CC BY-NC-ND 4.0 · Ann Natl Acad Med Sci 2023; 59(01): 036-048
DOI: 10.1055/s-0042-1760288
Original Article

Health Literacy and Clinic-Epidemiological Profile of Patients with COVID-19-Associated Mucormycosis: A Questionnaire-Based Study

Michell Gulabani
1   Department of Anaesthesia and Critical Care, University College of Medical Sciences, Delhi, India
Richa Chauhan
1   Department of Anaesthesia and Critical Care, University College of Medical Sciences, Delhi, India
Diksha Gaur
1   Department of Anaesthesia and Critical Care, University College of Medical Sciences, Delhi, India
Swati Das
1   Department of Anaesthesia and Critical Care, University College of Medical Sciences, Delhi, India
Megha Bajaj
1   Department of Anaesthesia and Critical Care, University College of Medical Sciences, Delhi, India
Ashok Kumar Saxena
1   Department of Anaesthesia and Critical Care, University College of Medical Sciences, Delhi, India
› Author Affiliations


Background The patient partnership is desirable for the optimal management of comorbidities. This became significant more so during the coronavirus disease 2019 (COVID-19) crisis wherein health infrastructure was overburdened.

Objectives The aim of this study was to estimate the clinicoepidemiological profile, health literacy regarding predisposing risk factors, and disease management in patients with COVID-19-associated mucormycosis (CAMCR).

Materials and Methods A structured questionnaire-based study on randomly chosen 100 microbiologically proven patients of CAMCR, consisting of 38 multiple choice questions, was designed with each answer having a patient and assessor response to it.

Results A male predilection was seen (68%) with rhino-orbital (73%) being the commonest anatomic site. Forty-nine percent of the study participants had pre-existing diabetes of which 62% did not carry out regular blood sugar monitoring and in 18%, blood sugars were controlled prior to COVID-19. Thirty-five percent of patients with mild COVID-19 illness were treated with unwarranted steroids and 56% of patients had fluctuating blood sugar levels, during COVID-19 illness.

Seventy-nine percent of patients were not vaccinated against COVID-19, 16% only partially vaccinated. Seventy-one percent of patients were not aware of red flag signs and of mucormycosis with 8% presenting early, on noticing nasal symptoms.

Conclusion This study observed diabetes as the most common comorbidity in patients with CAMCR. A lacuna in the health literacy of diabetics presenting with CAMCR was found. Additionally, knowledge regarding glycemic control during COVID-19 illness with or without the use of steroids and awareness of the “red flag” signs of CAMCR were mostly lacking. Interventions to improve awareness amongst patients with diabetes should help in optimal glycemic control, and avoid potential complications like severe COVID-19 illness, and mucormycosis.

Publication History

Article published online:
22 February 2023

© 2023. National Academy of Medical Sciences (India). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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  • References

