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 )
 3  23 May 2003 Version: Date: 
 Dan Lipsker Reviewer: 
 A paper of limited interest Level of interest: 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
Dapsone-induced agranulocytosis and dapsone syndrome are not synonymous. Most patients with 
dapsone-induced agranulocytosis do not simultaneously have a dapsone syndrome. These are two different side-effects of dapsone. Discussion should be modified accordingly. 
Authors state: " Although the patient also received clofazimine and one dose of rifampicin but these 
drugs cannot be implicated for the constellation of features that our patient had. Clofazimine does 
not usually cause hepatotoxicity and one dose of rifampicin is unlikely to have caused such severe 
reaction." 
Although I agree that it is probably dapsone that induced this DRESS syndrome, the potential role of 
clofazimine can not be excluded since both drugs were introduced on the same day (see Pavithran 
K. Exfoliative dermatitis after clofazimine. Int J Lepr Other Mycobact Dis. 1985 Dec;53(4):645-6.). 
This is of major importance since both drugs should be contra-indicated in this patient. Authors can 
only argue that based on published litterature, it was probably dapsone, rather than clofazimine, that 
induced this syndrome. 
Furthermore, as part of a hypersensitivity or DRESS syndrome, every drug can cause hepatotoxicity. 
DRESS should appear in the abstract. 
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 )
 3  23 May 2003 Version: Date: 
 Dan Lipsker Reviewer: 
 A paper of limited interest Level of interest: 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
Dapsone-induced agranulocytosis and dapsone syndrome are not synonymous. Most patients with 
dapsone-induced agranulocytosis do not simultaneously have a dapsone syndrome. These are two different side-effects of dapsone. Discussion should be modified accordingly. 
Authors state: " Although the patient also received clofazimine and one dose of rifampicin but these 
drugs cannot be implicated for the constellation of features that our patient had. Clofazimine does 
not usually cause hepatotoxicity and one dose of rifampicin is unlikely to have caused such severe 
reaction." 
Although I agree that it is probably dapsone that induced this DRESS syndrome, the potential role of 
clofazimine can not be excluded since both drugs were introduced on the same day (see Pavithran 
K. Exfoliative dermatitis after clofazimine. Int J Lepr Other Mycobact Dis. 1985 Dec;53(4):645-6.). 
This is of major importance since both drugs should be contra-indicated in this patient. Authors can 
only argue that based on published litterature, it was probably dapsone, rather than clofazimine, that 
induced this syndrome. 
Furthermore, as part of a hypersensitivity or DRESS syndrome, every drug can cause hepatotoxicity. 
DRESS should appear in the abstract. 
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 )
 3  23 May 2003 Version: Date: 
 Dan Lipsker Reviewer: 
 A paper of limited interest Level of interest: 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
Dapsone-induced agranulocytosis and dapsone syndrome are not synonymous. Most patients with 
dapsone-induced agranulocytosis do not simultaneously have a dapsone syndrome. These are two different side-effects of dapsone. Discussion should be modified accordingly. 
Authors state: " Although the patient also received clofazimine and one dose of rifampicin but these 
drugs cannot be implicated for the constellation of features that our patient had. Clofazimine does 
not usually cause hepatotoxicity and one dose of rifampicin is unlikely to have caused such severe 
reaction." 
Although I agree that it is probably dapsone that induced this DRESS syndrome, the potential role of 
clofazimine can not be excluded since both drugs were introduced on the same day (see Pavithran 
K. Exfoliative dermatitis after clofazimine. Int J Lepr Other Mycobact Dis. 1985 Dec;53(4):645-6.). 
This is of major importance since both drugs should be contra-indicated in this patient. Authors can 
only argue that based on published litterature, it was probably dapsone, rather than clofazimine, that 
induced this syndrome. 
Furthermore, as part of a hypersensitivity or DRESS syndrome, every drug can cause hepatotoxicity. 
DRESS should appear in the abstract. 
Competing interests: 
None declared. 
assistant