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

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On Sep 2018

Prof. Somashekhar Nimbalkar

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

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 : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : DC01 - DC05 Full Version

Microbiological Genus Characterisation, Clinical Features, and Outcome in Patients of COVID-19 Associated Mucormycosis: A Single-centre Cross-sectional Study

Published: November 1, 2023 | DOI:
Sneha Gupta, Rushika Patel, Nita Gangurde, Ashok Vankudre, Shreeya Kulkarni

1. Assistant Professor, Department of Microbiology, Dr Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik, Maharashtra, India. 2. Associate Professor, Department of Otorhinolaryngology, Dr Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik, Maharashtra, India. 3. Professor and Head, Department of Microbiology, Dr Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik, Maharashtra, India. 4. Professor, Department of Community Medicine, Dr Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik, Maharashtra, India. 5. Professor and Head, Department of Otorhinolaryngology, Dr Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik, Maharashtra, India.

Correspondence Address :
Dr. Ashok Vankudre,
Professor, Department of Community Medicine, Dr Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik, Maharashtra, India.


Introduction: Mucormycosis is a known invasive fungal infection, its prevalence increased during the Coronavirus Disease-2019 (COVID-19) pandemic, particularly during the second wave. The most common clinical form is rhino-orbital-cerebral, but other forms such as pulmonary, gastrointestinal, cutaneous, and disseminated forms also exist. There have been very few Indian studies exploring the various aspects of COVID-19 Associated Mucormycosis (CAM).

Aim: To describe and characterise the genus of the causative agents of mucormycosis, an invasive fungal infection, and to analyse the clinical features and outcomes in the study participants.

Materials and Methods: This was a cross-sectional study conducted in a dedicated COVID-19 Care Hospital at Dr. Vasantrao Pawar Medical College in Nashik City, Maharashtra, India. The study duration was one year, from February 2021 to January 2022. The universal sampling strategy included all clinically diagnosed cases of mucormycosis (n=104). The study variables included demographic factors, presence of risk factors, organ involvement, and in-hospital mortality. Diagnosis was based on fungal Potassium Hydroxide (KOH) mount and fungal culture. Genus characterisation was performed using Lactophenol Cotton Blue (LPCB) mount. Data were analysed using Statistical Package for the Social Sciences (SPSS) version 16.0, and the Chi-square test was applied to study the association between qualitative variables.

Results: The majority of patients with the disease were male (77, 74%). The most commonly involved site was isolated paranasal sinuses (48, 46.1%), followed by paranasal sinus with maxilla involvement (24, 23.1%). The KOH report was positive in 100 (96.2%) of patients. Fungal growth in culture was reported in 69 (66.3%) patients, among them Rhizopus spp. (66, 95.6%) being the most common fungal genus isolated. Among 25 patients in the age category >60 years, 21 (84%) had a positive culture (p-value=0.041, significant). Diabetic patients had a significantly higher incidence of mucormycosis compared to non diabetics based on culture results (p-value=0.004). The mortality rate in this study was 26 (25%).

Conclusion: Mucormycosis was more prevalent in males and predominantly affected the paranasal sinuses. Risk factors such as age category, sex, and a history of diabetes were significantly associated with the presence of mucormycosis. KOH can be used as a quick diagnostic test to initiate prompt treatment.


Diabetes mellitus, Rhino-orbital-cerebral, Risk factors

Mucormycosis is a rare invasive fungal infection. This fatal disease came to the limelight during Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) pandemic when patients with recovered or ongoing severe COVID-19 started developing this invasive fungal infection as a post-COVID-19 complication, especially during the second wave. The disease is caused by Mucormycetes of the order Mucorales, as well as zygomycotic species. Hence, the disease is also called Zygomycosis (1). Rhino-orbital-cerebral is the most common clinical form, and other clinical forms like pulmonary, gastrointestinal, cutaneous, and disseminated forms also exist. The prognosis for these patients depends on early treatment in the form of aggressive surgical debridement and systemic antifungals. There are many predisposing factors for the development of mucormycosis in COVID-19 patients. These include uncontrolled diabetes mellitus, immunosuppression by steroids, prolonged Intensive Care Unit (ICU) stay, post-transplant/malignancy, and voriconazole therapy, etc., (2),(3). It is a known fact that invasive mucormycosis has a very high mortality rate, and therefore establishing the correct diagnosis in a timely manner is of utmost importance. The diagnosis of mucormycosis is mainly based on clinical features, which are generally non specific, and investigations like radiographic imaging, which can determine the organ involvement and extent of the disease. The definitive diagnosis and identification of the aetiological agent are established only through fungal microscopy, fungal culture, and histopathology on appropriate biopsy samples. According to the “One World One Guideline” by the European Confederation of Medical Mycology (ECMM), appropriate imaging is strongly recommended to document the extent of the disease when mucormycosis is suspected. Biopsy is also strongly recommended for microscopy and culture if mucormycosis is a potential diagnosis (4). Culture of specimens is also strongly recommended for genus and species identification. Identification at the genus level is strongly supported for improved epidemiological understanding of mucormycosis (4).

