Hemophagocytic Lymphohistiocytosis and Miliary Tuberculosis in an Apparently Immunocompetent Patient: A Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors present a case of a previously well man who presented who was diagnosed with Tuberculosis. After commencing anti-tuberculous treatment, he went on to develop pancytopenia and was diagnosed with haemophagocytic lymphohistiocytosis. He was then managed with IVIG and corticosteroids.

The case is presented in a detailed manner, clearly describing the narrative and I found it easy to follow.

Specific Comments

Line 41-42: To avoid the risk of identification, please consider changing the case descriptors to remove mention of Gambia (just say Western Africa) and just say how many years he had been in Italy (5 years), rather than stating the year he moved (2017).

Line 53: Similarly, please consider changing the date of admission to the ID Department to the number of days post-presentation.

Line 54: The patient is described as “pyretic”, it would be helpful if the authors could include the maximal temperatures recorded. Additionally, it would be helpful if the authors could summarise the patients’ temperatures (or at least the trend) between the time of admission and diagnosis of HLH. Refractory pyrexia (typically >39 Celsius) despite what would normally be considered adequate antimicrobial treatment should alert clinicians to the development of HLH.

Figure 1: Again, please consider substituting the actual dates in the timeline for days-post-admission or alternative, to reduce the risk of identification.

Figure 2: Could the 3 graphs be annotated with vertical lines indicating the points at which that key relevant treatments were started and diagnoses made? This would help the reader interpret the response of the clinical markers to treatment. Please also consider adding a graph for serum ferritin, as this is considered a very useful and dynamic marker in the diagnosis and monitoring of HLH.

Comments on the Quality of English Language

Overall, the quality of the English is high. 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Line 31- HLH due to tick borne disease needs to be mentioned as well as recently reported in this journal by Jevtic D at all. HLH triggered by tick borne infection is particularly difficult to distinguish since both groups of the disease present with cytopenia and fever, but once recognized and treated with appropriate antimicrobials has good prognosis even without immunosuppressive therapy

 

2. Introduction should describe different forms of TB

 

3. Line 101- can you report HLH score? Was IRIS considered?

4. Patient had DILI - drug induced liver injury, please update terminology frm hepatic cholestasis and cytolisis to DILI, mixed pattern

5. How many cases in the literature did you find of TB triggered HLH? what was mortality? Compared to other infections triggers do patient with TB triggered HLH have lower or higher mortality? Pleas provide more discussion about this

Comments on the Quality of English Language

minor edits

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have addressed all of my points. I am

pleased with the revised version , and in my opinion it can be accepted in its current form

Comments on the Quality of English Language

None