Aspergillus oesophagitis in a patient with solid tumors: a case report
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Oesophageal aspergillosis is a rare occurrence primarily documented in hematologic malignancies, and only rarely occurring among patients with solid tumours. In this case report, we present the unique case of an 81-year-old Lebanese man who had a remarkable medical history, including four solid tumours. The patient sought medical attention due to dysphagia and weight loss, prompting a gastroscopic examination that revealed a necrotic abscess at the oesophagogastric junction. Initial treatment with fluconazole and esomeprazole was administered, but the recurrence of similar symptoms led to a repeat gastroscopy, unveiling a diagnosis of Aspergillus oesophagitis. Intravenous voriconazole was promptly initiated; however, the patient developed a significant pericardial effusion and expired, with Aspergillus species identified in the pericardial fluid prior to patient expiring. This exceptional case emphasizes the importance of considering oesophageal aspergillosis in cancer patients who present with refractory symptoms such as epigastric pain, dysphagia, nausea, and vomiting, despite symptomatic treatment. Our findings underscore the need for increased awareness and the inclusion of gastrointestinal endoscopy as part of the diagnostic approach for this rare but potentially life-threatening condition.
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Comments to Author
This manuscript by Vanessa Abi Rached et al, Manuscript ID; ACMI-D-24-00090R2, entitled "Aspergillus esophagitis in a patient with solid tumors: a case report" presents an unusual and significant case of esophageal aspergillosis in a patient with multiple solid tumors. Although the paper is well-written, in my view, it does not fully meet the crucial criteria for publication due to the absence of molecular identification methods.
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 …
Comments to Author
This manuscript by Vanessa Abi Rached et al, Manuscript ID; ACMI-D-24-00090R2, entitled "Aspergillus esophagitis in a patient with solid tumors: a case report" presents an unusual and significant case of esophageal aspergillosis in a patient with multiple solid tumors. Although the paper is well-written, in my view, it does not fully meet the crucial criteria for publication due to the absence of molecular identification methods.
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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The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
This manuscript by Vanessa Abi Rached et al, Manuscript ID; ACMI-D-24-00090R1, entitled "Aspergillus esophagitis in a patient with solid tumors: a case report" presents an unusual and significant case of esophageal aspergillosis in a patient with multiple solid tumors. The topic is of interest to clinicians dealing with immunocompromised patients, particularly those with cancer. The manuscript has been revised based on reviewer comments and suggestions, but some important points need to be revised. During molecular era identification based on molecular method is much more reliable than conventional method; probably you missed or misdiagnosed. You know aspergills have different cryptic spices, and they have different susceptibility o antifungal drug, so the molecular identification is crucial for this …
Comments to Author
This manuscript by Vanessa Abi Rached et al, Manuscript ID; ACMI-D-24-00090R1, entitled "Aspergillus esophagitis in a patient with solid tumors: a case report" presents an unusual and significant case of esophageal aspergillosis in a patient with multiple solid tumors. The topic is of interest to clinicians dealing with immunocompromised patients, particularly those with cancer. The manuscript has been revised based on reviewer comments and suggestions, but some important points need to be revised. During molecular era identification based on molecular method is much more reliable than conventional method; probably you missed or misdiagnosed. You know aspergills have different cryptic spices, and they have different susceptibility o antifungal drug, so the molecular identification is crucial for this issue. In the molecular era, identification based on molecular methods is indeed more reliable and accurate than conventional methods. Molecular techniques, such as DNA sequencing and polymerase chain reaction (PCR), allow for precise detection and differentiation of various species, including closely related organisms and cryptic species that may be challenging to identify using traditional methods. Aspergillus species having different cryptic species and varying susceptibility to antifungal drugs is valid. Cryptic species are morphologically similar but genetically distinct species that may exhibit different clinical manifestations and drug susceptibility profiles. Therefore, molecular identification is essential for accurate species-level diagnosis, which in turn can guide appropriate therapeutic interventions. By incorporating molecular methods into the diagnostic process, researchers and clinicians can better understand the epidemiology, pathogenicity, and drug susceptibility patterns of various fungal species. This approach can lead to improved patient outcomes, particularly in cases involving drug-resistant or difficult-to-treat infections. Given the current state of research and diagnostics, molecular techniques are essential for accurate species identification, especially in cases where traditional methods may not suffice.
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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Comments to Author
Many thanks for taking the reviewer comments into consideration and for the changes and made. The clarifications and added figure have improved the content of the review.
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
-
-
The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments.
