high potential for morbidity and mortality, Chris and Eileen focus on the complexities of cryptococcal meningitis medical management, including the role of immune constitution, timing of ART initiation, and the risk of IRIS. Listen as they work through the treatment requirements and clinical decisions involved in this complicated case.    

References Cited

• Boulware DR, Meya DB, Muzoora C, et al. Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. N Engl J Med. 2014;370(26):2487-2498. PMID: 24963568
• Chang CC, Dorasamy AA, Gosnell BI, et al. Clinical and mycological predictors of cryptococcosis-associated immune reconstitution inflammatory syndrome. AIDS. 2013;27(13):2089-2099. PMID: 23525034
• Gandhi RT, Landovitz RJ, Sax PE, et al. Antiretroviral Drugs for Treatment and Prevention of HIV in Adults: 2024 Recommendations of the International Antiviral Society-USA Panel. JAMA. 2025;333(7):609-628. PMID: 39616604
• Ingle SM, Miro JM, May MT, et al. Early Antiretroviral Therapy Not Associated With Higher Cryptococcal Meningitis Mortality in People With Human Immunodeficiency Virus in High-Income Countries: An International Collaborative Cohort Study. Clin Infect Dis. 2023;77(1):64-73. PMID: 36883578
• Kwizera R, Kiiza TK, Akampurira A, Kimuda S, Mugabi T, Meya DB. Evolution of Laboratory Diagnostics for Cryptococcosis and Missing Links to Optimize Diagnosis and Outcomes in Resource-Constrained Settings. Open Forum Infect Dis. 2024;11(9):ofae487. Published 2024 Aug 27. PMID: 3928635
• Makadzange AT, Ndhlovu CE, Takarinda K, Reid M, Kurangwa M, Gona P, Hakim JG. Early versus delayed initiation of antiretroviral therapy for concurrent HIV infection and cryptococcal meningitis in sub-saharan Africa. Clin Infect Dis. 2010 Jun 1;50(11):1532-8. PMID: 20415574.
• Srichatrapimuk S, Sungkanuparph S. Integrated therapy for HIV and cryptococcosis. AIDS Res Ther. 2016;13(1):42. Published 2016 Nov 29. PMID: 27906037

Related Guidelines

• Clinical info HIV.gov: Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV: Cryptococcosis
• IAS-USA: Antiretroviral Drugs for Treatment and Prevention of HIV in Adults: 2024 Recommendations of the International Antiviral Society-USA Panel  
• NYSDOH AI Clinical Guidelines Program: Management of IRIS