Reviewer ’s report  
 
Title: Lichenoid esophagitis presenting as fatal upper gastrointestinal bleeding in a 52 year -old 
woman. Rep ort of a case diagnosed by autopsy  
 
Version: 0 Date: 28 Jan 2017  
 
Reviewer: Manuele Furnari  
 
Reviewer's report:  
 
I read with interest the case reported by dr. Mitchell. It describes a case of death in a middle -age 
woman due to esophageal b leeding potentially caused by lichenoid inflamation.  
 
 
Esophageal involvement by lichen planus is quite rare. When present, symptoms are chronic and 
recurrent. Often skin lesions are concurrent (30 -50%). Histologic reports are even more difficult 
to find in litterature.  
 
 
Typically, long term complication is esophageal stricture. Deep ulceration leading to death has 
been never reported.  
 
 
 
Coexistence of DKA further blurs the picture.  
 
All that makes the case very intriguing. Although some aspects have to be better  discussed.  
 
 
- against what expected, there was no chronicity in the esophageal involvement. GI 
symptoms (which must be better specified in the manuscript) apparently started only in 
the very last period, and  esophageal damage was abruptly severe.  
 
 
- how do the authors explain the presence of DKA? coincidence or concurrent factor? It is 
a bit strange that the patient had two acute manifestations of two chronic disorders at the 
same time without prior symptoms.  
 
 
- since histologic features of lichenoid  esophagitis is rarely described, would it be possible 
for the authors to provide further details about the pathology? (i.e. atrophy and acanthosis 
of the squamos epithelium/Civatte bodies/etc of the mucosa next to the margin of the 
ulcer or in the brownis h mucosa close to the cardias or in the oral cavity)  
 
 
- suboptimal quality of the autopsy material, absence of positive control for CD markers, 
marked post -mortem autolysis, etc make pathology findings and conclusions weak. I feel 
hesitant and a bit scared to state this was the first case of death due to massive bleeding 
ulcer caused by LE. Therefore, I invite the authors to tone down their statement  
 
 
- I believe there are a couple of senteces that might be reviewed.....i.e "It was later learned 
that several prior to her death she had.....". Please check again the entire manuscript for 
mistyping errors.  
 
 
 
 
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 comme nts to the authors.  
 
Unable to assess  
 
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 r eview?  
If an additional statistical review is recommended, 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 man uscript:  
 
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 publi cation 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 curr ently 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 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 repo rt 
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 a n Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understan d 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: Lichenoid esophagitis presenting as fatal upper gastrointestinal bleeding in a 52 year -old 
woman. Rep ort of a case diagnosed by autopsy  
 
Version: 0 Date: 28 Jan 2017  
 
Reviewer: Manuele Furnari  
 
Reviewer's report:  
 
I read with interest the case reported by dr. Mitchell. It describes a case of death in a middle -age 
woman due to esophageal b leeding potentially caused by lichenoid inflamation.  
 
 
Esophageal involvement by lichen planus is quite rare. When present, symptoms are chronic and 
recurrent. Often skin lesions are concurrent (30 -50%). Histologic reports are even more difficult 
to find in litterature.  
 
 
Typically, long term complication is esophageal stricture. Deep ulceration leading to death has 
been never reported.  
 
 
 
Coexistence of DKA further blurs the picture.  
 
All that makes the case very intriguing. Although some aspects have to be better  discussed.  
 
 
- against what expected, there was no chronicity in the esophageal involvement. GI 
symptoms (which must be better specified in the manuscript) apparently started only in 
the very last period, and  esophageal damage was abruptly severe.  
 
 
- how do the authors explain the presence of DKA? coincidence or concurrent factor? It is 
a bit strange that the patient had two acute manifestations of two chronic disorders at the 
same time without prior symptoms.  
 
 
- since histologic features of lichenoid  esophagitis is rarely described, would it be possible 
for the authors to provide further details about the pathology? (i.e. atrophy and acanthosis 
of the squamos epithelium/Civatte bodies/etc of the mucosa next to the margin of the 
ulcer or in the brownis h mucosa close to the cardias or in the oral cavity)  
 
 
- suboptimal quality of the autopsy material, absence of positive control for CD markers, 
marked post -mortem autolysis, etc make pathology findings and conclusions weak. I feel 
hesitant and a bit scared to state this was the first case of death due to massive bleeding 
ulcer caused by LE. Therefore, I invite the authors to tone down their statement  
 
 
- I believe there are a couple of senteces that might be reviewed.....i.e "It was later learned 
that several prior to her death she had.....". Please check again the entire manuscript for 
mistyping errors.  
 
 
 
 
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 comme nts to the authors.  
 
Unable to assess  
 
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 r eview?  
If an additional statistical review is recommended, 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 man uscript:  
 
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 publi cation 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 curr ently 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 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 repo rt 
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 a n Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understan d 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: Lichenoid esophagitis presenting as fatal upper gastrointestinal bleeding in a 52 year -old 
woman. Rep ort of a case diagnosed by autopsy  
 
Version: 0 Date: 28 Jan 2017  
 
Reviewer: Manuele Furnari  
 
Reviewer's report:  
 
I read with interest the case reported by dr. Mitchell. It describes a case of death in a middle -age 
woman due to esophageal b leeding potentially caused by lichenoid inflamation.  
 
 
Esophageal involvement by lichen planus is quite rare. When present, symptoms are chronic and 
recurrent. Often skin lesions are concurrent (30 -50%). Histologic reports are even more difficult 
to find in litterature.  
 
 
Typically, long term complication is esophageal stricture. Deep ulceration leading to death has 
been never reported.  
 
 
 
Coexistence of DKA further blurs the picture.  
 
All that makes the case very intriguing. Although some aspects have to be better  discussed.  
 
 
- against what expected, there was no chronicity in the esophageal involvement. GI 
symptoms (which must be better specified in the manuscript) apparently started only in 
the very last period, and  esophageal damage was abruptly severe.  
 
 
- how do the authors explain the presence of DKA? coincidence or concurrent factor? It is 
a bit strange that the patient had two acute manifestations of two chronic disorders at the 
same time without prior symptoms.  
 
 
- since histologic features of lichenoid  esophagitis is rarely described, would it be possible 
for the authors to provide further details about the pathology? (i.e. atrophy and acanthosis 
of the squamos epithelium/Civatte bodies/etc of the mucosa next to the margin of the 
ulcer or in the brownis h mucosa close to the cardias or in the oral cavity)  
 
 
- suboptimal quality of the autopsy material, absence of positive control for CD markers, 
marked post -mortem autolysis, etc make pathology findings and conclusions weak. I feel 
hesitant and a bit scared to state this was the first case of death due to massive bleeding 
ulcer caused by LE. Therefore, I invite the authors to tone down their statement  
 
 
- I believe there are a couple of senteces that might be reviewed.....i.e "It was later learned 
that several prior to her death she had.....". Please check again the entire manuscript for 
mistyping errors.  
 
 
 
 
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 comme nts to the authors.  
 
Unable to assess  
 
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 r eview?  
If an additional statistical review is recommended, 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 man uscript:  
 
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 publi cation 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 curr ently 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 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 repo rt 
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 a n Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understan d 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