Multiple systemic infections caused by Rhodococcus equi: a case report
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Background. Rhodococcus equi is one of the most important causes of zoonotic infections from grazing animals. It poses a particular risk to immunocompromised individuals, including those who are undergoing long-term immunosuppressive therapy.
Case presentation. We report a case of Rhodococcus equi infection in a 65-year-old man with a medical history of diabetes, hypertension, and Adult Still’s Disease, currently taking long-term hormone therapy. The non-human immunodeficiency virus (HIV)-infected patient had blood, lung tissue, and sputum samples infected with Rhodococcus equi . His condition initially failed to improve despite multiple therapies, including vancomycin and meropenem. Although his symptoms improved after shifting his antibiotics to cover for the causative agent, he did not completely recover upon hospital discharge.
Conclusions. In recent years, the number of Rhodococcus equi cases has increased. This report describes a lethal case of Rhodococcus equi infection in a patient without HIV.
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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 study would be a valuable contribution to the existing literature. You have not addressed the reviewers’ comments sufficiently after revision.
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Comments to Author
Many thanks for re-submitting your work and your responses to my concerns. Overall, I do believe that your manuscript can still be further improved. Grammatical errors still persist throughout, especially with regards to spacing; and although all the information is there, it would benefit greatly from a restructure - salient points can be condensed and should be followed by clear rationale with the avoidance of repetition. Your case is important for clinicians and I do encourage you to work on the manuscript with perhaps a native English speaker, if possible, to really get it over the line. Line 52 - Adult Steele's Disease should be corrected to Adult Still's Disease Line 54 - Additional samples were collected…What were these samples? Repeat blood cultures? Or a pan-culture? Lines 56-59 - Again, …
Comments to Author
Many thanks for re-submitting your work and your responses to my concerns. Overall, I do believe that your manuscript can still be further improved. Grammatical errors still persist throughout, especially with regards to spacing; and although all the information is there, it would benefit greatly from a restructure - salient points can be condensed and should be followed by clear rationale with the avoidance of repetition. Your case is important for clinicians and I do encourage you to work on the manuscript with perhaps a native English speaker, if possible, to really get it over the line. Line 52 - Adult Steele's Disease should be corrected to Adult Still's Disease Line 54 - Additional samples were collected…What were these samples? Repeat blood cultures? Or a pan-culture? Lines 56-59 - Again, you have stated that Chest and Abdominal CTs were performed early in your report, but the clinical rationale for performing those tests are only mentioned at Lines 69-71. The structure of this report can be improved; it should be sequential with clear rationales at each step so that it is more cohesive. Lines 65-66 - These initial observations could be moved to Lines 53-54 when you already mentioned the temperature on admission. Line 72 - Again, you have repeated that the CT was done with relevant findings, which was stated earlier on. Avoid repetition. Lines 77-78 - Please state how was susceptibility testing performed. Broth microdilution? Gradient strip e-tests? Lines 82-83 - I presume you meant that linezolid was discontinued. These lines can also be condensed; perhaps something like - Due to drug-induced bone marrow suppression and liver injury, both linezolid and meropenem were discontinued respectively. Some general queries; - As asked previously, was an echocardiogram considered? - Given the drug-induced toxicity, was an alternative antimicrobial regimen considered? Or was the patient palliated with the view that there was no curative option? - Is it possible to construct a visual timeline of the patient's in-hospital course? Admission - Blood Culture/Sputum/Lung Biopsy Positive - Antimicrobials Commenced - Susceptibility Results Reported/Antimicrobial Regimen Altered - Drug-Induced Toxicity - Death . If not, that's fine, I just think that it would be a welcome addition to only improve the understanding of the timeline of the presentation.
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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Comments to Author
Many thanks for your manuscript, and for highlighting the importance of such an underestimated pathogen - Rhodococcus equi. General thoughts are that the manuscript would benefit from a thorough proof-read, there are quite a few grammatical and syntax errors that really takes away from the interesting case you are reporting, and bacterial species should be italicised. Specifically; Background: * You mention that R. equi is an aetiological agent of infection - perhaps you can describe the nature of some of these infections. Are they skin and soft tissue primarily? Invasive disease with bacteraemia? Deep-seated abscesses? * I don't quite understand what you mean by Line 39-40; "So laboratory personnel should alert clinicians whether the infection with R. equi is accompanied by other factors that …
Comments to Author
Many thanks for your manuscript, and for highlighting the importance of such an underestimated pathogen - Rhodococcus equi. General thoughts are that the manuscript would benefit from a thorough proof-read, there are quite a few grammatical and syntax errors that really takes away from the interesting case you are reporting, and bacterial species should be italicised. Specifically; Background: * You mention that R. equi is an aetiological agent of infection - perhaps you can describe the nature of some of these infections. Are they skin and soft tissue primarily? Invasive disease with bacteraemia? Deep-seated abscesses? * I don't quite understand what you mean by Line 39-40; "So laboratory personnel should alert clinicians whether the infection with R. equi is accompanied by other factors that contribute to the patient's immune deficiency." Are you saying that laboratory staff, on identifying R. equi should investigate for immunodeficiency and alert clinicians of same? Or should it not read, something along the lines of, "Identification of R. equi in clinical samples should prompt clinicians to investigate for probable causes of underlying immunocompromise." * If you can perhaps source data on morbidity and mortality rates, it would augment your case and the significance of this pathogen. Case Report: * What was the patient on for his Adult-Onset Still's Disease - usual therapies may render a person immunocompromised and it would be important to state this information. * Based on your overall presentation, I presume that the patient was commenced on antimicrobials following the temperature spike; was this meropenem and vancomycin? Seems very broad spectrum for an isolated temperature spike with otherwise unremarkable vital signs quoted below. Is this as per local policy? * He also had extensive investigations, the Cranial-CT understandable because of his limb weakness, but what prompted the CT-Chest and Abdominal-CT? Also, can you state exactly where the abdominal abscess was? Liver? Musculature? And given these widespread abscesses, was there any consideration of an Echocardiogram to investigate for infective endocarditis and these phenomenon as a consequence of septic emboli? * The blood results may also be better suitably displayed in a table, with a few values across his admission so that we can see a trend; perhaps on admission, when antimicrobials were changed and on discharge. * I also have some concerns regarding his treatment regimen. He was continued on meropenem and vancomycin for 20 days. Did it take that long for susceptibility results to be returned? And regarding susceptibility testing, how was this performed and I presume meropenem susceptibility was inferred from imipenem susceptibility? * R. equi was isolated from blood, lung tissue and sputum - was a lung biopsy done? How was lung tissue obtained? * Line 69, "She resoulted her symptoms." - Please correct, grammatically incorrect and the patient was male. * Overall, I think the case can benefit from more reporting of the clinical status of the patient throughout his admission, with a clearer timeline. Discussion: * Please reference the Sanford Guide to Antimicrobial Therapy and state which version/year is being quoted. * Line 129 - I do not understand how reduced activity against Rikettsia is relevant * I think it's important to highlight that this is a case of R. equi in a non-HIV individual but someone who was still likely immunocompromised due to medications being taken for his Still's Disease; and therefore, clinicians should be wary of probable infections caused by R. equi in immunocompromised patients.
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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The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
The report has potential but there are lots of typographical errors as well as technical errors across all sections of the manuscript. The manuscript needs a thorough language and spelling check. All the scientific names should be italicized. The references should be in the appropriate format
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, …
Comments to Author
The report has potential but there are lots of typographical errors as well as technical errors across all sections of the manuscript. The manuscript needs a thorough language and spelling check. All the scientific names should be italicized. The references should be in the appropriate format
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
-