Rhizopus homothallicus, an emerging pathogen causing cavitary lung lesions
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Introduction. Rhizopus homothallicus is an emerging pathogen that causes pulmonary mucormycosis.
Case Presentation. We report a case of pneumonia caused by R. homothallicus in a 54-year-old type 2 diabetic patient. The organism was isolated from bronchoalveolar lavage fluid and preliminarily identified by fungal morphology and finally by sequencing of the internal transcribed spacer region.
Conclusion. Mucormycosis may be associated with cavitary lung lesions against a backdrop of poorly controlled diabetes or other immunosuppressed states. Pulmonary mucormycosis may have variable clinical and radiological presentations. Therefore, strong clinical suspicion and prompt management can address the high fatality associated with the disease.
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The authors have addressed the reviewer concerns well and this article will be a valuable addition to the literature.
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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. The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
The description of the case is acceptable. However, the discussion needs major improvement. The importance of the case-report lies in its striking clinical findings. Also, the discussion should be able to highlight your findings and provide extra information about the organism to the readers. 1. Was this patient on any hypoglycaemic drugs for DM? Please mention 2. Why patient was not started on anti-fungal on Day 4. as the rate of mortality increases with delay in the treatment. 3. Line 77: The authors should mention that after how many days the fungal culture revealed growth in SDA tubes? 4. Figure 2: Please describe in the legend, what green and red colour dots and boxes depicts? 5. In discussion, the authors have mentioned that patient was in acute renal failure, hence Posaconazole was initiated. …
Comments to Author
The description of the case is acceptable. However, the discussion needs major improvement. The importance of the case-report lies in its striking clinical findings. Also, the discussion should be able to highlight your findings and provide extra information about the organism to the readers. 1. Was this patient on any hypoglycaemic drugs for DM? Please mention 2. Why patient was not started on anti-fungal on Day 4. as the rate of mortality increases with delay in the treatment. 3. Line 77: The authors should mention that after how many days the fungal culture revealed growth in SDA tubes? 4. Figure 2: Please describe in the legend, what green and red colour dots and boxes depicts? 5. In discussion, the authors have mentioned that patient was in acute renal failure, hence Posaconazole was initiated. However, previous studies have shown that amphotericin B is generally well-tolerated and can be safely administered in subjects undergoing dialysis. (Wood et al. doi: 10.1097/00000441-200401000-00002; Anaissie et al, doi: 10.1128/AAC.42.3.606.) Please clarify this in discussion. 6. Line 102: Please mention the region/area of the world from which these cases are isolates. 7. Discussion on whole should be re-written: 1. Firstly, the discussion should include the importance of R. homothallicus with its prevalence in the world. 2. Secondly, the authors should discuss the pathogenesis of mucormycosis and how this patient was susceptible to mucormycosis 3. Thirdly, Control of hyperglycaemia, early treatment with liposomal amphotericin B, and surgery are essential for the successful management of mucormycosis. The authors should discuss these points and what was done and what could not be done in their patient. 4. Lastly, discuss the causes of mortality in pulmonary mucormycosis. Also the trend of case fatality.
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Partially 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
Please include a histopathology photo of the BAL sample in KOH examination which showed broad aseptate fungal hyphae, in current paper
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
-
Comments to Author
This is a case of pulmonary mucormycosis in a person with diabetes. About the case presentation, I'd like to suggest the authors to 1. provide further information on the duration of the diabetes?, what was the diabetes treatment the patient was on if any, did you get information on HbA1c?. 2. Also, it would be great to know not only the total WBC count but also the type of WBC increased (neutrophils?) and also to know if you found some other inflammatory markers increased. 3. Patient didn't have story of COVID but did you test him for COVID or any other viruses? was the patient vaccinated for flu and/or COVID? 4. You mentioned patient started with broad spectrum antibiotics, could you specify what antibiotics? Why did you start on posaconazole instead of L-AMB?. 5. Finally, I think you need to add …
Comments to Author
This is a case of pulmonary mucormycosis in a person with diabetes. About the case presentation, I'd like to suggest the authors to 1. provide further information on the duration of the diabetes?, what was the diabetes treatment the patient was on if any, did you get information on HbA1c?. 2. Also, it would be great to know not only the total WBC count but also the type of WBC increased (neutrophils?) and also to know if you found some other inflammatory markers increased. 3. Patient didn't have story of COVID but did you test him for COVID or any other viruses? was the patient vaccinated for flu and/or COVID? 4. You mentioned patient started with broad spectrum antibiotics, could you specify what antibiotics? Why did you start on posaconazole instead of L-AMB?. 5. Finally, I think you need to add more details about the molecular identification, your document says you extracted DNA followed by Sanger sequencing, but if I'm not mistaken you amplified the DNA ITS2 region before sequencing, this need to be said and also mentioning the primers used if you designed them or if you used previously used primers and add the reference, same as details on the PCR procedure. 6. I would highly recommend figures description have more information about the findings and also clearly identify these findings using marks/arrows to identify them in the figure.
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
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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