Reviewer's report 
 Fibrinogen Storage Disease Associated With Estrogen Therapy Title: 
 1  18 May 2005 Version: Date: 
 A S S. Knisely Reviewer: 
Reviewer's report: 
General 
The authors in this manuscript (MS) report their findings in a woman who received oestrogens, who 
developed abnormalities in clinical-laboratory assays of hepatobiliary injury, and whose clinical-laboratory abnormalities resolved after oestrogen administration was discontinued. Light microscopy, with immunostaining, of paired liver biopsy specimens obtained during and after the 
period of oestrogen administration and clinical-laboratory abnormalities identified, respectively, 
fibrinogen storage within hepatocytes and resolution of fibrinogen storage. Findings on transmission 
electron microscopy are not described. The patient's "serum fibrinogen level was normal". Results of 
assays of fibrinogen function are not described. The authors attempt to place their observations in 
the context of previous reports of fibrinogen storage disorder and suggest that oestrogen 
administration precipitated clinically manifest liver disease, with fibrinogen storage, in this patient. Their observations are interesting and the sequence of events that they describe supports their 
suggested interpretation of the phenomena that they observed. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
1) This MS must be submitted to the care of a native speaker of English with expertise in scientific or 
medical language. So many errors are present that the useful and interesting features of the MS are 
at risk of being occulted; so many are present that to list them, and to request individual corrections, 
would be tedious. 
2) An opportunity to assess functional characteristics of this patient's fibrinogen during an 
oestrogen-triggered episode of fibrinogen retention within hepatocytes may have been lost. Assays 
for dysfibrinogenaemia, with clotting studies, should, however, be carried out while the patient has normal clinical-biochemistry indices of hepatobiliary injury and can be presumed to be in a 
"non-storing" or "baseline" condition. If the patient's fibrinogen is found to be dysfunctional at 
"baseline", the authors may be able to speculate more informedly on mechanisms of disease. If "baseline" abnormalities are found, to study first-degree family members, perhaps including liver biopsy, may be in order. 
3) An opportunity for ultrastructural study of liver, and of fibrinogen, 
primarily fixed for transmission electron microscopy may have been lost. Paraffin-embedded tissue should, however, be retrieved and processed for ultrastructural study. If the fingerprint-like inclusions identified 
in instances of fibrinogen brescia or aguadilla accumulation are seen, this 
may assist the authors to speculate more informedly on mechanisms of disease. (Is it necessary to adduce work on peroxisomal proliferation -- the authors' Ref 5 -- when no ultrastructural observations are presented?) 
4) The authors state -- echoing Marucci et al. and Medicina et al., their Refs 6 and 10 -- that three 
types of fibrinogen storage disorder exist. Yet they do not define those three types, nor do they say into which category their patient's disorder falls, although to judge by the images presented their patient's disorder might be one of the rarer forms. They should further attempt to characterise their 
findings and thereby should eliminate a prominent "loose end". 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
1) The authors in the Introduction write: "Fibrinogen storage disease is the accumulation of structurally modified fibrinogen in ER". Yet they also 
write in the Discussion that "...simultaneous deposition of multiple 
secretory proteins indicates a dysfunction in the secretory apparatus 
rather than the retention [of] a single mutant protein". Their patient's hepatocellular inclusions, to judge by the immunohistochemical results presented, contained more than one protein normally destined for 
secretion. Is their initial definition correct? Do the authors equate 
mutation with "structurally modified"? I can not be sure. 
2) The authors write that no evidence of infection was present in their patient. Yet they describe 
microabscesses in the first liver biopsy specimen. To what do they ascribe this finding? 
3) The authors, in the Table, present "baseline" values for the patient that surely represent her 
clinical-biochemistry test results at their most disordered. This is a mis-use of "baseline". To see "before" and "after" values, designated as "with exogenous oestrogens" and "without exogenous oestrogens", would be useful. 
