Streptococcus parasanguinis: An emerging pathogen causing neonatal endocarditis: A case report
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Background The microbial infection of the endocardium, popularly known as Infective Endocarditis (IE), is typically classified on the basis of anatomy, valve nativity and its associated microbiology. As per the associated microbiology, Staphylococcus aureus is the most common microorganism responsible for the cause of IE. Even though, Streptococcus group accounts for a smaller percentage of IE, however this doesn’t give us the liberty of ignoring the high mortality and morbidity associated with this pathogen. Case presentation We report an unusual case of neonatal sepsis, complicated with endocarditis, caused by penicillin resistant Streptococcus parasanguinis. The neonate however died of the same despite all efforts. The said baby was given birth by a mother with gestational diabetes mellitus. Conclusion High index of clinical suspicion and prompt diagnosis are the most important factors of patient management, especially in cases of life threatening neonatal infections. In such conditions a coordinated interdepartmental approach is very much needed.
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Thank you for submitting a revised version of your manuscript. You have addressed all concerns and points raised by the reviewers satisfactorily.
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Dear authors, many thanks for the submission of your revised manuscript. However, there are still some minor points that need addressing as expressed by onw of the reviewers. Please clarify the imaging criteria in the case description, and clarify part of your discussion as well as changing lakh to unit that is internationally understood.
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Comments to Author
The presentation of the case has been improved by the revision and the addition of a timeline. The clarification regarding the imaging criteria for endocarditis is crucial, and I suggest that this is expanded upon in the case description. The second part of the discussion is still quite difficult for me to follow. Especially this part is difficult for me to parse. What is the main message that you want to convey? "The epidemiology of this condition has evolved over time due to ongoing medical advancements, making it challenging for doctors to effectively treat it. Furthermore, if we follow western norms, it becomes difficult to handle infective endocarditis in developing nations where the typical profile is found more frequently. Everything in India is evolving because it is a developing country, …
Comments to Author
The presentation of the case has been improved by the revision and the addition of a timeline. The clarification regarding the imaging criteria for endocarditis is crucial, and I suggest that this is expanded upon in the case description. The second part of the discussion is still quite difficult for me to follow. Especially this part is difficult for me to parse. What is the main message that you want to convey? "The epidemiology of this condition has evolved over time due to ongoing medical advancements, making it challenging for doctors to effectively treat it. Furthermore, if we follow western norms, it becomes difficult to handle infective endocarditis in developing nations where the typical profile is found more frequently. Everything in India is evolving because it is a developing country, including the host factors, vulnerable population, diagnostic methods, antibiotics, and surgical procedures. Due to the dual load of conventional and modern requirements, the issue becomes more complicated" I also suggest changing the use of lakh to either 100.000 or 10⁵ as the use of "lakh" as far as I know is limited to India and neighbouring contries and thus makes the text more difficult to read for an international audience.
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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The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments. The language used is poor, which can cause ambiguity at times. Please carefully rewrite it. We offer a discounted translation service, Editage (https://www.editage.com/; see https://www.microbiologyresearch.org/prepare-an-article#13 for more information).
