Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr. Mamta Gupta,
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Aug 2018

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : EC09 - EC11 Full Version

Effectiveness of COVID-19 Vaccination against COVID -associated Mucormycosis

Published: November 1, 2022 | DOI:
Rohit Mahla, Saurabh Shrivastava

1. Postgraduate Student, Department of Pathology, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India. 2. Assistant Professor, Department of Pathology, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India.

Correspondence Address :
Dr. Saurabh Shrivastava,
House #71, Arya Nagar, 1st Lane, Morar, Gwalior, Madhya Pradesh, India.


Introduction: Coronavirus Disease-2019 (COVID-19) infections may be associated with a wide range of opportunistic bacterial and fungal co-infections. Both Aspergillus and Candida have been reported as the main fungal pathogens for co-infection in people with COVID-19. During the COVID-19 pandemic, another threat has emerged as a challenge to India was in the form of COVID-associated mucormycosis.

Aim: To study the incidence of COVID-associated rhino-orbital mucormycosis in vaccinated and unvaccinated patients.

Materials and Methods: A prospective observational study was carried out at Gajra Raja Medical College and Jay Arogya Hospital, Gwalior, Madhya Pradesh, India, over a period of two months (May to June 2021). A total of 94 patients with post-COVID rhino-orbital mucormycosis were reported in the institute during the study period. Biopsy or postoperative surgical specimens were received for histopathological examination with a proper history of diabetes mellitus, steroid intake, and vaccination status. Histologically confirmed COVID-associated rhino-orbital mucormycosis cases were included in the study and its incidence was compared in vaccinated and unvaccinated patients.

Results: Total 94 patients were confirmed histopathologically, with mucormycosis. It was noted that mucormycosis was more common in males as compared to females. Of the total number of cases, 71 (75.5%) cases had a history of diabetes mellitus and 73 (77.7%) had a history of steroid intake. Eightysix (91.5%) cases were unvaccinated while only 8 (8.5%) were either completely or partially vaccinated. Incidence of mucormycosis was found to be more amongst unvaccinated patients as compared to vaccinated patients.

Conclusion: Mucormycosis is one of the major post-COVID threats. Diabetes mellitus and steroid intake were found to be the main risk factors for post-COVID mucormycosis. However, it has also been noted that mucormycosis can occur without a previous history of diabetes and steroid intake. Incidence of mucormycosis was found to be higher amongst unvaccinated patients as compared to vaccinated patients. Hence, vaccination against COVID-19 is likely to be effective in the prevention of COVID-associated mucormycosis.


Corticosteroid, Coronavirus disease-2019, Diabetes mellitus, Fungal infection, Histopathological examination, Hyphae, Incidence, Steroid

After the COVID-19 pandemic another threat has emerged as a challenge to India in the form of COVID-associated mucormycosis (1). Mucormycosis is caused by a group of moulds called Mucormycetes, which are rare but potentially fatal if inadequately treated (2). Mucormycosis is popularly known as “black fungus”. Cases were reported in almost every state of India following COVID-19. Most patients presented with complaints of headache and facial pain. Hard palate involvement was observed in patients and unilateral presentation was more common. Various research studies have been conducted to establish the risk factors and pattern of disease. The most common risk factors associated with post-COVID mucormycosis are diabetes and steroid intake (3),(4).

However, a number of cases had no history of diabetes or steroid intake. Various states have quickly undertaken measures to control the situation by setting up special task forces, issuing guidelines, arranging separate wards in hospitals for the management of mucormycosis cases, and procuring the drugs required for treatment. Now the disease is under control with less number of cases are being reported.

Now COVID-19 vaccines are widely available, which have reduced the disease burden significantly (5). Although various studies have reported that diabetes mellitus or immunocompromised state are
the major risk factors of mycormycosis, there have been cases without such a history (3),(4). Researchers have hypothesised that immediate vaccination will help in generating herd immunity, thereby
reducing the chances of black fungus infection and its associated severe health complications (6).

The aim of the study was to investigate the incidence of COVIDassociated rhino-orbital mucormycosis in vaccinated and unvaccinated patients. This would help to establish the efficacy of vaccination in preventing COVID-associated rhino-orbital mucormycosis. Another objective was to find out the associated risk factors predisposing to post-COVID mucormycosis.

Material and Methods

A prospective observational study was conducted at Gajra Raja Medical College and Jay Arogya Hospital, Gwalior, India, over a period of two months (May to June 2021). The study was approved by the Institutional Ethics Committee (IEC) (Approval no. P/412/21). Informed consent was obtained from the participants.

