Reviewer ’s report  
 
Title: Hepatic predominant presentation of Kawasaki Disease in Adolescence and review of  
literature  
 
Version: 0 Date: 04 May 2020  
 
Reviewer's report:  
 
This is an interesting unusual case report of Kawasaki Disease in in adolescent presenting with 
concomitant hepatic picture. Although the case itself is interesting, There are several important 
points need to be clarified:  
 
1. Is this an IVIG resistant case?  In Summary Part, Lin e 30, P3: The authors wrote: ....."that was 
initially resistant to intravenous immunoglobulin (IVIG)." However, in the Treatment section, the 
authors wrote:........."The patient had a single low -grade fever two days after receiving IVIG 
though continued to  improve in all other clinical parameters". It seems that the post -IVIG low 
grade fever dose not fulfill the criteria of IVIG resistance!  
 
2. Is the initial diagnosis delayed? According to the 2004 and 2017 Scientific Statement for KD 
by AHA, the IVIG treat ment of KD with IVIG is appropriate if IVIG is given within 10 days of 
fever onset. For this particular case, the authors did not specify when the IVIG was given, they 
only mentioned that (Line 137 -141:.....five days after presentation and an echocardiogra m was 
normal for age.Treatment was commenced with Intravenous Immunoglobulin(IVIG) 2g/kg total 
in divided doses. Since the case had 3 days of high fever before admission, it seems that IVIG was 
give on the 8th day of fever,. This is well within the IVIG tr eatment gold -period. Thus it is not 
appropriate to say that the initial diagnosis is delayed. It is well known that clinicians often need 
to make many differential diagnosis before making the diagnosis of KD. This process is not equal 
to delay in diagnosis ! We may say the initial diagnosis was not  KD, but soon correction was made 
and appropriate IVIG subsequently given in time.  Line 181 should also be corrected accordingly.   
 
3. The following statement is not appropriate: In Line 31...."Classical symptoms  including 
peripheral desquamation, strawberry tongue, cervical lymphadenopathy and fevers subsequently 
developed". Obviously the patient had fever first, followed by the the other symptoms with 
peripheral desquamation being the last to appear. Please rear range the symptoms according to the 
time-sequence of the symptoms. Line 114 -115 should also be corrected accordingly.  
 
4. The following statement is not appropriate: In Line 50 &amp;  51: ....."it is a self -limiting 
condition that usually resolves within 12 days without treatment".Self -limiting usually means it is 
rather benign. However, KD is not benign because it will result in serious complications if 
untreated. Please consider to delete the sentence about KD is a self -limiting disease with 
spontaneous res olution and change it to more neutral sentence (for example: the fever may resolve 
within 5 -15 days. IVIG Treatment within 10 days of fever -onset will greatly reduce the 
complication......" The importance of in -time IVIG treatment should not be ignored.  
 
5. Please re -arrange Table 1. This table seems to adopt from 2017 Scientific Statement for KD by 
AHA. The classical presentation of the main clinical symptoms of KD should include fever longer 
than 5  
days with no other explanation and at least 4 of the 5 cri teria(group of symptoms).  
 
6. Time sequence is very important for the diagnosis and treatment of KD. Please re -format the 
case presentation section in the manuscript so that time sequence can be more easily appreciated.  
 
7. This case appears also had pneumo nia. Please add in the discussion part about this and discuss 
the association of concomitant occurrence of KD, penumonia and hepatic involvement.  
 
Are the methods appropriate and wel l described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequa tely supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an additional 
statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript : 
 
Acceptable  
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in  any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that holds 
or has applied for patents relating to t he content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing intere sts' below.  
If your reply is yes to any, please give details below.  
 
'I declare that I have no competing interests  
 
Reviewer Publication Consent. I agree for my report to be made available under an Open Access  
Creative Commons CC -BY License ( http://creativec ommons.org/licenses/by/4.0 ) if this 
manuscript is accepted for publication. Any comments that I do not wish to be included in the 
published report have been included as confidential comments to the editor, which will not be 
published.  If you are not happy for us to publish this report, please contact the edi torial office 
before completing the review.  If you wish, you can include your name in your publish ed report. 
Please note you must decide whether to include your name at the start of the process and  confirm 
this decision whenever prompted. If you change your decision later, we will not be able to publish 
your name.  
 
