Rethinking Routine Lumbar Puncture and Induction Therapy in Non-HIV Pulmonary Cryptococcosis: A Call for Risk-Based Management.

Current guidelines recommend lumbar puncture (LP) in patients with pulmonary cryptococcosis (PC) to exclude central nervous system (CNS) involvement. However, recent multicenter data suggest that CNS dissemination is rare in immunocompetent, asymptomatic patients with low serum CrAg titers. And, although guidelines advocate induction therapy for severe PC, most patients in practice receive fluconazole monotherapy with favorable outcomes. This Perspective evaluates the gap between guideline-based universal intervention and real-world clinical practices, advocating for a risk-stratified management strategy. We outline clinical and laboratory features that may guide stratification and propose a pragmatic approach to streamline care and reduce unnecessary invasive procedures.