Inclusion criteria

• Histopathologically confirmed mucormycosis cases.
• Either post-COVID or presently COVID-positive mucormycosis patients.

Exclusion criteria

• Incomplete medical history.
• Patient suspected to be a case of mucormycosis but not histopathologically confirmed.


The samples from patients who were admitted in the mucormycosis ward between May-June 2021 were submitted for histopathological examination. Their medical history was taken for current COVID-19 status, history of diabetes mellitus, steroid intake, and vaccination status and the data was recorded. Total 95 histopathological samples were submitted to the Histopathology Department. Proper history of one patient could not be obtained and hence excluded from the present study.

All histopathological specimens with suspected COVID-associated rhino-orbital mucormycosis received in the Department of Pathology, which were either COVID-positive or had recovered from COVID19, were included in the study. A total of 94 patients with COVIDassociated rhino-orbital mucormycosis were reported during the study.

All samples were fixed in 10% neutral buffered formalin, embedded in paraffin blocks, and stained with Haematoxylin and Eosin (H&E) stain. All histopathologically confirmed cases of mucormycosis
were then compared with their COVID vaccination status, history of diabetes mellitus and steroid intake during management of COVID-19.


Descriptive data were entered in Microsoft excel and were analysed using the Statistical Package for the Social Sciences (SPSS) version 20.0 and mean age, gender distribution and percentage were analysed.


The mean age of the patients in the present study was 45.2 years, although there was a wide spectrum of age varying between 28-81 years. Out of 94 patients, 70 were males and 24 were females, indicating that there was a male predominance. Out of 94 mucormycosis patients, 23 (24.5%) had no history of diabetes mellitus, while 71 (75.5%) were diabetic. Twenty-one patients had not taken steroid in any form, while 73 had a history of steroid use. Total 86 (91.5%) patients were unvaccinated, while five had received their 1st dose of COVID-19 vaccine. The data showed that only three patients had received two doses of the COVID-19 vaccine. The frequency of COVID-associated mucormycosis was much higher in unvaccinated patients as compared to vaccinated patients (Table/Fig 1).

Histopathological examination: Broad aseptate fungal hyphae with large areas of necrosis, mycotic infiltration of blood vessels, tissue infarction, haemorrhage, giant cell reaction, and acute neutrophilic infiltrate. Periodic acid-Schiff (PAS) stain was used in a few cases to identify fungi [Table/Fig-(2),(3),(4).


Although mucormycosis is an extremely rare condition in healthy people, immunocompromised individuals are at a higher risk of infection. These include co-morbid and other conditions, such as diabetes mellitus, haematological and other malignancies, organ transplantation, prolonged neutropenia, immunosuppressive drugs, such as corticosteroids, (7) as well as other drugs like deferoxamine and voriconazole, severe burns, Acquired Immune Deficiency Syndrome (AIDS), drug abuse, malnutrition, and open wounds following trauma (8). The recent surge in mucormycosis cases have been observed in post-COVID patients, largely due to excessive use of immunosuppressive steroids to treat the condition.

Histologically, giant cell invasion, thrombosis, and eosinophilic necrosis of the underlying tissues are the pathological hallmarks of mucormycosis. Pathological examination of biopsy samples can identify the hyphae based on diameter, presence or absence of septa, branching angle (right or acute branching), and pigmentation, which differentiates it from other fungal infections (9). Special stains like PAS or Grocott Methenamine Silver (GMS) can be used to highlight the microbe.

A systematic review by Singh AK et al., showed male predominance comprising of 78.9% male patients. There was a history of diabetes mellitus in 80% and steroid intake in 76.3% of patients (7). This data was in concordance with the present study, which showed that 74.5% were male patients. Data on risk factors, such as history of steroid intake and diabetes in the present study have also been presented in (Table/Fig 1).

As of 28th May 2021, when India had 14,872 mucormycosis cases, most of them had diabetes mellitus and prolonged steroid intake. This Indian epidemiological study showed that 55-76% of mucormycosis patients had diabetes (10). In comparison, the present study showed that 75.5% of patients had diabetes. The variation may be attributed to the difference in sample sizes.

In another study, Arakeri G et al., showed a male predominance. They also showed that 68.3% of patients had a history of uncontrolled diabetes and 46% for steroid intake. Moreover, only two cases were fully vaccinated (11). Comparison of this study with the present study show that the results were similar with reference to vaccination status, as most of the cases were unvaccinated in both the studies, as well as the fact that diabetes and steroid intake were both contributing risk factors.