There were very few Indian studies that have explored the various aspects of CAM and its risk factors (4),(5). The aim of the study was to describe and characterise the causative agents of mucormycosis, an invasive fungal infection. The objective of the study was to determine the association of various predisposing factors with the disease. This study highlights the most common aetiological agents of mucormycosis and stresses the importance of a multidisciplinary approach for diagnosis, including clinical features, radiographic imaging, fungal microscopic KOH mount, and fungal culture, for timely intervention and treatment of the disease.

Material and Methods

This was a cross-sectional study conducted in a dedicated COVID-19 Care Hospital at Dr. Vasantrao Pawar Medical College in Nashik City, Maharashtra, India. The study duration was one year, from February 2021 to January 2022. Institutional Ethics Committee permission was obtained before commencing the study (Ref no. Dr.VPMCH&RC/IEC/17/2021-22, dated 25/06/2021). Informed consent was obtained from the study participants. During the study period, the city was reporting many cases of CAM. The patients included in the study were admitted to the institute from April to September 2021. It was a universal sampling approach, as all clinically diagnosed cases of mucormycosis who met the eligibility criteria were included in the study (n=104).

Inclusion criteria:

a) Clinically suspected cases of mucormycosis as per Indian Council of Medical Research (ICMR) Advisory (6) admitted to the ENT ward or presenting to the Ear, Nose and Throat (ENT) OPD or referred from other hospitals, irrespective of age and sex.
b) Past or present documented history of COVID-19 (RT-PCR or Antigen positive).
c) Willingness to participate in the study.

Exclusion criteria: Documented history of mucormycosis in the past was excluded from the study.

Study Procedure

All participants were personally contacted, and interviews were conducted using a predesigned proforma. Moribund patients’ indoor records were screened for data collection. Appropriate diagnostic samples were collected from all these patients as per the protocol and sent to the Microbiology Department, where microscopy and fungal culture were performed.

Study variables:

a) Demographic factors: Age, sex, and place of residence of all participants included in the study were analysed.
b) Presence of risk factors (7): Diabetes mellitus, Systemic corticosteroids, Basal blood sugar levels on admission, supportive oxygen therapy, and ICU admission were the risk factors studied for their association with the disease.
c) Clinical syndromes: The type of organ involvement, as per radiological imaging, such as Rhino-orbital-cerebral, Rhino-orbital, Rhino-cerebral, Sinusitis alone, etc.,
d) In-hospital mortality.

Microbiological diagnosis:

Microscopy (KOH Mount): The most common samples obtained were nasal discharge, nasal scrapings, biopsy samples, and postoperative samples.

Culture: Each sample was inoculated on three slants of Sabouraud dextrose agar and incubated at 30°C for 14 days. Colonies were fast-growing, covering the surface of the agar, with dense cottony growth.

Genus: The genus of the isolated fungal agent in culture was subjected to LPCB for genus identification.

Statistical Analysis

All these parameters were analysed using appropriate statistical tools. Descriptive statistics, such as frequency tables, were used for descriptive data. Cross tabulations and Chi-square tests were used to test the association between qualitative variables. A p-value <0.05 was considered as a significant association, while a p-value <0.01 was considered as a highly significant association. Statistical analysis was performed using SPSS version 16 software.


A total of 104 patients were admitted to this hospital for the treatment of CAM during the study period. The results are compiled in the following tables.

The majority of patients were male (77, 74%), and the majority of patients were from rural areas (63, 60.6%). The mean age for males was 49.16±12.53 years, while for females it was 53.7±12.51 years (Table/Fig 1).

The most commonly affected site was the paranasal sinus, accounting for 48 cases (46.1%), followed by the paranasal sinus with involvement of the maxilla, which accounted for 24 cases (23.1%) (Table/Fig 2).

