Reviewer's report 
 Dapsone induced cholangitis as a part of dapsone syndrome: a case report Title: 
Authors: 
Srivenu Itha ( srivenu@sgpgi.ac.in )
Dr Ashish Kumar ( ashishk@sgpgi.ac.in )
Sadhna Dhingra ( sdhingra@sgpgi.ac.in )
Gourdas Choudhuri ( gourdas@satyam.net.in )
 1  25 Feb 2003 Version: Date: 
 Dan Lipsker Reviewer: 
 A paper of limited interest Level of interest: 
 Other (see below) Advice on publication: 
Dapsone induced cholangitis as part of dapsone syndrome: a case report 
Authors report a 40-year-old patient who developed a typical DRESS syndrome probably related to 
dapsone. This patient also developed jaundice and had slightly elevated AST, ALT and alkaline 
phosphatase levels which the authors interpreted as acute cholangitis on the grounds of a liver 
biopsy. 
Discretionary revisions 
Some minor typographical errors need to be corrected: 
Abstract 
Background, line 2: ....anemia. Cholangitis instead of ....anemia Cholangitis 
Case presentation, line 5 ... injury....instead of ijury. 
Case report 
Line 4: He suffered from urticaria for many years instead of of hehad .... Conclusions Line before last: dermatitis herpetiformis instead of herpatiformis. 
Case report 
Was oedema of head or of hands and feet present (a common finding during the hypersensitivity syndrome)? Absolut value of reticulocyte count should be provided. How was hypoalbuminemia 
explained? Were the other medications (clofazimine and rifampicine) also stopped? Figure 2 is of 
poor quality (at least in this electronic version). 
Compulsory revisions 
This patient had a typical hypersensitivity syndrome, sometimes also called DRESS (drug reaction 
with eosinophilia and systemic symptoms, see Dermatol Online J 2002 Jun;8(1):5). Although this is 
probably related to dapsone, the responsibility of clofazimine or rifampicine can not be completely 
ruled out (see Pavithran K. Exfoliative dermatitis after clofazimine. Int J Lepr Other Mycobact Dis. 
1985 Dec;53(4):645-6.). Authors should briefly address this point in the discussion section. The 
denomination DRESS should be included in this manuscript. In the great majority of patients with a hypersensitivity syndrome, a liver biopsy is not performed. Thus, the findings reported here might 
not be uncommon during this syndrome, and this point should also be briefly addressed. Do authors 
consider that it is clinically relevant to distinguish between drug-induced hepatocellular injury and 
drug-induced cholangitis? Briefly comment. 
Competing interests: 
None declared. 
Reviewer's report 
 Dapsone induced cholangitis as a part of dapsone syndrome: a case report Title: 
Authors: 
Srivenu Itha ( srivenu@sgpgi.ac.in )
Dr Ashish Kumar ( ashishk@sgpgi.ac.in )
Sadhna Dhingra ( sdhingra@sgpgi.ac.in )
Gourdas Choudhuri ( gourdas@satyam.net.in )
 1  25 Feb 2003 Version: Date: 
 Dan Lipsker Reviewer: 
 A paper of limited interest Level of interest: 
 Other (see below) Advice on publication: 
Dapsone induced cholangitis as part of dapsone syndrome: a case report 
Authors report a 40-year-old patient who developed a typical DRESS syndrome probably related to 
dapsone. This patient also developed jaundice and had slightly elevated AST, ALT and alkaline 
phosphatase levels which the authors interpreted as acute cholangitis on the grounds of a liver 
biopsy. 
Discretionary revisions 
Some minor typographical errors need to be corrected: 
Abstract 
Background, line 2: ....anemia. Cholangitis instead of ....anemia Cholangitis 
Case presentation, line 5 ... injury....instead of ijury. 
Case report 
Line 4: He suffered from urticaria for many years instead of of hehad .... Conclusions Line before last: dermatitis herpetiformis instead of herpatiformis. 