4) The authors' emphasis on fibrinogen inclusions seen in fibrolamellar hepatocellular carcinoma 
could be interpreted as suggesting that such inclusions are characteristic of this subtype of hepatocellular carcinoma, even though the authors make no such suggestion. An article by Prof Callea in the same number of APPL PATHOL as that cited by the authors (their Ref 14) makes it 
clear that inclusion bodies, including fibrinogen inclusions, are a feature of many kinds of 
hepatocellular carcinoma. The accumulation of fibrinogen within malignant cells is at best tangential 
to the message of this MS, as is the observation of pancreatic malignancy in association with poorly 
characterised fibrinogen storage disease (the authors' Ref 13). The MS would be better, I think, 
without either. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
Consanguine marriage is frequent among some Turkish populations, and the MS is submitted from 
Turkey. We are not told if the patient herself was of consanguine parentage. The interest of this MS, 
and of the inferences that might be drawn from it on how oestrogen affects fibrinogen synthesis, 
would be greatly increased if additional studies could be carried out further to characterise 
fibrinogen, the fibrinogen genes, and the inheritance of any mutation in one of the fibrinogen genes 
in this patient. 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of limited interest Level of interest: 
 Not suitable for publication unless extensively edited Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Reviewer's report 
 Fibrinogen Storage Disease Associated With Estrogen Therapy Title: 
 1  18 May 2005 Version: Date: 
 A S S. Knisely Reviewer: 
Reviewer's report: 
General 
The authors in this manuscript (MS) report their findings in a woman who received oestrogens, who 
developed abnormalities in clinical-laboratory assays of hepatobiliary injury, and whose clinical-laboratory abnormalities resolved after oestrogen administration was discontinued. Light microscopy, with immunostaining, of paired liver biopsy specimens obtained during and after the 
period of oestrogen administration and clinical-laboratory abnormalities identified, respectively, 
fibrinogen storage within hepatocytes and resolution of fibrinogen storage. Findings on transmission 
electron microscopy are not described. The patient's "serum fibrinogen level was normal". Results of 
assays of fibrinogen function are not described. The authors attempt to place their observations in 
the context of previous reports of fibrinogen storage disorder and suggest that oestrogen 
administration precipitated clinically manifest liver disease, with fibrinogen storage, in this patient. Their observations are interesting and the sequence of events that they describe supports their 
suggested interpretation of the phenomena that they observed. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
1) This MS must be submitted to the care of a native speaker of English with expertise in scientific or 
medical language. So many errors are present that the useful and interesting features of the MS are 
at risk of being occulted; so many are present that to list them, and to request individual corrections, 
would be tedious. 
2) An opportunity to assess functional characteristics of this patient's fibrinogen during an 
oestrogen-triggered episode of fibrinogen retention within hepatocytes may have been lost. Assays 
for dysfibrinogenaemia, with clotting studies, should, however, be carried out while the patient has normal clinical-biochemistry indices of hepatobiliary injury and can be presumed to be in a 
"non-storing" or "baseline" condition. If the patient's fibrinogen is found to be dysfunctional at 
"baseline", the authors may be able to speculate more informedly on mechanisms of disease. If "baseline" abnormalities are found, to study first-degree family members, perhaps including liver biopsy, may be in order. 
3) An opportunity for ultrastructural study of liver, and of fibrinogen, 
primarily fixed for transmission electron microscopy may have been lost. Paraffin-embedded tissue should, however, be retrieved and processed for ultrastructural study. If the fingerprint-like inclusions identified 
in instances of fibrinogen brescia or aguadilla accumulation are seen, this 
may assist the authors to speculate more informedly on mechanisms of disease. (Is it necessary to adduce work on peroxisomal proliferation -- the authors' Ref 5 -- when no ultrastructural observations are presented?) 
4) The authors state -- echoing Marucci et al. and Medicina et al., their Refs 6 and 10 -- that three 
types of fibrinogen storage disorder exist. Yet they do not define those three types, nor do they say into which category their patient's disorder falls, although to judge by the images presented their patient's disorder might be one of the rarer forms. They should further attempt to characterise their 
findings and thereby should eliminate a prominent "loose end". 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
1) The authors in the Introduction write: "Fibrinogen storage disease is the accumulation of structurally modified fibrinogen in ER". Yet they also 
write in the Discussion that "...simultaneous deposition of multiple 
secretory proteins indicates a dysfunction in the secretory apparatus 
rather than the retention [of] a single mutant protein". Their patient's hepatocellular inclusions, to judge by the immunohistochemical results presented, contained more than one protein normally destined for 
secretion. Is their initial definition correct? Do the authors equate 
mutation with "structurally modified"? I can not be sure. 
2) The authors write that no evidence of infection was present in their patient. Yet they describe 
microabscesses in the first liver biopsy specimen. To what do they ascribe this finding? 
3) The authors, in the Table, present "baseline" values for the patient that surely represent her 
clinical-biochemistry test results at their most disordered. This is a mis-use of "baseline". To see "before" and "after" values, designated as "with exogenous oestrogens" and "without exogenous oestrogens", would be useful. 
4) The authors' emphasis on fibrinogen inclusions seen in fibrolamellar hepatocellular carcinoma 
could be interpreted as suggesting that such inclusions are characteristic of this subtype of hepatocellular carcinoma, even though the authors make no such suggestion. An article by Prof Callea in the same number of APPL PATHOL as that cited by the authors (their Ref 14) makes it 
clear that inclusion bodies, including fibrinogen inclusions, are a feature of many kinds of 
hepatocellular carcinoma. The accumulation of fibrinogen within malignant cells is at best tangential 
to the message of this MS, as is the observation of pancreatic malignancy in association with poorly 
characterised fibrinogen storage disease (the authors' Ref 13). The MS would be better, I think, 
without either. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
Consanguine marriage is frequent among some Turkish populations, and the MS is submitted from 
Turkey. We are not told if the patient herself was of consanguine parentage. The interest of this MS, 
and of the inferences that might be drawn from it on how oestrogen affects fibrinogen synthesis, 
would be greatly increased if additional studies could be carried out further to characterise 
fibrinogen, the fibrinogen genes, and the inheritance of any mutation in one of the fibrinogen genes 
in this patient. 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of limited interest Level of interest: 
 Not suitable for publication unless extensively edited Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Please review this paper.