The KOH test was positive in 100 participants (96.2%), compared to a culture positivity rate of 69 cases (66.3%). The most common genus isolated in culture was Rhizopus spp., accounting for 66 cases (95.6%) (Table/Fig 3).

Among the 25 patients in the age category >60 years, 21 (84%) reported culture positivity, followed by 24 patients (70.6%) in the age group category of 45 to 60 years (N=34). It was observed that as age increases, the culture tends to be positive (p-value=0.041, significant). Among the 77 males, 46 (59.7%) were culture positive, compared to 23 (85.2%) culture positive cases among the 27 females, which was relatively higher. The observed difference was found to be statistically significant (p-value=0.016).

Among the 34 patients with a history of diabetes, 29 (85.3%) reported positive culture results, while out of the 70 non diabetic patients, 40 (57.1%) reported culture positivity. Diabetic patients had a significantly higher incidence of mucormycosis compared to non diabetic patients by culture (p-value=0.004). Although the proportion of culture positive cases was higher, with 36 (72%) patients having higher sugar levels at the time of admission compared to 17 (58.6%) patients with normal sugar levels, the association was found to be statistically non significant. Long-standing steroid use is a major risk factor for mucormycosis, but in this study, it was found to be statistically not significant, with 35 cases (71.4%) among those who underwent steroid therapy (N=49) compared to 34 cases (61.8%) among those who did not receive steroids (N=55) (Table/Fig 4).

It was found that 23 (33.3%) culture-positive patients among the 69 succumbed, compared to only 3 (8.6%) out of 35 culture-negative patients. There was a significantly strong association (p-value=0.006) between culture positivity and mortality. The proportion of mortality among males was 19 (24.7%) out of 77, which is comparable to females with 7 (25.9%) out of 27. The association between gender and mortality was not significant (p-value=0.897).

The proportion of mortality was highest in the age group > 60 years, with 11 (44%) out of 25 patients, followed by the age group of 45 to 60 years with 8 (23.5%) out of 34 patients, and 7 (17.5%) out of 40 patients in the age group of 30 to 45 years. There was significant association between age group and mortality (p-value=0.043) (Table/Fig 5).


COVID-19 has been the most disastrous pandemic, looming over the world for almost two and a half years now. CAM, which is the most devastating fungal disease associated with COVID-19, came into the limelight during the second wave of the pandemic. This fungal infection is not unusual in India, as the case rate in the pre-COVID-19 era was estimated to be 70 times higher compared to the developed world (8),(9). The incidence of mucormycosis started increasing during the first wave itself. A multicentre retrospective study across India, conducted to evaluate the epidemiology and outcomes among cases of CAM during September-December 2020, showed a 2.1-fold rise in mucormycosis during the study period compared to September-December 2019 (9).

In the present study, 104 patients were analysed with CAM admitted and treated in the hospital.

Among the baseline characteristics of the patients, 77 (74%) of the patients affected by CAM were men, 63 (60.6%) were from rural areas, and 40 (38.5%) belonged to the 30-45 year age group, followed by 45-60 years with 34 (32.7%) patients, respectively. The mean age at which males were affected was 49.16 years. Present study findings were similar to a multicentre study conducted by Patel A et al., and a systematic review of the literature by Nagalli S and Kikkeri NS where they found that 74.6% and 77% of males were affected by the disease compared to females, respectively, and the most common age group affected was 56.9 and 54.9 years, respectively (9),(10). This gender predisposition and age group susceptibility could be because males are involved more in outdoor activities, and this fungus is a typically innocuous environmental fungus that is ubiquitous in nature and primarily affects immunocompromised patients.

Based on the anatomical site of involvement, mucormycosis is classified into Rhino-Orbito-Cerebral (ROCM), pulmonary, gastrointestinal, cutaneous, renal, and disseminated (11). ROCM is the most common form and is often seen in patients with diabetic ketoacidosis or uncontrolled diabetes mellitus. In the present study, paranasal sinuses were the most commonly involved site (98%), either isolated (46.2%) or in combination with other sites such as the maxilla (23.1%), orbit (18.3%), palate (1.9%), intracranial (3.8%), and orbital with intracranial involvement (4.8%). These findings were corroborated by Nagalli S and Kikkeri NS where paranasal sinuses were involved in 79.4% of patients, with the maxillary sinus (47.4%) being the most frequently infected site (10).