I agree to the terms of the CC -BY 4.0 license; please do not publish my name with my report.  
(default)  
Reviewer ’s report  
 
Title: Hepatic predominant presentation of Kawasaki Disease in Adolescence and review of  
literature  
 
Version: 0 Date: 04 May 2020  
 
Reviewer's report:  
 
This is an interesting unusual case report of Kawasaki Disease in in adolescent presenting with 
concomitant hepatic picture. Although the case itself is interesting, There are several important 
points need to be clarified:  
 
1. Is this an IVIG resistant case?  In Summary Part, Lin e 30, P3: The authors wrote: ....."that was 
initially resistant to intravenous immunoglobulin (IVIG)." However, in the Treatment section, the 
authors wrote:........."The patient had a single low -grade fever two days after receiving IVIG 
though continued to  improve in all other clinical parameters". It seems that the post -IVIG low 
grade fever dose not fulfill the criteria of IVIG resistance!  
 
2. Is the initial diagnosis delayed? According to the 2004 and 2017 Scientific Statement for KD 
by AHA, the IVIG treat ment of KD with IVIG is appropriate if IVIG is given within 10 days of 
fever onset. For this particular case, the authors did not specify when the IVIG was given, they 
only mentioned that (Line 137 -141:.....five days after presentation and an echocardiogra m was 
normal for age.Treatment was commenced with Intravenous Immunoglobulin(IVIG) 2g/kg total 
in divided doses. Since the case had 3 days of high fever before admission, it seems that IVIG was 
give on the 8th day of fever,. This is well within the IVIG tr eatment gold -period. Thus it is not 
appropriate to say that the initial diagnosis is delayed. It is well known that clinicians often need 
to make many differential diagnosis before making the diagnosis of KD. This process is not equal 
to delay in diagnosis ! We may say the initial diagnosis was not  KD, but soon correction was made 
and appropriate IVIG subsequently given in time.  Line 181 should also be corrected accordingly.   
 
3. The following statement is not appropriate: In Line 31...."Classical symptoms  including 
peripheral desquamation, strawberry tongue, cervical lymphadenopathy and fevers subsequently 
developed". Obviously the patient had fever first, followed by the the other symptoms with 
peripheral desquamation being the last to appear. Please rear range the symptoms according to the 
time-sequence of the symptoms. Line 114 -115 should also be corrected accordingly.  
 
4. The following statement is not appropriate: In Line 50 &amp;  51: ....."it is a self -limiting 
condition that usually resolves within 12 days without treatment".Self -limiting usually means it is 
rather benign. However, KD is not benign because it will result in serious complications if 
untreated. Please consider to delete the sentence about KD is a self -limiting disease with 
spontaneous res olution and change it to more neutral sentence (for example: the fever may resolve 
within 5 -15 days. IVIG Treatment within 10 days of fever -onset will greatly reduce the 
complication......" The importance of in -time IVIG treatment should not be ignored.  
 
5. Please re -arrange Table 1. This table seems to adopt from 2017 Scientific Statement for KD by 
AHA. The classical presentation of the main clinical symptoms of KD should include fever longer 
than 5  
days with no other explanation and at least 4 of the 5 cri teria(group of symptoms).  
 
6. Time sequence is very important for the diagnosis and treatment of KD. Please re -format the 
case presentation section in the manuscript so that time sequence can be more easily appreciated.  
 
7. This case appears also had pneumo nia. Please add in the discussion part about this and discuss 
the association of concomitant occurrence of KD, penumonia and hepatic involvement.  
 
Are the methods appropriate and wel l described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequa tely supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an additional 
statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript : 
 
Acceptable  
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in  any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that holds 
or has applied for patents relating to t he content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing intere sts' below.  
If your reply is yes to any, please give details below.  
 
'I declare that I have no competing interests  
 
Reviewer Publication Consent. I agree for my report to be made available under an Open Access  
Creative Commons CC -BY License ( http://creativec ommons.org/licenses/by/4.0 ) if this 
manuscript is accepted for publication. Any comments that I do not wish to be included in the 
published report have been included as confidential comments to the editor, which will not be 
published.  If you are not happy for us to publish this report, please contact the edi torial office 
before completing the review.  If you wish, you can include your name in your publish ed report. 
Please note you must decide whether to include your name at the start of the process and  confirm 
this decision whenever prompted. If you change your decision later, we will not be able to publish 
your name.  
 
