Reviewer ’s report  
 
Title:  Celiac Crisis, a rare and profound presentation of Celiac disease: a case report.  
 
Version: 0 Date: 24 Dec 2017 
 
Reviewer:  Giovanni Mario  Pes 
 
Reviewer’s report:  
 
Study summary  
 
The manuscript by Forrest and co -authors describes the case of an adult woman diagnosed with 
celiac crisis associated with severe vitamin B12 deficiency and subacute spinal degeneration. 
The manuscript is well written and draws attention to an  under -recognized problem that can 
present as a medical emergency.  
 
 
Comments  
 
Since the patient had already been diagnosed with celiac disease 3 years earlier, and she likely 
was already under GFD, the real challenge lies in identifying the possible precip itating cause of 
crisis. I suggest three points that might be further expanded:  
 
(i) celiac disease is sometimes associated with type 1 diabetes, as both diseases depend on HLA 
class II genes. The patient's signs were compatible with a sudden onset of such condition? 
Maybe the authors have checked this point, but it would be advisable to state it explicitly in the 
text; 
 
(ii) celiac crisis has been reported following treatment for H. pylori infection (which has been 
hypothesized to protect from celiac disease ). H pylori infection may also explain vitamin B12 
deficiency and bone marrow failure. Perhaps the authors could briefly specify if this infection 
has been excluded.  
 
(iii) it is probable that the crisis was triggered by poor dietary compliance and consequent severe 
malnutrition.  
 
Last comment: the authors wisely decided not to initiate glucocorticoid therapy (page 6, lines 2 -
5), which although recommended by some autho rs (eg., reference number 4) may cause 
deterioration of the patient's condition (Gupta et al. Indian Pediatr. 2014;51:756 -7) and may 
exacerbate hypokalemia.  
 
 
Minor points  
 
page 1, line 44:  In the abstract and at page 3, line 22 the measurement un it of BMI should 
be added: 14.7 kg/m²  
 
page 3, line 1:   "hypokaelmia" should be corrected into "hypokalaemia" or "hypokalemia"  
 
page 3, line 34:  Please make consistent the spelling of "hypalbuminaemia" (page 3, line 
34) and "hypoalbuminemia" ( pag 4, line 17)  
 
page 4, line 39:  "Colon" is another term for "large intestine / large bowel" therefore the 
expression "large colon" sounds a bit odd  
 
page 4, line 41   The authors should explain what CUs are (arbitrary units?)  
 
page 5, line 24:  In the discussion, "mucous", better: "mucosa"  
 
page 8, line 17:  In the acknowledgements, please eliminate the article "the" before or after 
"anonymously".  
 
page 8, line 29:  The surname of the last author in reference 1 is not Gellier but Ce llier. 
 
Are the methods appropriate and well 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.  
 
No 
 
Are the conclusions drawn adequately 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 manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is rec ommended, please specify 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, fees, funding, or salary from an 
organisation  that may in any way gain or lose financially 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 relati ng to the 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 interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Acc ess Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential  comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title:  Celiac Crisis, a rare and profound presentation of Celiac disease: a case report.  
 
Version: 0 Date: 24 Dec 2017 
 
Reviewer:  Giovanni Mario  Pes 
 
Reviewer’s report:  
 
Study summary  
 
The manuscript by Forrest and co -authors describes the case of an adult woman diagnosed with 
celiac crisis associated with severe vitamin B12 deficiency and subacute spinal degeneration. 
The manuscript is well written and draws attention to an  under -recognized problem that can 
present as a medical emergency.  
 
 
Comments  
 
Since the patient had already been diagnosed with celiac disease 3 years earlier, and she likely 
was already under GFD, the real challenge lies in identifying the possible precip itating cause of 
crisis. I suggest three points that might be further expanded:  
 
(i) celiac disease is sometimes associated with type 1 diabetes, as both diseases depend on HLA 
class II genes. The patient's signs were compatible with a sudden onset of such condition? 
Maybe the authors have checked this point, but it would be advisable to state it explicitly in the 
text; 
 
(ii) celiac crisis has been reported following treatment for H. pylori infection (which has been 
hypothesized to protect from celiac disease ). H pylori infection may also explain vitamin B12 
deficiency and bone marrow failure. Perhaps the authors could briefly specify if this infection 
has been excluded.  
 
(iii) it is probable that the crisis was triggered by poor dietary compliance and consequent severe 
malnutrition.  
 