It is known that the infection begins in the nose and paranasal sinuses due to the inhalation of fungal spores. The fungus then invades the arteries, leading to thrombosis, which subsequently causes tissue necrosis. Finally, the infection spreads to orbital and intracranial structures either through direct invasion or through the blood vessels.

The microbiological diagnosis of mucormycosis mainly relies on the direct visualisation of fungal structures in KOH mount and fungal culture, which are considered the gold standard tests for diagnosis (12). In the KOH mount, the hyphae of Mucorales have a variable width (ranging from 6 to 25 μm), are non septate or pauci septate, and exhibit an irregular, ribbon-like appearance (13). The angle of branching varies and includes wide-angle bifurcations. Mucorales grow rapidly (3 to 7 days) on most fungal culture media, such as Sabouraud agar and potato dextrose agar, incubated at temperatures at 25°C and 30°C (14). In this study, fungal microscopy yielded positive results in 96.2% of the tested samples, while culture positivity was found to be 66.3%. When samples are received in the laboratory, they typically undergo microscopy examination first, followed by culture. Preliminary examination of the sample in the form of a simple KOH mount can be an excellent tool for making a definitive diagnosis and can prove to be lifesaving for the patient. A review article by Skiada A et al., states that even when fungal hyphae are seen in microscopy, fungal cultures are positive in only 50% of cases. Hyphae are fragile in nature and may be damaged during tissue manipulation (avoidance of excessive tissue homogenisation is recommended) (15),(16). The most commonly isolated fungal agent on culture was Rhizopus spp. (95.6%), followed by Rhizomucor spp. (2.9%) and Lichtheimia spp. (1.5%), respectively. Identification of Zygomycetes organisms to the genus and species level still relies on colonial and microscopic morphology on culture. Identification carries valuable epidemiological, therapeutic, and prognostic implications. For example, Rhizopus oryzae is the most common zygomycete recovered from clinical specimens but tends to exhibit in-vitro resistance to posaconazole (16).

In the present study, the association of some risk factors associated with mucormycosis with fungal culture positivity were analysed. Among the 25 patients in the age category >60 years, 21 (84%) reported positive in culture, followed by 24 patients (70.6%) out of 34 in the age group category of 45 to 60 years. It was observed that as age increases, the likelihood of positive culture results also tends to increase (p-value=0.041, significant). The geriatric age group is more prone to severe disease due to the presence of risk factors such as diabetes mellitus, severe COVID-19, and the use of steroids (7). Among the 34 patients with a history of diabetes, 29 (85.3%) reported positive in culture, while out of the 70 non diabetic patients, only 40 (57.1%) reported culture positive. Diabetic patients reported a significantly higher rate of mucormycosis compared to non diabetic patients by fungal culture (p-value=0.004). CAM caused a devastating situation, particularly in India, possibly due to the high incidence rate of type 2 diabetes. Mononuclear and polymorphonuclear phagocytes are the first line of defense against the inhaled spores of Mucorales, producing oxidative metabolites and cationic peptide defensins to prevent their invasion into deeper tissues (17). Steroids and hyperglycaemia impair the ability of phagocytes to respond to invading organisms, leading to impaired chemotaxis, dysfunctional phagocytes, and defective intracellular killing (18). Ketoacidosis associated with uncontrolled diabetes enhances the growth of mucormycosis due to the ketoreductase enzyme produced by the fungus in diabetic patients, allowing it to utilise the patient’s ketone bodies (19). Additionally, studies have shown that Mucorales utilise iron for growth, and ketoacidosis promotes the release of iron from its protein-bound form (20). Although long-term steroid use is a major risk factor for mucormycosis, it was not found to be statistically significant in the present study, although the proportion of mucormycosis was 71.4% among those who underwent steroid therapy compared to 61.8% among those who did not. The widespread use of steroids and broad-spectrum antibiotics as part of the COVID-19 treatment regimen is known to exacerbate pre-existing fungal diseases. Authors experience highlights the significant association of uncontrolled blood sugars with the emergence of mucormycosis, even in the absence of long-term steroid therapy. Similar findings were noted in a recently published case series by Sarkar S et al., in which all patients were diabetic with elevated blood sugar levels and received steroids as per guidelines (21).