-
Comments to Author
This case report describes a case of male 81 year old patient with oesophageal aspergillosis (due to Aspergillus fumigatus), with a history of multiple solid tumours including the lung, GI tract and urothelium. The authors report this to be a rare case as solid tumours are rarely found alongside this diagnosis. 1. Description of case Detailed clinical description with adequate use of patient vitals Clear timeline of patient's past medical history Queries: Lines 91-92: Past MH of SCC of the lung which was managed by lobectomy in Nov 2000. Can you kindly clarify whether this was fully treated or did eventual follow-up result in any further findings of recurrence? Lines 106-108: The text is unclear on reasons for initiating with that specific therapy, please clarify is this for treatment of presumed …
Comments to Author
This case report describes a case of male 81 year old patient with oesophageal aspergillosis (due to Aspergillus fumigatus), with a history of multiple solid tumours including the lung, GI tract and urothelium. The authors report this to be a rare case as solid tumours are rarely found alongside this diagnosis. 1. Description of case Detailed clinical description with adequate use of patient vitals Clear timeline of patient's past medical history Queries: Lines 91-92: Past MH of SCC of the lung which was managed by lobectomy in Nov 2000. Can you kindly clarify whether this was fully treated or did eventual follow-up result in any further findings of recurrence? Lines 106-108: The text is unclear on reasons for initiating with that specific therapy, please clarify is this for treatment of presumed radiation esophagitis or for other reasons? Line 120: I would be interested in which gastroscopies resulted in biopsies- initial or both? 2. Presentation of results Clearly laid out with appropriate subheadings Figure 1: Please consider addition of a small arrow pointing to the Aspergillus hyphae 3. How the style and organisation of the paper communicates and represents key findings Follows the clinical story well 4. Literature analysis of discussion Lines 152-156: This would suggest a 20 year latency (surgery for lobectomy in 2000)- please can you kindly elaborate if is this common/seen? This has been seen chronic pulmonary aspergillosis- see Marshall et al, 2010J Radiol Case Rep. Good examples of previous reviews and clinical cases which show some similarities to this case (haematological malignancies)- cases are somewhat listed in discussion, would benefit from a better flow in text if possible e.g. grouping of patients who had successful outcomes Good to see recommendations on faster diagnosis/consideration of aspergillosis and treatment of possible future cases in comparison to limitations of own case 5. Any other relevant comments Line 36: Please consider naming the proton pump inhibitor rather than use of "proton pump inhibitor" Line 38/128/132: Please kindly consider consistency in naming medications- capitalised or not (as line 36). Line 40: Regarding Aspergillus species identified in pericardial fluid. Please kindly clarify in this sentence that this was found prior to patient expiring as stated in the report later on. Line 141/152: Please kindly capitalise/italicize Aspergillus.
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
-
Comments to Author
This manuscript by Vanessa Abi Rached et al, Manuscript ID; ACMI-D-22-00116, entitled "Aspergillus esophagitis in a patient with solid tumors: a case report" presents an unusual and significant case of esophageal aspergillosis in a patient with multiple solid tumors. The topic is of interest to clinicians dealing with immunocompromised patients, particularly those with cancer. The manuscript is well-structured, and the case is clearly described, providing valuable insights into the diagnostic and therapeutic challenges associated with such rare infections. The addressed subject is interesting and within the journal's scope, but this manuscript contains some major points. * Please clarify within the manuscript which molecular technique and specific gene were employed for Aspergillus species …
Comments to Author
This manuscript by Vanessa Abi Rached et al, Manuscript ID; ACMI-D-22-00116, entitled "Aspergillus esophagitis in a patient with solid tumors: a case report" presents an unusual and significant case of esophageal aspergillosis in a patient with multiple solid tumors. The topic is of interest to clinicians dealing with immunocompromised patients, particularly those with cancer. The manuscript is well-structured, and the case is clearly described, providing valuable insights into the diagnostic and therapeutic challenges associated with such rare infections. The addressed subject is interesting and within the journal's scope, but this manuscript contains some major points. * Please clarify within the manuscript which molecular technique and specific gene were employed for Aspergillus species identification. Include a detailed description of the protocol used in the context of this study, and provide relevant references to support the chosen methodology. * Did you deposit the sequence in GenBank, please add the obtained accession number to the manuscript? * To enhance the reader's understanding of the study's progression and chronological sequence of events, it is recommended that a timeline figure be included in the manuscript. This figure should summarize key milestones, treatments, and clinical outcomes throughout the patient's case. * Please compile a table summarizing the relevant studies from the literature review, including key details such as authors, publication year, study objectives, methodologies, and primary findings. Herein are some comments to improve the manuscript: Introduction: * The introduction sets the stage well, but it could benefit from a brief overview of the incidence and significance of esophageal aspergillosis in cancer patients. * Line 65: Kindly remove '(IA)'. Case Presentation * Line 81: It is recommended that the authors include a detailed examination of the four solid tumors within the body of the manuscript. * Line 85: Please delete "(white patches on the tongue or inner cheeks)". * Line 98: Please remove '(MRI)'. * Line 121 & 135: Please italicize "Aspergillus". * Please include the name of the staining technique used for the microscopic analysis within the manuscript. * You mention that "Aspergillus species, characterized by fungal hyphae exhibiting dichotomous branching (Figure 1).", you know exhibiting dichotomous branching in presented in other fungal genera such as Fusarium, Penicillium, Scedosporium. * Please include the details of the medium and incubation conditions used for isolating fungal species in the manuscript. The names of the company and country for the used culture media and stuffs should be included. * Please clarify within the manuscript which molecular technique was employed for Aspergillus species identification, and describe the specific protocol used in the context of this study. * The follow-up and outcomes are described adequately. A table summarizing the patient's clinical course, including key laboratory findings and interventions, could enhance clarity. * Line 128 & 132: Please correct "Voriconazole" to "voriconazole". Discussion and Review of the literature * Please include an additional one or two paragraphs in the Discussion section to summarize the unique aspects of this case, emphasizing any novel findings, unexpected outcomes, or notable challenges encountered during the patient's treatment. By highlighting these distinctive elements, readers will better appreciate the significance of the case report and its potential contributions to the broader medical literature. * Please include a comprehensive scientific discussion in the Discussion section that addresses both the strengths and limitations associated with this case report. * The discussion could be expanded to include more details on the implications of delayed diagnosis and the management of similar cases in the future. * Line 138, 150, 155: Please italicize "Aspergillus". * Line 141&152: Please capitalize "aspergillus". Figure 1 * The quality of the figures is very low, please be prepared to provide high-resolution figures, at least 300 DPI. * Please add the name of the staining technique used for Figure 1 to the figure's legend. * Please add labels (a) and (b) to Figure 1. * Please add arrow for showing fungal elements to Figure 1. * Please add a scale bar to Figure 1 to indicate the magnification or size of the presented images.
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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