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Comments to Author
The authors present a case with a neonatal fatal infection caused by S. parasanguinis. The case has some interesting parts, but is sadly difficult for me to follow. The case report hinges on three main findings as I see it: the fact that the causative organism is S. parasanguinis, that neonate had endocarditis, and the very antibiotic resistant nature of the bacterial isolate. The bacterial species is (from my perspective) quite certain if Vitek MALDI-TOF was performed with a suitable library, as it is able to differentiate S. parasanguinis from other members of the S. mitis-group. 1. Did the patient actually have endocarditis? The manuscript references the Duke criteria, but unless I misunderstand something, the patient only fulfills one major criteria and 1-2 minor critera (predisposing heart …
Comments to Author
The authors present a case with a neonatal fatal infection caused by S. parasanguinis. The case has some interesting parts, but is sadly difficult for me to follow. The case report hinges on three main findings as I see it: the fact that the causative organism is S. parasanguinis, that neonate had endocarditis, and the very antibiotic resistant nature of the bacterial isolate. The bacterial species is (from my perspective) quite certain if Vitek MALDI-TOF was performed with a suitable library, as it is able to differentiate S. parasanguinis from other members of the S. mitis-group. 1. Did the patient actually have endocarditis? The manuscript references the Duke criteria, but unless I misunderstand something, the patient only fulfills one major criteria and 1-2 minor critera (predisposing heart condition and possibly fever) placing the child in the "Possible" cathegory. While cardiac imaging is not my specialty, I see no mention of vegetations, nor a root abscess or other unequivocal signs of endocarditis. Was this seen? If so, please state this more clearly. 2. The bacterial isolate is reported to be extremely, and unusually, resistant to many antibiotic classes that S. parasanguinis is almost universally susceptible to. Due to the low pre-test probability of such a resistant isolate (even in a setting with higher levels of resistance) I suggest re-testing the antibiotic susceptibility with another method (if possible I suggest broth dilution as the ISO-standard for susceptibility testing). The resistance mechanisms would also be of interest. 3. The presentation of the case would possibly benefit from a time line. 4. I suggest a language revision, it is often somewhat difficult to follow the reaspning and the flow of events. 5.The introduction states that the pathogenicity of S. parasanguinis is not established. I would argue that studies such as "Prevalence of Infective Endocarditis in Streptococcal Bloodstream Infections Is Dependent on Streptococcal Species" by Chamat-Hedeman et al (Circulation 2020) and "HANDOC: A Handy Score to Determine the Need for Echocardiography in Non-β-Hemolytic Streptococcal Bacteremia" byt Sunnerhagen et al (Clinical Infectious Diseases 2018) quite firmly indicate that S. parasanguinis is a somewhat common cause of infective endocarditis (at least in adults). 6. The following sentences in the discussion are difficult for me to understand: "With continuous developments in the field of medicine the epidemiology of this disease has changed over time, making it difficult for the physicians to treat this disease. And, in developing countries where the customary profile of infective endocarditis is seen more commonly, it becomes tough to manage it if we stick to western guidelines". Please consider rephrasing. 7. While three sets of blood cultures are recommended to increase the detecion of endocarditis in adults (and would increase the detection rate in children as well), I would not necessarily state that three sets of blood cultures are strictly necessary in neonatal infections. Consider the findings of Hellström et al in this context: "Neonatal clinical blood sampling led to major blood loss and was associated with bronchopulmonary dysplasia" (Acta Pediatrica 2020). 8. I see no mention of approval of an ethical review board for this case report, nor consent by relatives of the deceased patient.
Please rate the quality of the presentation and structure of the manuscript
Poor
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?
No: I see no mention of approval of an ethical review board for this case report, nor consent by relatives of the deceased patient.
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Comments to Author
This short case study describes an unusual case of infection of a new born child by Streptococcus parasanguinis that sadly resulted in the death of the mother. The infection was unusual and correctly diagnosed because of thorough testing. It provides a warning of a possible emerging pathogen that could be incorrectly diagnosed. The major weakness of the manuscript is that although the English is intelligible, it is full of errors. The manuscript would be much easier to read and make a greater impact if it is thoroughly edited by a colleague whose first language is English. The many types of fault include poor word choice, incorrect use of punctuation throughout, use of nouns without articles, and sentences that are far too long. Regarding sentence length, see the first three lines of the …
Comments to Author
This short case study describes an unusual case of infection of a new born child by Streptococcus parasanguinis that sadly resulted in the death of the mother. The infection was unusual and correctly diagnosed because of thorough testing. It provides a warning of a possible emerging pathogen that could be incorrectly diagnosed. The major weakness of the manuscript is that although the English is intelligible, it is full of errors. The manuscript would be much easier to read and make a greater impact if it is thoroughly edited by a colleague whose first language is English. The many types of fault include poor word choice, incorrect use of punctuation throughout, use of nouns without articles, and sentences that are far too long. Regarding sentence length, see the first three lines of the Introduction for such an example. As it would be very easy for a colleague whose first language is English to improve this manuscript, I recommend that this paper should not be accepted or publication until these minor corrections have been made. Almost every sentence contains at least one error.
Please rate the quality of the presentation and structure of the manuscript
Poor
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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