  • 1 Mishra N, Mutya V, Thomas A. et al. A case series of invasive mucormycosis in patients with COVID-19 infection. Int J Otorhinolaryngol Head Neck Surg 2021; 7 (05) 867
  • 2 Prakash H, Chakrabarti A. Epidemiology of mucormycosis in India. Microorganisms 2021; 9 (03) 523
  • 3 Chakrabarti A, Das A, Mandal J. et al. The rising trend of invasive zygomycosis in patients with uncontrolled diabetes mellitus. Med Mycol 2006; 44 (04) 335-342
  • 4 Kuchay MS, Reddy PK, Gagneja S, Mathew A, Mishra SK. Short term follow-up of patients presenting with acute onset diabetes and diabetic ketoacidosis during an episode of COVID-19. Diabetes Metab Syndr 2020; 14 (06) 2039-2041
  • 5 Honavar SG. Code Mucor: Guidelines for the diagnosis, staging and management of rhino-orbito-cerebral mucormycosis in the setting of COVID-19. Indian J Ophthalmol 2021; 69 (06) 1361-1365
  • 6 Lin X, Xu Y, Pan X. et al. Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. Sci Rep 2020; 10 (01) 14790
  • 7 Boddu SK, Aurangabadkar G, Kuchay MS. New onset diabetes, type 1 diabetes and COVID-19. Diabetes Metab Syndr 2020; 14 (06) 2211-2217
  • 8 Singh AK, Misra A. Impact of COVID-19 and comorbidities on health and economics: focus on developing countries and India. Diabetes Metab Syndr 2020; 14 (06) 1625-1630
  • 9 Raut A, Huy NT. Rising incidence of mucormycosis in patients with COVID-19: another challenge for India amidst the second wave?. Lancet Respir Med 2021; 9 (08) e77
  • 10 Corticosteroid Adverse Effects - StatPearls - NCBI Bookshelf. ( n.d. ). Accessed December 19, 2022, at:
  • 11 Banerjee M, Chakraborty S, Pal R. Diabetes self-management amid COVID-19 pandemic. Diabetes Metab Syndr 2020; 14 (04) 351-354
  • 12 Belsti Y, Akalu Y, Fekadu H, Animut Y. Awareness of complications of diabetes mellitus and its associated factors among type 2 diabetic patients at Addis Zemen District Hospital, northwest Ethiopia. BMC Res Notes 2019; 12 (01) 602 DOI: 10.1186/s13104-019-4637-x.
  • 13 Melesie Taye G, Bose L, Beressa TB. et al. COVID-19 knowledge, attitudes, and prevention practices among people with hypertension and diabetes mellitus attending public health facilities in Ambo, Ethiopia. Infect Drug Resist 2020; 13: 4203-4214
  • 14 Cheng AY. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Introduction. Can J Diabetes 2013; 37 (Suppl. 01) S1-S3
  • 15 Saleem S, Jan S. Modified Kuppuswamy socioeconomic scale updated for the year 2021. Ind J Forensic Comm Med 2021; 8 (01) 1-3
  • 16 Jeong W, Keighley C, Wolfe R. et al. The epidemiology and clinical manifestations of mucormycosis: a systematic review and meta-analysis of case reports. Clin Microbiol Infect 2019; 25 (01) 26-34
  • 17 Patel A, Kaur H, Xess I. et al. A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India. Clin Microbiol Infect 2020; 26 (07) 944.e9-944.e15
  • 18 Bala K, Chander J, Handa U, Punia RS, Attri AK. A prospective study of mucormycosis in North India: experience from a tertiary care hospital. Med Mycol 2015; 53 (03) 248-257
  • 19 Prakash H, Chakrabarti A. Global epidemiology of mucormycosis. J Fungi (Basel) 2019; 5 (01) 26
  • 20 John TM, Jacob CN, Kontoyiannis DP. When uncontrolled diabetes mellitus and severe COVID-19 converge: the perfect storm for mucormycosis. J Fungi (Basel) 2021; 7 (04) 298
  • 21 Patel A, Agarwal R, Rudramurthy SM. et al; MucoCovi Network3. Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India. Emerg Infect Dis 2021; 27 (09) 2349-2359
  • 22 Skiada A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and diagnosis of mucormycosis: an update. J Fungi (Basel) 2020; 6 (04) 265
  • 23 Moorthy A, Gaikwad R, Krishna S. et al. SARS-CoV-2, uncontrolled diabetes and corticosteroids-an unholy trinity in invasive fungal infections of the maxillofacial region? A retrospective, multi-centric analysis. J Maxillofac Oral Surg 2021; 20 (03) 418-425
  • 24 Bhanuprasad K, Manesh A, Devasagayam E. et al. Risk factors associated with the mucormycosis epidemic during the COVID-19 pandemic. Int J Infect Dis 2021; 111: 267-270
  • 25 Manesh A, Rupali P, Sullivan MO. et al. Mucormycosis-A clinicoepidemiological review of cases over 10 years. Mycoses 2019; 62 (04) 391-398
  • 26 Lionakis MS, Kontoyiannis DP. Glucocorticoids and invasive fungal infections. Lancet 2003; 362 (9398): 1828-1838
  • 27 Gianchandani R, Esfandiari NH, Ang L. et al. Managing hyperglycemia in the COVID-19 inflammatory storm. Diabetes 2020; 69 (10) 2048-2053
  • 28 Mulakavalupil B, Vaity C, Joshi S, Misra A, Pandit RA. Absence of Case of Mucormycosis (March 2020-May 2021) under strict protocol driven management care in a COVID-19 specific tertiary care intensive care unit. Diabetes Metab Syndr 2021; 15 (04) 102169
  • 29 Pal R, Bhadada SK. COVID-19 and diabetes mellitus: an unholy interaction of two pandemics. Diabetes Metab Syndr 2020; 14 (04) 513-517
  • 30 Ezeokoli OT, Gcilitshana O, Pohl CH. Risk factors for fungal co-infections in critically Ill COVID-19 patients, with a focus on immunosuppressants. J Fungi (Basel) 2021; 7 (07) 545
  • 31 Pal R, Bhadada SK, Misra A. COVID-19 vaccination in patients with diabetes mellitus: current concepts, uncertainties and challenges. Diabetes Metab Syndr 2021; 15 (02) 505-508
  • 32 Li M, Liu Q, Wu D. et al. Association of COVID-19 vaccination and clinical severity of patients infected with delta or omicron variants - China, May 21, 2021-February 28, 2022. China CDC Wkly 2022; 4 (14) 293-297
  • 33 Tenforde MW, Self WH, Adams K. et al; Influenza and Other Viruses in the Acutely Ill (IVY) Network. Association between mRNA vaccination and COVID-19 hospitalization and disease severity. JAMA 2021; 326 (20) 2043-2054
  • 34 Banerjee M, Pal R, Bhadada SK. Intercepting the deadly trinity of mucormycosis, diabetes and COVID-19 in India. Postgrad Med J 2022; 98 (e2): e108-e109
  • 35 Mucormycosis in COVID-19 | AIIMS Covid Information Portal. (n.d.). Accessed December 19, 2022 at: