Guideline sources The following summarized guidelines for the evaluation and management of COVID-19-associated pulmonary mucormycosis are prepared by our editorial team based on guidelines from the Academy of Pulmonary Sciences (APS/FISF 2022). 1 Guidelines 1. Diagnostic investigations Diagnostic imaging: obtain CT with IV contrast in the initial evaluation of patients with COVID-19- associated pulmonary mucormycosis. E Show 2 more Laboratory tests: obtain conventional microbiological testing from the lower respiratory tract samples in the initial evaluation of patients with COVID-19-associated pulmonary mucormycosis. E Show 3 more 2. Diagnostic procedures https://web.pathway.md/diseases/recVWJ0xdQoTmH9Xj 1/3 6/29/23, 3:24 AM COVID-19-associated pulmonary mucormycosis Pathway Bronchoscopy: Perform early flexible bronchoscopy in most patients with COVID-19-associated pulmonary mucormycosis due to the following advantages: visualization of airway abnormalities performing endobronchial biopsies provision of samples representing the lower respiratory tract (BAL or bronchial washings). E Biopsy: perform transthoracic tru-cut core-needle biopsy for diagnosing COVID-19-associated pulmonary mucormycosis in patients with peripheral chest lesions. E 3. Medical management Antifungal therapy (initial): administer liposomal amphotericin B 5 mg/kg/day as first-line therapy in patients with COVID-19-associated pulmonary mucormycosis. Consider escalating the dose to 10 mg/kg/day in patients with intracranial involvement. E Show 2 more Antifungal therapy (maintenance): initiate maintenance therapy with isavuconazole or posaconazole after achieving a complete or partial response. E Antifungal therapy (treatment failure): Do not combine antifungal drugs (posaconazole or isavuconazole with amphotericin) in patients with a treatment failure. D Continue liposomal amphotericin B or initiate posaconazole or isavuconazole for a longer duration until a complete or partial response is achieved, as salvage therapy in patients with treatment failure. E 4. Surgical interventions Lung resection: perform lung resection in all patients with potentially resectable lung disease. E Show 2 more Clinical findings Symptoms Past medical history Black sputum Covid-19 infection Brown sputum Diabetes mellitus Chest pain Immunocompromising condition Cough Fever Hemoptysis Shortness of breath Sputum production https://web.pathway.md/diseases/recVWJ0xdQoTmH9Xj 2/3 6/29/23, 3:24 AM COVID-19-associated pulmonary mucormycosis Pathway Imaging findings Lung consolidation Mediastinal lymphadenopathy Mycotic aneurysm Pneumothorax Pulmonary air-fluid levels Reversed halo sign Thick-walled pulmonary cavity Tree-in-bud pattern References 1. Valliappan Muthu, Ritesh Agarwal, Atul Patel et al. Definition, diagnosis, and management of COVID 19 associated pulmonary mucormycosis: Delphi consensus statement from the Fungal Infection Study Forum and Academy of Pulmonary Sciences, India. Lancet Infect Dis. 2022 Apr 04. Open https://web.pathway.md/diseases/recVWJ0xdQoTmH9Xj 3/3