A fatal case of necrotizing fasciitis by Aeromonas jandaei
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Introduction : Necrotizing soft tissue infections are associated with an extremely fulminating course, owing to their rapid destruction of tissue planes underlying the skin. Aeromonas associated monomicrobial NSTIs are usually associated with exposure to fresh water, via trauma, trivial abrasions or even reptile bites, particularly among agricultural workers and fish handlers. Albeit uncommon in incidence, urgent medical and surgical intervention is required once diagnosis is reached. Case report : A 40-year-old male patient, known case of alcoholic liver disease, presented to the emergency department with pain and diffuse swelling of bilateral lower limbs, which quickly progressed to form blackish discolouration and blebs. Blood for preliminary haematological and biochemical investigations, as well as fluid draining from blebs were sent for microbiological investigation. The gram stain revealed occasional neutrophils and gram-negative bacilli, pure growth in aerobic culture was identified as Aeromonasjandaei by Matrix-assisted laser desorption/ionization Time of Flight Mass Spectrometry (MALDI-TOF MS). Patient was started on empirical antimicrobials, though lesions continued to progress and he ultimately succumbed within 12 hours of his hospital stay. Conclusion : As appropriate antimicrobial therapy and early surgical intervention are required for management of the same, occupational exposure and the fulminant course should raise suspicion of likelihood of Aeromonas associated infections.
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Reviewer and editor comments have been sufficiently addressed.
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Though some reviewer comments and questions have been satisfactorily resolved, several minor issues persist in the revised version of the manuscript. The submission has small grammatical errors throughout that make the manuscript difficult to read and understand. Please carefully edit the submission for these errors. We offer a discounted translation service, Editage, if external assistance is needed; see https://www.editage.com/ and https://www.microbiologyresearch.org/prepare-an-article#13 for more information. The manuscript is currently inconsistent in reporting the patient's time of death relative to hospital admission. The abstract (line 50) states that the patient passed away within 24 hours, while the main text (lines 88-89) states that he passed within 12 hours. Please correct these discrepancies for accuracy and consistency …
Though some reviewer comments and questions have been satisfactorily resolved, several minor issues persist in the revised version of the manuscript. The submission has small grammatical errors throughout that make the manuscript difficult to read and understand. Please carefully edit the submission for these errors. We offer a discounted translation service, Editage, if external assistance is needed; see https://www.editage.com/ and https://www.microbiologyresearch.org/prepare-an-article#13 for more information. The manuscript is currently inconsistent in reporting the patient's time of death relative to hospital admission. The abstract (line 50) states that the patient passed away within 24 hours, while the main text (lines 88-89) states that he passed within 12 hours. Please correct these discrepancies for accuracy and consistency throughout the case report. In relation to Reviewer 1's questions regarding antibiotic treatment of the patient, the authors have stated that imipenem was "resistant" and meropenem was "sensitive" during AST. As it is the bacteria, not the antibiotics, that are either sensitive or resistant, please clarify what is meant in this answer. In response to Reviewer 1's inquiry about "occasional pus cells," the authors responded that this refers to neutrophils present in the gram stain. However, the text (line 46) still states that "occasional pus cells" were found. Please revise this and clarify in the text that these cells are neutrophils.
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The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
This is a well-written manuscript that only needs few minor changes. My suggestions are therefore as follows: Abstract: P1, L 37: Please add an abbreviation for necrotizing soft tissue infections (NSTIs). The abstract is too long and should be shortened, P1, L 50: Please don't just use abbreviations for the first time and edit MALDI-TOF MS to matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Case report: P4, L72: Please don't just use abbreviations for the first time and edit TLC to total leukocyte count. P4, L82: Please don't just use abbreviations for the first time and edit DLC to Differential leukocyte count.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions …
Comments to Author
This is a well-written manuscript that only needs few minor changes. My suggestions are therefore as follows: Abstract: P1, L 37: Please add an abbreviation for necrotizing soft tissue infections (NSTIs). The abstract is too long and should be shortened, P1, L 50: Please don't just use abbreviations for the first time and edit MALDI-TOF MS to matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Case report: P4, L72: Please don't just use abbreviations for the first time and edit TLC to total leukocyte count. P4, L82: Please don't just use abbreviations for the first time and edit DLC to Differential leukocyte count.
Please rate the quality of the presentation and structure of the manuscript
Good
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
1. Description of the case(s): The case description is written clearly and in a good style. 2. Presentation of results: not applicable 3. How the style and organization of the paper communicates and represents key findings: Iam not realy sure of the consequences of this case report, especially for future patient management. 4. Literature analysis or discussion: Recent papers are included and discussed. Compared to the introduction and the case report, the discussion is a bit to long, missing a clear structure and has some redundances. 5. Any other relevant comments: a) Since liver cirrhosis seems to be one of the main predictors of a fatal outcome of nectrotzing fasciits, you should state the severity of this underlying disease in this patient, e.g. MELD-score or Child-Pugh-Score. Did you know of …
Comments to Author
1. Description of the case(s): The case description is written clearly and in a good style. 2. Presentation of results: not applicable 3. How the style and organization of the paper communicates and represents key findings: Iam not realy sure of the consequences of this case report, especially for future patient management. 4. Literature analysis or discussion: Recent papers are included and discussed. Compared to the introduction and the case report, the discussion is a bit to long, missing a clear structure and has some redundances. 5. Any other relevant comments: a) Since liver cirrhosis seems to be one of the main predictors of a fatal outcome of nectrotzing fasciits, you should state the severity of this underlying disease in this patient, e.g. MELD-score or Child-Pugh-Score. Did you know of any preexisting wounds on the lower limbs as site of entry? Did the patient still work as a farmer until admission? Is there a known appearance of Aeromonas jandaei in the fresh water of your region? b) Early surgical intervention is required for the management of necrotizing fasciitis, but I did not find any surgical procedure in your case. Isn´t radical debridement essential for a good outcome? c) Why did you use Imipenem/Cilastatin instead of Meropenem after you found gram-negative bacilli? Is the difference in sensibility testing between imipenem/cilastatin and meropenem reasonable, stating your antibiotic therapy was not active? Did you detect any metallo-beta-lactamases (MBL) or other carbapenemases? Some small hints: - use "imipenem/Cilastatin" instead of "meropenem" - What are "occasional pus cells", granulocytes? [line 48]
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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