A 55-year-old diabetic patient with poorly controlled glycaemia presents with unilateral facial pain, black nasal discharge and proptosis developing over 4 days. CT shows sinus erosion and orbital invasion. Tissue biopsy shows broad aseptate hyphae with right-angle branching. Which antifungal and surgical approach constitutes first-line management?
- A Voriconazole IV + limited surgical biopsy for histology only
- B Liposomal amphotericin B (L-AmB) 5–10 mg/kg/day + urgent surgical debridement of necrotic tissue ✓
- C Micafungin + fluconazole combination antifungal therapy
- D Posaconazole oral solution as primary therapy with close monitoring
Explanation
Rhinocerebro-orbital mucormycosis in a diabetic patient (the Mucorales order — Rhizopus, Mucor, Lichtheimia) requires aggressive dual management: L-AmB at high doses (5–10 mg/kg/day, ECMM/ESCMID recommendation) and urgent surgical debridement, which is the most important determinant of survival, with extensive removal of all necrotic tissue. Voriconazole has no meaningful activity against Mucorales — a classic pitfall. Echinocandins (micafungin) lack activity against Mucorales. Posaconazole is used as step-down oral therapy after initial L-AmB response, not as primary treatment.
Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.