user
Reviewer's report 
 Fibrinogen Storage Disease Associated With Estrogen Therapy Title: 
 1  18 May 2005 Version: Date: 
 A S S. Knisely Reviewer: 
Reviewer's report: 
General 
The authors in this manuscript (MS) report their findings in a woman who received oestrogens, who 
developed abnormalities in clinical-laboratory assays of hepatobiliary injury, and whose clinical-laboratory abnormalities resolved after oestrogen administration was discontinued. Light microscopy, with immunostaining, of paired liver biopsy specimens obtained during and after the 
period of oestrogen administration and clinical-laboratory abnormalities identified, respectively, 
fibrinogen storage within hepatocytes and resolution of fibrinogen storage. Findings on transmission 
electron microscopy are not described. The patient's "serum fibrinogen level was normal". Results of 
assays of fibrinogen function are not described. The authors attempt to place their observations in 
the context of previous reports of fibrinogen storage disorder and suggest that oestrogen 
administration precipitated clinically manifest liver disease, with fibrinogen storage, in this patient. Their observations are interesting and the sequence of events that they describe supports their 
suggested interpretation of the phenomena that they observed. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
1) This MS must be submitted to the care of a native speaker of English with expertise in scientific or 
medical language. So many errors are present that the useful and interesting features of the MS are 
at risk of being occulted; so many are present that to list them, and to request individual corrections, 
would be tedious. 
2) An opportunity to assess functional characteristics of this patient's fibrinogen during an 
oestrogen-triggered episode of fibrinogen retention within hepatocytes may have been lost. Assays 
for dysfibrinogenaemia, with clotting studies, should, however, be carried out while the patient has normal clinical-biochemistry indices of hepatobiliary injury and can be presumed to be in a 
"non-storing" or "baseline" condition. If the patient's fibrinogen is found to be dysfunctional at 
"baseline", the authors may be able to speculate more informedly on mechanisms of disease. If "baseline" abnormalities are found, to study first-degree family members, perhaps including liver biopsy, may be in order. 
3) An opportunity for ultrastructural study of liver, and of fibrinogen, 
primarily fixed for transmission electron microscopy may have been lost. Paraffin-embedded tissue should, however, be retrieved and processed for ultrastructural study. If the fingerprint-like inclusions identified 
in instances of fibrinogen brescia or aguadilla accumulation are seen, this 
may assist the authors to speculate more informedly on mechanisms of disease. (Is it necessary to adduce work on peroxisomal proliferation -- the authors' Ref 5 -- when no ultrastructural observations are presented?) 
4) The authors state -- echoing Marucci et al. and Medicina et al., their Refs 6 and 10 -- that three 
types of fibrinogen storage disorder exist. Yet they do not define those three types, nor do they say into which category their patient's disorder falls, although to judge by the images presented their patient's disorder might be one of the rarer forms. They should further attempt to characterise their 
findings and thereby should eliminate a prominent "loose end". 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
1) The authors in the Introduction write: "Fibrinogen storage disease is the accumulation of structurally modified fibrinogen in ER". Yet they also 
write in the Discussion that "...simultaneous deposition of multiple 
secretory proteins indicates a dysfunction in the secretory apparatus 
rather than the retention [of] a single mutant protein". Their patient's hepatocellular inclusions, to judge by the immunohistochemical results presented, contained more than one protein normally destined for 
secretion. Is their initial definition correct? Do the authors equate 
mutation with "structurally modified"? I can not be sure. 
2) The authors write that no evidence of infection was present in their patient. Yet they describe 
microabscesses in the first liver biopsy specimen. To what do they ascribe this finding? 
3) The authors, in the Table, present "baseline" values for the patient that surely represent her 
clinical-biochemistry test results at their most disordered. This is a mis-use of "baseline". To see "before" and "after" values, designated as "with exogenous oestrogens" and "without exogenous oestrogens", would be useful. 
4) The authors' emphasis on fibrinogen inclusions seen in fibrolamellar hepatocellular carcinoma 
could be interpreted as suggesting that such inclusions are characteristic of this subtype of hepatocellular carcinoma, even though the authors make no such suggestion. An article by Prof Callea in the same number of APPL PATHOL as that cited by the authors (their Ref 14) makes it 
clear that inclusion bodies, including fibrinogen inclusions, are a feature of many kinds of 
hepatocellular carcinoma. The accumulation of fibrinogen within malignant cells is at best tangential 
to the message of this MS, as is the observation of pancreatic malignancy in association with poorly 
characterised fibrinogen storage disease (the authors' Ref 13). The MS would be better, I think, 
without either. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
Consanguine marriage is frequent among some Turkish populations, and the MS is submitted from 
Turkey. We are not told if the patient herself was of consanguine parentage. The interest of this MS, 
and of the inferences that might be drawn from it on how oestrogen affects fibrinogen synthesis, 
would be greatly increased if additional studies could be carried out further to characterise 
fibrinogen, the fibrinogen genes, and the inheritance of any mutation in one of the fibrinogen genes 
in this patient. 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of limited interest Level of interest: 
 Not suitable for publication unless extensively edited Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
assistant