Rhino-orbito-cerebral mucormycosis is an aggressive disease, seen most commonly in immunocompromised or diabetic patients. It has mortality rates as high as 70-90%, especially in solid organ transplant recipients, and those with delayed initiation of antifungal therapy. Liver transplant patients have the highest incidence, and fastest onset, of mucormycosis infection, out of all solid organ transplant recipients. A 73 yo lady 1 yr s/p OLT (orthotopic liver transplant), on tacrolimus and prednisone, presented with 2 weeks of rhinorrhea and sinus pain, and 3 days of L orbital erythema, edema and fever. Imaging revealed extensive sinus opacification, extending to the left orbit and skull base, with osteomyelitis. Urgent nasal endoscopy showed turbinate and skull base necrosis. Biopsies revealed mucormycosis. Immunosuppression was held, with close monitoring of liver enzymes and eospinophil count. She had multiple surgical debridements, alongside amphotericin-B + micafungin. After 2 weeks of antifungal therapy, biopsy revealed absence of mucormycosis without further necrosis. Tacrolimus was then restarted, with a low goal of 2, and indefinite posaconzaole was started, on which she was discharged, asymptomatic and without evidence of liver rejection. 6 months later, she remains symptom free. Rhino-orbito-cerebral mucormycosis is a life threatening infection, requiring a low threshold of suspicion. Liposomal Amphoterecin B + aggressive debridement are the most effective treatment options, along with reduction in immunosuppression. Initiation of antifungal therapy in < 6 days confers the greatest reduction in mortality (therapy was started day 4 in our patient). Almyroudis et al reported a lower mortality for patients in whom immunosuppression (IS) was discontinued or reduced during the acute infection (p=0.05). Current guidelines do not specifically address what to do with the immunosuppression. Given that our patient did not start to improve until after her immunosuppression was completely held, we suggest that holding IS during acute rhino-orbito-cerebral mucormycosis infection may lead to faster resolution and decrease in mortality. Further studies need to be done assessing this hypothesis, alongside close monitoring for signs of organ rejection. Awareness also needs to be raised regarding the benefit of maintaining a low threshold of suspicion for this disease, and the drastic increase in mortality as time to initiation of therapy increases.Figure: Fungal hyphae seen on microscopy of nasal endoscopy biopsy specimens,Figure: relationship of time to initiation of antifungal therapy and survival in mucormycosis infection. (Yohai RA1, Bullock JD, Aziz AA, Markert RJ. Survival factors in rhino-orbital-cerebral mucormycosis. Surv Ophthalmol. 1994 Jul-Aug; 39(1):3-22.)Figure: Trend in LFT's throughout admission, demonstrating lack of significant change or evidence of rejection.