There are not many studies related to mucormycosis incidence in vaccinated and unvaccinated patients. However, one survey conducted in Hyderabad showed that 86% of mucormycosis patients were not vaccinated against COVID-19 (12). In the present study, 91.5% of patients with mucormycosis were not vaccinated against COVID-19, while 5.3% had taken the 1st dose and only 3.2% were fully vaccinated (Table/Fig 1). The results of these two studies are somewhat similar.

The most notable finding of the present study was that the majority of mucormycosis cases were unvaccinated, which is also true for a study conducted by Joshi PK and Jadhav KK (13). In this study also, males were more prone to COVID-associated mucormycosis and the incidence was observed more in unvaccinated patients than vaccinated patients.


The sample size was quite small. Also, there was no data on actual incidence of mucormycosis as only histopathologically confirmed cases were included.


Males are more prone to COVID-associated mucormycosis. Also, diabetes and steroid intake are the most common risk factors, although this isn’t true for all cases. Most importantly, it is highly plausible that vaccination against COVID-19 is likely to reduce the incidence of COVID-associated mucormycosis.


Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, et al. Coronavirus disease (COVID-19) associated mucormycosis (CAM): Case report and systematic review of literature. Mycopathologia. 2021;186(2):289-98. Doi: PMID: 33544266.[crossref] [PubMed]
Sharma S, Grover M, Bhargava S, Samdani S, Kataria T. Post coronavirus disease mucormycosis: A deadly addition to the pandemic spectrum. J Laryngol Otol. 2021;135(5):442-47. Doi: PMID: 33827722.[crossref] [PubMed]
Desai EJ, Pandya A, Upadhya I, Patel T, Banerjee S, Jain V. Epidemiology, clinical features and management of rhino orbital mucormycosis in post COVID-19 patients. Indian J Otolaryngol Head Neck Surg. 2022;74(1):103-07. Doi: https:// PMID: 34414101.[crossref] [PubMed]
Gupta S, Ahuja P. Risk factors for procurence of mucormycosis and its manifestations post COVID-19: A single arm retrospective unicentric clinical study. Indian J Otolaryngol Head Neck Surg. 2021;18:01-08. Doi: https://doi. org/10.1007/s12070-021-02825-0. PMID: 34567997.[crossref] [PubMed]
Bhatia R, Abraham P. COVID-19 vaccines and pandemic. Indian J Med Res. 2021;153(5-6):517-21. Doi: PMID: 34341226.[crossref] [PubMed]
Vaccine reduces chance of black fungus: Experts July 09, 2021, 15:18 IST. [Accessed on Aug 06 2021].
Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021;15(4):102146. Doi: PMID: 34192610.[crossref] [PubMed]
Spellberg B, Edwards J Jr, Ibrahim A. Novel perspectives on mucormycosis: Pathophysiology, presentation, and management. Clin Microbiol Rev. 2005;18(3):556-69. Doi: PMID: 16020690.[crossref] [PubMed]
Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev. 2011;24(2):247-80. Doi: CMR.00053-10. PMID: 21482725.[crossref] [PubMed]
Prakash H, Chakrabarti A. Epidemiology of mucormycosis in India. Microorganisms. 2021;9(3):523. Doi: 10.3390/microorganisms9030523. PMID: 33806386.[crossref] [PubMed]
Arakeri G, Patil S, Rao USV, Mendes AR, Oeppen RS, Brennan PA. Pathogenesis of COVID-19-associated mucormycosis (CAM) in India: Probing the triggering factors. Br J Oral Maxillofac Surg. 2022;60(4):e533-34. Doi: https://doi. org/10.1016/j.bjoms.2021.10.018. PMID: 35351328.[crossref] [PubMed]
86% mucormycosis cases among unvaccinated, says report: Hyderabad NewsTimes of India [Accessed on Aug 26 2021].
Joshi PK, Jadhav KK. A retrospective study of risk factors of mucormycosis in COVID-19 patients at a dedicated COVID hospital. Natl J Physiol Pharm Pharmacol. 2022;12 (Online First). Doi: 12022.[crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/58073.17010

Date of Submission: May 30, 2022
Date of Peer Review: Jul 07, 2022
Date of Acceptance: Aug 08, 2022
Date of Publishing: Nov 01, 2022

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Jun 06, 2022
• Manual Googling: Aug 04, 2022
• iThenticate Software: Aug 06, 2022 (18%)

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