In the present study, mucormycosis was found to be fatal in 25% of the study participants, while 75% recovered and were discharged from the hospital. A systematic review of cases reported worldwide, including India, reported a mortality rate of 30.7% (22). An interesting multicentre epidemiologic study of CAM in India showed that the combined 6-week mortality rate was 38.3%, and the 12-week mortality rate was 45.7% (9). In the present study, the proportion of mortality was highest in the age group >60 years (44%), followed by the age group of 45 to 60 years (23.5%), and 17.5% in the 30 to 45 years age group. There was a significant association between age group and mortality (p-value=0.043), with mortality increasing as age increases. The same multicentre epidemiologic study also reported similar findings (9).

It was found in the present study that 23 culture-positive patients (33.3%) succumbed to the disease compared to only 3 culture-negative patients (8.6%). There was a significantly strong association (p-value=0.006) between culture positivity and mortality. This can be attributed to the fulminant disease and high fungal load in these patients, leading to such a significant association. A high fungal load contributes to increased disease severity and mortality, which can only be addressed through timely diagnosis using clinical features, radiological imaging to determine the extent of infection, and planning appropriate intervention, including fungal microscopy KOH mount, and fungal culture (23). Therefore, a multidisciplinary approach is crucial for the correct and timely diagnosis of this rare invasive fungal disease. Molecular diagnosis for identifying the fungal agent, along with antifungal susceptibility testing, should also be prioritised to initiate treatment with appropriate antifungals. Furthermore, guidelines should be developed and implemented in all healthcare facilities to enable epidemiological data collection and rapid reporting of any outbreaks. Antifungal stewardship programs should be implemented to ensure appropriate prescription and use of antifungal agents, as well as control and monitoring of infections caused by clinically relevant pathogens in healthcare facilities. Rational use of corticosteroids should also be undertaken and monitored. Finally, strict protective measures must be implemented to prevent the dissemination of this life-threatening fungal pathogen.


The present study was a single-centre study, and in order to generalise the results, more centres need to be incorporated with a wider sample size.


Mucormycosis tends to be common among men as well as the older age group. The presence of diabetes predisposes patients to mucormycosis, so special care needs to be taken if the patient has diabetes. The paranasal sinuses are most commonly involved, so they should be screened radiologically at the earliest. The preliminary examination of the sample in the form of a simple KOH mount can be an excellent tool for quick and definitive diagnosis of mucormycosis. Culture-positive patients exhibit higher mortality. Thus, a multidisciplinary approach is needed for the correct and timely diagnosis of this rare invasive fungal disease.


