A diabetic patient with recent COVID-19 pneumonia and prolonged steroid use develops rapidly progressing black eschar over the palate and necrotic ulcers in the nasal cavity. Sputum KOH mount shows broad, irregular, non-septate (pauciseptate) hyphae at right angles. Biopsy confirms angioinvasion. Which combination of management steps is most appropriate?

• A Amphotericin B deoxycholate IV + aggressive surgical debridement + optimise glycaemic control + correct immunosuppression
• B Liposomal amphotericin B IV + isavuconazole OR posaconazole as step-down therapy + aggressive surgical debridement + reverse immunosuppression ✓
• C Voriconazole IV + intranasal antifungal washes + prolonged steroid continuation for immune reconstitution inflammatory syndrome
• D Caspofungin IV + surgical debridement; echinocandins are preferred for mucormycosis due to lower nephrotoxicity

Explanation

Rhinocerebral mucormycosis caused by Mucor/Rhizopus species (class Zygomycetes) is a life-threatening emergency in diabetic ketoacidosis and immunosuppressed patients. Management requires: (1) Liposomal amphotericin B (LAmB) 5–10 mg/kg/day IV as first-line antifungal (lower nephrotoxicity than deoxycholate); (2) Aggressive surgical debridement of necrotic tissue to reduce fungal burden; (3) Isavuconazole or posaconazole as step-down or salvage therapy; (4) Reversal of predisposing factors — discontinue/taper steroids, achieve tight glycaemic control, correct DKA. Voriconazole is NOT active against Mucorales. Echinocandins have no meaningful activity against mucormycosis.

Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.