I agree to the terms of the CC -BY 4.0 license; please do not publish my name with my report.  
(default)  
Please review this paper.
user
Reviewer ’s report  
 
Title: Hepatic predominant presentation of Kawasaki Disease in Adolescence and review of  
literature  
 
Version: 0 Date: 04 May 2020  
 
Reviewer's report:  
 
This is an interesting unusual case report of Kawasaki Disease in in adolescent presenting with 
concomitant hepatic picture. Although the case itself is interesting, There are several important 
points need to be clarified:  
 
1. Is this an IVIG resistant case?  In Summary Part, Lin e 30, P3: The authors wrote: ....."that was 
initially resistant to intravenous immunoglobulin (IVIG)." However, in the Treatment section, the 
authors wrote:........."The patient had a single low -grade fever two days after receiving IVIG 
though continued to  improve in all other clinical parameters". It seems that the post -IVIG low 
grade fever dose not fulfill the criteria of IVIG resistance!  
 
2. Is the initial diagnosis delayed? According to the 2004 and 2017 Scientific Statement for KD 
by AHA, the IVIG treat ment of KD with IVIG is appropriate if IVIG is given within 10 days of 
fever onset. For this particular case, the authors did not specify when the IVIG was given, they 
only mentioned that (Line 137 -141:.....five days after presentation and an echocardiogra m was 
normal for age.Treatment was commenced with Intravenous Immunoglobulin(IVIG) 2g/kg total 
in divided doses. Since the case had 3 days of high fever before admission, it seems that IVIG was 
give on the 8th day of fever,. This is well within the IVIG tr eatment gold -period. Thus it is not 
appropriate to say that the initial diagnosis is delayed. It is well known that clinicians often need 
to make many differential diagnosis before making the diagnosis of KD. This process is not equal 
to delay in diagnosis ! We may say the initial diagnosis was not  KD, but soon correction was made 
and appropriate IVIG subsequently given in time.  Line 181 should also be corrected accordingly.   
 
3. The following statement is not appropriate: In Line 31...."Classical symptoms  including 
peripheral desquamation, strawberry tongue, cervical lymphadenopathy and fevers subsequently 
developed". Obviously the patient had fever first, followed by the the other symptoms with 
peripheral desquamation being the last to appear. Please rear range the symptoms according to the 
time-sequence of the symptoms. Line 114 -115 should also be corrected accordingly.  
 
4. The following statement is not appropriate: In Line 50 &amp;  51: ....."it is a self -limiting 
condition that usually resolves within 12 days without treatment".Self -limiting usually means it is 
rather benign. However, KD is not benign because it will result in serious complications if 
untreated. Please consider to delete the sentence about KD is a self -limiting disease with 
spontaneous res olution and change it to more neutral sentence (for example: the fever may resolve 
within 5 -15 days. IVIG Treatment within 10 days of fever -onset will greatly reduce the 
complication......" The importance of in -time IVIG treatment should not be ignored.  
 
5. Please re -arrange Table 1. This table seems to adopt from 2017 Scientific Statement for KD by 
AHA. The classical presentation of the main clinical symptoms of KD should include fever longer 
than 5  
days with no other explanation and at least 4 of the 5 cri teria(group of symptoms).  
 
6. Time sequence is very important for the diagnosis and treatment of KD. Please re -format the 
case presentation section in the manuscript so that time sequence can be more easily appreciated.  
 
7. This case appears also had pneumo nia. Please add in the discussion part about this and discuss 
the association of concomitant occurrence of KD, penumonia and hepatic involvement.  
 
Are the methods appropriate and wel l described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequa tely supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an additional 
statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript : 
 
Acceptable  
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in  any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that holds 
or has applied for patents relating to t he content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing intere sts' below.  
If your reply is yes to any, please give details below.  
 
'I declare that I have no competing interests  
 
Reviewer Publication Consent. I agree for my report to be made available under an Open Access  
Creative Commons CC -BY License ( http://creativec ommons.org/licenses/by/4.0 ) if this 
manuscript is accepted for publication. Any comments that I do not wish to be included in the 
published report have been included as confidential comments to the editor, which will not be 
published.  If you are not happy for us to publish this report, please contact the edi torial office 
before completing the review.  If you wish, you can include your name in your publish ed report. 
Please note you must decide whether to include your name at the start of the process and  confirm 
this decision whenever prompted. If you change your decision later, we will not be able to publish 
your name.  
 
I agree to the terms of the CC -BY 4.0 license; please do not publish my name with my report.  
(default)  
assistant