Case report 
Was oedema of head or of hands and feet present (a common finding during the hypersensitivity syndrome)? Absolut value of reticulocyte count should be provided. How was hypoalbuminemia 
explained? Were the other medications (clofazimine and rifampicine) also stopped? Figure 2 is of 
poor quality (at least in this electronic version). 
Compulsory revisions 
This patient had a typical hypersensitivity syndrome, sometimes also called DRESS (drug reaction 
with eosinophilia and systemic symptoms, see Dermatol Online J 2002 Jun;8(1):5). Although this is 
probably related to dapsone, the responsibility of clofazimine or rifampicine can not be completely 
ruled out (see Pavithran K. Exfoliative dermatitis after clofazimine. Int J Lepr Other Mycobact Dis. 
1985 Dec;53(4):645-6.). Authors should briefly address this point in the discussion section. The 
denomination DRESS should be included in this manuscript. In the great majority of patients with a hypersensitivity syndrome, a liver biopsy is not performed. Thus, the findings reported here might 
not be uncommon during this syndrome, and this point should also be briefly addressed. Do authors 
consider that it is clinically relevant to distinguish between drug-induced hepatocellular injury and 
drug-induced cholangitis? Briefly comment. 
Competing interests: 
None declared. 
Please review this paper.
user
Reviewer's report 
 Dapsone induced cholangitis as a part of dapsone syndrome: a case report Title: 
Authors: 
Srivenu Itha ( srivenu@sgpgi.ac.in )
Dr Ashish Kumar ( ashishk@sgpgi.ac.in )
Sadhna Dhingra ( sdhingra@sgpgi.ac.in )
Gourdas Choudhuri ( gourdas@satyam.net.in )
 1  25 Feb 2003 Version: Date: 
 Dan Lipsker Reviewer: 
 A paper of limited interest Level of interest: 
 Other (see below) Advice on publication: 
Dapsone induced cholangitis as part of dapsone syndrome: a case report 
Authors report a 40-year-old patient who developed a typical DRESS syndrome probably related to 
dapsone. This patient also developed jaundice and had slightly elevated AST, ALT and alkaline 
phosphatase levels which the authors interpreted as acute cholangitis on the grounds of a liver 
biopsy. 
Discretionary revisions 
Some minor typographical errors need to be corrected: 
Abstract 
Background, line 2: ....anemia. Cholangitis instead of ....anemia Cholangitis 
Case presentation, line 5 ... injury....instead of ijury. 
Case report 
Line 4: He suffered from urticaria for many years instead of of hehad .... Conclusions Line before last: dermatitis herpetiformis instead of herpatiformis. 
Case report 
Was oedema of head or of hands and feet present (a common finding during the hypersensitivity syndrome)? Absolut value of reticulocyte count should be provided. How was hypoalbuminemia 
explained? Were the other medications (clofazimine and rifampicine) also stopped? Figure 2 is of 
poor quality (at least in this electronic version). 
Compulsory revisions 
This patient had a typical hypersensitivity syndrome, sometimes also called DRESS (drug reaction 
with eosinophilia and systemic symptoms, see Dermatol Online J 2002 Jun;8(1):5). Although this is 
probably related to dapsone, the responsibility of clofazimine or rifampicine can not be completely 
ruled out (see Pavithran K. Exfoliative dermatitis after clofazimine. Int J Lepr Other Mycobact Dis. 
1985 Dec;53(4):645-6.). Authors should briefly address this point in the discussion section. The 
denomination DRESS should be included in this manuscript. In the great majority of patients with a hypersensitivity syndrome, a liver biopsy is not performed. Thus, the findings reported here might 
not be uncommon during this syndrome, and this point should also be briefly addressed. Do authors 
consider that it is clinically relevant to distinguish between drug-induced hepatocellular injury and 
drug-induced cholangitis? Briefly comment. 
Competing interests: 
None declared. 
assistant