Kwon-Chung KJ. Taxonomy of fungi causing mucormycosis and entomophthoramycosis (zygomycosis) and nomenclature of the disease: Molecular mycologic perspectives. Clin Infect Dis. 2012;54(Suppl 1):S8-S15. Doi: 10.1093/cid/cir864.[crossref][PubMed]
Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005;41(5):634-53. Doi: 10.1086/432579. [crossref][PubMed]
Skiada A, Pagano L, Groll A, Zimmerli S, Dupont B, Lagrou K, et al; European Confederation of Medical Mycology Working Group on Zygomycosis. Zygomycosis in Europe: analysis of 230 cases accrued by the registry of the European Confederation of Medical Mycology (ECMM) Working Group on Zygomycosis between 2005 and 2007. Clin Microbiol Infect. 2011;17(12):1859- 67. Doi: 10.1111/j.1469-0691. [crossref][PubMed]
Cornely OA, Alastruey-Izquierdo A, Arenz D, Chen SCA, Dannaoui E, Hochhegger B, et al. Mucormycosis ECMM MSG Global Guideline Writing Group. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis. 2019;19(12):e405-21. Doi: 10.1016/S1473-3099(19)30312-3. [crossref][PubMed]
Gupta R, Kesavadev J, Krishnan G, Agarwal S, Saboo B, Shah M, et al. COVID- 19 associated mucormycosis: A descriptive multisite study from India. Diabetes Metab Syndr. 2021;15(6):102322. Doi: 10.1016/j.dsx.2021.102322. [crossref][PubMed]
Chakrabarti A, Patel A, Soman R, Shastri P, Modi J, Parmar G, et al. Evidence based advisory in the time of covid-19 (screening, diagnosis & management of mucormycosis) . ICMR, Department of Health Research Ministry of Health and Family Welfare Government of India. 2021. [cited 2022 June 18] Available from ADVISORY_FROM_ ICMR_ In_ COVID19_time. Pdf.
Taghinejad Z , Asgharzadeh M, Asgharzadeh V, Kazemi A. Risk factors for mucormycosis in COVID-19 patients. Jundishapur J Microbiol. 2021;14(8):e117435. [crossref]
Prakash H, Chakrabarti A. Global epidemiology of mucormycosis. J Fungi (Basel). 2019;5(1):26. Doi: 10.3390/jof5010026. [crossref][PubMed]
Patel A, Agarwal R, Rudramurthy SM, Shevkani M, Xess I, Sharma R, et al. Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India. Emerg Infect Dis. 2021;27(9):2349-59. Doi: 10.3201/ eid2709.210934. [crossref][PubMed]
Nagalli S, Kikkeri NS. Mucormycosis in COVID-19: A systematic review of literature. Infez Med. 2021;29(4):504-12. Doi: 10.53854/liim-2904-2. [crossref]
Jeong W, Keighley C, Wolfe R, Lee WL, Slavin MA, Kong DCM, et al. The epidemiology and clinical manifestations of mucormycosis: A systematic review and meta-analysis of case reports. Clin Microbiol Infect. 2019;25(1):26-34. Doi: 10.1016/j.cmi.2018.07.011. [crossref][PubMed]
Lackner N, Posch W, Lass-Flörl C. Microbiological and molecular diagnosis of mucormycosis: from old to new. Microorganisms. 2021;9(7):1518. Doi: 10.3390/ microorganisms9071518. [crossref][PubMed]
Monheit JE, Cowan DF, Moore DG. Rapid detection of fungi in tissues using calcofluor white and fluorescence microscopy. Arch Pathol Lab Med. 1984;108(8):616-18.
Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human disease. Clin Microbiol Rev. 2000;13(2):236-301. Doi: 10.1128/CMR.13.2.236. [crossref][PubMed]
Skiada A, Lass-Floerl C, Klimko N, Ibrahim A, Roilides E, Petrikkos G. Challenges in the diagnosis and treatment of mucormycosis. Med Mycol. 2018;56(suppl_1):93-101. Doi: 10.1093/mmy/myx101. [crossref][PubMed]
Walsh TJ, Gamaletsou MN, McGinnis MR, Hayden RT, Kontoyiannis DP. Early clinical and laboratory diagnosis of invasive pulmonary, extrapulmonary, and disseminated mucormycosis (zygomycosis). Clin Infect Dis. 2012;54(Suppl_1):S55-60. Doi: 10.1093/cid/cir868. [crossref][PubMed]
Waldorf AR. Pulmonary defense mechanisms against opportunistic fungal pathogens. Immunol Ser. 1989;47:243-71.
Chinn RY, Diamond RD. Generation of chemotactic factors by Rhizopus oryzae in the presence and absence of serum: Relationship to hyphal damage mediated by human neutrophils and effects of hyperglycaemia and ketoacidosis. Infect Immun. 1982;38(3):1123-29. Doi: 10.1128/iai.38.3.1123-1129.1982. [crossref][PubMed]
Pandey A, Bansal V, Asthana AK, Trivedi V, Madan M, Das A. Maxillary osteomyelitis by mucormycosis: Report of four cases. Int J Infect Dis. 2011;15(1):e66-69. Doi: 10.1016/j.ijid.2010.09.003. [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: 10.1128/CMR.18.3.556-569.2005. [crossref][PubMed]
Sarkar S, Gokhale T, Choudhury SS, Deb AK. COVID-19 and orbital mucormycosis. Indian J Ophthalmol. 2021;69(4):1002-04. Doi: 10.4103/ijo. IJO_3763_20. [crossref][PubMed]
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: 10.1016/j.dsx.2021.05.019. [crossref][PubMed]
Alshahawey MG, El-Housseiny GS, Elsayed NS, Alshahrani MY, Wakeel LM, Aboshanab KM. New insights on mucormycosis and its association with the COVID-19 pandemic. Future Sci OA. 2021;8(2):FSO772.Doi: 10.2144/fsoa- 2021-0122.[crossref][PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/65471.18698

Date of Submission: May 17, 2023
Date of Peer Review: Jul 06, 2023
Date of Acceptance: Oct 21, 2023
Date of Publishing: Nov 01, 2023

• 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: May 20, 2023
• Manual Googling: Jul 20, 2023
• iThenticate Software: Oct 18, 2023 (17%)

ETYMOLOGY: Author Origin


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