Last comment: the authors wisely decided not to initiate glucocorticoid therapy (page 6, lines 2 -
5), which although recommended by some autho rs (eg., reference number 4) may cause 
deterioration of the patient's condition (Gupta et al. Indian Pediatr. 2014;51:756 -7) and may 
exacerbate hypokalemia.  
 
 
Minor points  
 
page 1, line 44:  In the abstract and at page 3, line 22 the measurement un it of BMI should 
be added: 14.7 kg/m²  
 
page 3, line 1:   "hypokaelmia" should be corrected into "hypokalaemia" or "hypokalemia"  
 
page 3, line 34:  Please make consistent the spelling of "hypalbuminaemia" (page 3, line 
34) and "hypoalbuminemia" ( pag 4, line 17)  
 
page 4, line 39:  "Colon" is another term for "large intestine / large bowel" therefore the 
expression "large colon" sounds a bit odd  
 
page 4, line 41   The authors should explain what CUs are (arbitrary units?)  
 
page 5, line 24:  In the discussion, "mucous", better: "mucosa"  
 
page 8, line 17:  In the acknowledgements, please eliminate the article "the" before or after 
"anonymously".  
 
page 8, line 29:  The surname of the last author in reference 1 is not Gellier but Ce llier. 
 
Are the methods appropriate and well 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.  
 
No 
 
Are the conclusions drawn adequately 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 manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is rec ommended, please specify 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, fees, funding, or salary from an 
organisation  that may in any way gain or lose financially 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 relati ng to the 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 interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Acc ess Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential  comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title:  Celiac Crisis, a rare and profound presentation of Celiac disease: a case report.  
 
Version: 0 Date: 24 Dec 2017 
 
Reviewer:  Giovanni Mario  Pes 
 
Reviewer’s report:  
 
Study summary  
 
The manuscript by Forrest and co -authors describes the case of an adult woman diagnosed with 
celiac crisis associated with severe vitamin B12 deficiency and subacute spinal degeneration. 
The manuscript is well written and draws attention to an  under -recognized problem that can 
present as a medical emergency.  
 
 
Comments  
 
Since the patient had already been diagnosed with celiac disease 3 years earlier, and she likely 
was already under GFD, the real challenge lies in identifying the possible precip itating cause of 
crisis. I suggest three points that might be further expanded:  
 
(i) celiac disease is sometimes associated with type 1 diabetes, as both diseases depend on HLA 
class II genes. The patient's signs were compatible with a sudden onset of such condition? 
Maybe the authors have checked this point, but it would be advisable to state it explicitly in the 
text; 
 
(ii) celiac crisis has been reported following treatment for H. pylori infection (which has been 
hypothesized to protect from celiac disease ). H pylori infection may also explain vitamin B12 
deficiency and bone marrow failure. Perhaps the authors could briefly specify if this infection 
has been excluded.  
 
(iii) it is probable that the crisis was triggered by poor dietary compliance and consequent severe 
malnutrition.  
 
Last comment: the authors wisely decided not to initiate glucocorticoid therapy (page 6, lines 2 -
5), which although recommended by some autho rs (eg., reference number 4) may cause 
deterioration of the patient's condition (Gupta et al. Indian Pediatr. 2014;51:756 -7) and may 
exacerbate hypokalemia.  
 
 
Minor points  
 
page 1, line 44:  In the abstract and at page 3, line 22 the measurement un it of BMI should 
be added: 14.7 kg/m²  
 
page 3, line 1:   "hypokaelmia" should be corrected into "hypokalaemia" or "hypokalemia"  
 
page 3, line 34:  Please make consistent the spelling of "hypalbuminaemia" (page 3, line 
34) and "hypoalbuminemia" ( pag 4, line 17)  
 
page 4, line 39:  "Colon" is another term for "large intestine / large bowel" therefore the 
expression "large colon" sounds a bit odd  
 
page 4, line 41   The authors should explain what CUs are (arbitrary units?)  
 
page 5, line 24:  In the discussion, "mucous", better: "mucosa"  
 
page 8, line 17:  In the acknowledgements, please eliminate the article "the" before or after 
"anonymously".  
 
page 8, line 29:  The surname of the last author in reference 1 is not Gellier but Ce llier. 
 
Are the methods appropriate and well 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.  
 
No 
 
Are the conclusions drawn adequately 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 manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is rec ommended, please specify 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, fees, funding, or salary from an 
organisation  that may in any way gain or lose financially 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 relati ng to the 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 interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Acc ess Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential  comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant