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Lack of efficacy: case report A 70-year-old man exhibited lack of efficacy with amphotericin-B-liposomal, levofloxacin, meropenem and micafungin, while being treated for febrile neutropenia or acute rhinosinusitis [routes not stated]. The man presented at the haematology department with pancytopenia and general malaise. He had a history of untreated chronic renal disease and diabetes. At presentation, a diagnosis of acute monocytic leukaemia was made. His CSF cytology was class III. Subsequently, he started receiving remission induction therapy with cytarabine and daunorubicin, along with intrathecal chemotherapy. On the 16th day of remission induction therapy initiation, he started receiving antibiotic treatment with meropenem 1.5 g/day and antifungal therapy with micafungin 150 mg/day for febrile neutropenia. However, he had a headache and fever. His laboratory test results were as follows: WBC: 150 /µL, haemoglobin level: 6.9 g/dL, platelet count: 20,000 /µL, HbA1c level: 6.5%, creatinine clearance: 28.1 mL/min in a 24h urine collection test, CRP: 10.57 mg/dL, procalcitonin: 0.84 ng/mL and β-D glucan: 12.4 pg/mL. His serum aspergillus galactomannan antigen and two sets of blood culture were negative. Hence, the man’s antibiotic treatment was changed to levofloxacin 500 mg/day, and antifungal treatment was changed to amphotericin-B-liposomal [liposomal amphotericin B] 2.5 mg/kg/day. On day 22 (from the remission induction therapy initiation), no improvement in his clinical symptoms was observed. Based on CT scan and MRI findings, acute rhinosinusitis was suspected. Hence, treatment with levofloxacin was changed to meropenem 4 g/day. Also, his amphotericin-B-liposomal dosage was increased to 5 mg/kg/day. He had persistent fever and intermittent headache, along with syndrome of inappropriate secretion of ADH (SIADH). He had no local skin ulceration, nasal discharge and other neurologic symptoms. On day 32, an brain abscess with extended brain oedema was observed at the base of the posterior ethmoid sinus. Hence, emergency surgery was planned on the same day, and subsequently, he underwent endoscopic endonasal skull base surgery. Post-surgery, the amphotericin-B-liposomal dose was increased to 10 mg/kg/day based on the assumption of rhinocerebral mucormycosis with necrotic membrane and immunodeficiency. Based on findings, rhinocerebral mucormycosis and brain abscess were diagnosed. It was concluded that despite treatment with amphotericin-B-liposomal, levofloxacin, meropenem and micafungin he developed brain abscess (lack of efficacy). Post-operatively, his fever and headache resolved. On a postoperative day 17, he had a recurrence of acute monocytic leukaemia. On a postoperative day 30, he started receiving azacytidine for recurrence of acute monocytic leukaemia. However, on postoperative day 42, he died because of gram-negative septic shock caused by an intestinal infection. Uraguchi K, et al. A case of rhinocerebral mucormycosis with brain abscess drained by endoscopic endonasal skull base surgery. Medical M