Treatment of pulmonary mucormycosis: current concepts

INTRODUCTION: Pulmonary mucormycosis (PM) is a rapidly progressive angioinvasive fungal infection with high mortality. Despite therapeutic advances, optimal management remains uncertain. AREAS COVERED: We review the evidence on managing PM. We emphasize aggressive host factor optimization (glycemic control, immunosuppression reduction) and outline the evidence-based antifungal strategy: liposomal amphotericin B (L-AMB) for induction, followed by oral maintenance (posaconazole or isavuconazole). We discuss critical nuances, including LAMB dosing, timing, and duration of therapy, drug interactions, and therapeutic drug monitoring. We review the role of combination antifungals, newer agents, and adjunctive modalities (inhaled antifungals, immunomodulation, bronchoscopic interventions, and iron chelation), assessing their appropriate use. The timing, indications, feasibility, and perioperative risk of surgery are discussed. We provide practical guidance for PM in special populations, including children, pregnant women, individuals with chronic liver or renal disease, and transplant recipients. EXPERT OPINION: Optimal care of PM requires early recognition, prompt LAMB induction with rigorous host factor optimization, multidisciplinary surgical assessment, followed by oral triazole maintenance. Combination antifungal therapy lacks definite evidence and should be reserved for severe or refractory cases. Future research priorities include prospective evaluation of treatment strategies, host-directed therapies, emerging antifungals (oral nanocrystal amphotericin, fosmanogepix, etc.), and systematic assessment of adjunctive modalities.