Duped by dumping syndrome: Non-Endemic Vibrio cholerae bacteremia in an immunocompetent host with gastric bypass surgery, a case report
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Extra-intestinal infection with non-O1/non-O139 strains of Vibrio cholerae (NOVC) is rare, though bacteremia and hepatobiliary manifestations have been reported. Reduced stomach acid, or hypochlorhydria, can increase risk of V. cholerae infection. We describe a 42-year-old woman with hypochlorhydria due to untreated Helicobacter pylori infection, gastric-bypass surgery, and chronic proton pump inhibitors (PPI) exposure, who developed acute diarrhea following raw oyster consumption. Her symptoms were attributed to rapid gastric emptying (dumping syndrome) after a negative limited stool work-up. She had persistent diarrhea, weight loss, and after five months was admitted with acute cholecystitis and NOVC bacteremia, requiring cholecystectomy. This is the first reported case of NOVC bacteremia and cholecystitis in a patient with gastric bypass. This case highlights the potential for NOVC biliary carriage, the role of hypochlorhydria as a risk factor for Vibrio infection, and the importance of excluding infectious diarrhea in patients with new onset of symptoms compatible with dumping syndrome and a relevant travel history.
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The work presented is clear and the arguments well formed. This study would be a valuable contribution to the existing literature.
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This is a study that would be of interest to the field and community. The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
1. Description of the case(s) This work describes an interesting case with novel interest. The authors have covered the history, presentation, investigation, and management of the case thoroughly but concisely, maintaining a clear narrative throughout, supported by a timeline of key dates and exposures. 2. Presentation of results WGS results were well described, covering the specifics of the sequencing and bioinformatics done whilst remaining accessible to non-specialist readers. The table summarising the key gene virulence factors identified was particularly helpful to a non-Vibrio expert. 3. How the style and organization of the paper communicates and represents key findings The paper is well structured into clear sections, and the figures, particularly the timeline and the summary of the functions …
Comments to Author
1. Description of the case(s) This work describes an interesting case with novel interest. The authors have covered the history, presentation, investigation, and management of the case thoroughly but concisely, maintaining a clear narrative throughout, supported by a timeline of key dates and exposures. 2. Presentation of results WGS results were well described, covering the specifics of the sequencing and bioinformatics done whilst remaining accessible to non-specialist readers. The table summarising the key gene virulence factors identified was particularly helpful to a non-Vibrio expert. 3. How the style and organization of the paper communicates and represents key findings The paper is well structured into clear sections, and the figures, particularly the timeline and the summary of the functions of key genes identified by sequencing, support and enhance the narrative. 4. Literature analysis or discussion The discussion nicely frames the case in the context of the literature, and makes clear which elements of this case are novel. All potential questions I had whilst reading through the case description have been considered by the authors, and they have summarised with good take-home learning points. 5. Any other relevant comments A very enjoyable, well-written read, describing an interesting case with clearly laid out novel interest. The authors have covered the specifics of this case and the follow-up sequencing work in sufficient detail to make it clear to the reader exactly what was done, without getting lost in unnecessary details which could disrupt the narrative. It also raised excellent considerations on how the presentation and epidemiological history of V. cholerae infection may not fit the paradigm. Well done and thank you to the authors for this interesting piece of work.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
Dear author, A well written case report case report highlighting the effect of gastric-bypass surgery on Vibrio cholera. Some suggestions to optimise the report. Background Could you explain more in detail the inscreasing Non-01/non-0139 strains(NOVC) in the clinical setting. You only strength the potentially influence to climate changes in temperature. Do you have more literature for the association of NOVC with consumption of seafood or soft tissue injuries exposed to seawater Case presentation You state chronic omeprazole use - could you more in detail define the time period. How you define the dumping syndrome? I suggest to add the reference values for the elevated liver enzymes Discussion and conclusion Given the absence of standard therapeutic guidelines for NOVC infections, …
Comments to Author
Dear author, A well written case report case report highlighting the effect of gastric-bypass surgery on Vibrio cholera. Some suggestions to optimise the report. Background Could you explain more in detail the inscreasing Non-01/non-0139 strains(NOVC) in the clinical setting. You only strength the potentially influence to climate changes in temperature. Do you have more literature for the association of NOVC with consumption of seafood or soft tissue injuries exposed to seawater Case presentation You state chronic omeprazole use - could you more in detail define the time period. How you define the dumping syndrome? I suggest to add the reference values for the elevated liver enzymes Discussion and conclusion Given the absence of standard therapeutic guidelines for NOVC infections, antimicrobial susceptibility testing remains critical. You should describe more in detail the antibiotic testing/treatment. Was the H. pylori infection erradicated? I suggest to stress more on the relation of consumption of raw oyster consumption in stead of chronic omeprazole treatment. I suggest to add the publication of De Keukeleire et al., 2018 - atypical manifestation of Vibrio cholerae: fear the water - a case report from an epidemic NOVC strain. You should stress more the relation of production of biofilms in order to develop bacteremia.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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