Reviewer's report
Title:Combination therapy of infliximab and thalidomide for refractory
entero-Behcet's disease: a case report
Version: 3Date:6 October 2013
Reviewer: Antonio Di Sabatino
Reviewer's report:
In this paper the Authors describe the case of a 23-year-old male patient affected
by recurrent abdominal pain, who underwent both gastroscopy and double
balloon enteroscopy which revealed duodenal and jejunal ulcers. On the basis of
endoscopic and clinical features (abdominal symptoms associated to recurrent
oral and genital ulcers) the patient was diagnosed as affected by Behcet’s
disease and treated with a combination of two TNF-alpha inhibitors, i.e.
thalidomide and infliximab, with clinical and endoscopic improvement. The
authors conclude that combination therapy with thalidomide and infliximab seems
to be effective in refractory entero-Behcet’s disease.
The description of the case suffers from a number of limitations. My major
concern regards the diagnosis, since on the basis of jejunal ulcers refractory
celiac disease and ulcerative jejunoileitis should have been excluded. Indeed,
celiac antibodies, such as anti-transglutaminase and anti-endomysial, have not
been included among the serum antibody panel, and there is no histologic
information concerning the degree of villous flattening and intraepithelial
lymphocyte infiltration both at duodenal and jejunal level. Based on the
localization of intestinal ulcers (jejunum) the esclusion of celiac disease and its
complications is mandatory, as Behcet’s ulcers are mainly located in the
ileocecal tract. Moreover, though rare, the association of Behcet’s disease and
celiac disease has been already reported in literature. The clinical improvement
observed could be explained by the fact that refractory celiac disease has been
shown to respond to anti-TNF treatment.
Minor points:
- Page 5, line 11: How “the possibility of intestinal lymphoma was excluded”? No
investigation have been done to esclude an enteropathy-associated T-cell
lymphoma (entero-TC or entero-RM).
- Page 6, line 7: The use of CDAI does not make sense in this case. It is even
low appropriate to assess efficacy of anti-TNFs in Crohn’s disease (endoscopic
scores evaluating mucosal healing are more accurate).
- The language should be improved.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests
Reviewer's report
Title:Combination therapy of infliximab and thalidomide for refractory
entero-Behcet's disease: a case report
Version: 3Date:6 October 2013
Reviewer: Antonio Di Sabatino
Reviewer's report:
In this paper the Authors describe the case of a 23-year-old male patient affected
by recurrent abdominal pain, who underwent both gastroscopy and double
balloon enteroscopy which revealed duodenal and jejunal ulcers. On the basis of
endoscopic and clinical features (abdominal symptoms associated to recurrent
oral and genital ulcers) the patient was diagnosed as affected by Behcet’s
disease and treated with a combination of two TNF-alpha inhibitors, i.e.
thalidomide and infliximab, with clinical and endoscopic improvement. The
authors conclude that combination therapy with thalidomide and infliximab seems
to be effective in refractory entero-Behcet’s disease.
The description of the case suffers from a number of limitations. My major
concern regards the diagnosis, since on the basis of jejunal ulcers refractory
celiac disease and ulcerative jejunoileitis should have been excluded. Indeed,
celiac antibodies, such as anti-transglutaminase and anti-endomysial, have not
been included among the serum antibody panel, and there is no histologic
information concerning the degree of villous flattening and intraepithelial
lymphocyte infiltration both at duodenal and jejunal level. Based on the
localization of intestinal ulcers (jejunum) the esclusion of celiac disease and its
complications is mandatory, as Behcet’s ulcers are mainly located in the
ileocecal tract. Moreover, though rare, the association of Behcet’s disease and
celiac disease has been already reported in literature. The clinical improvement
observed could be explained by the fact that refractory celiac disease has been
shown to respond to anti-TNF treatment.
Minor points:
- Page 5, line 11: How “the possibility of intestinal lymphoma was excluded”? No
investigation have been done to esclude an enteropathy-associated T-cell
lymphoma (entero-TC or entero-RM).
- Page 6, line 7: The use of CDAI does not make sense in this case. It is even
low appropriate to assess efficacy of anti-TNFs in Crohn’s disease (endoscopic
scores evaluating mucosal healing are more accurate).
- The language should be improved.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests
Please review this paper.
user
Reviewer's report
Title:Combination therapy of infliximab and thalidomide for refractory
entero-Behcet's disease: a case report
Version: 3Date:6 October 2013
Reviewer: Antonio Di Sabatino
Reviewer's report:
In this paper the Authors describe the case of a 23-year-old male patient affected
by recurrent abdominal pain, who underwent both gastroscopy and double
balloon enteroscopy which revealed duodenal and jejunal ulcers. On the basis of
endoscopic and clinical features (abdominal symptoms associated to recurrent
oral and genital ulcers) the patient was diagnosed as affected by Behcet’s
disease and treated with a combination of two TNF-alpha inhibitors, i.e.
thalidomide and infliximab, with clinical and endoscopic improvement. The
authors conclude that combination therapy with thalidomide and infliximab seems
to be effective in refractory entero-Behcet’s disease.
The description of the case suffers from a number of limitations. My major
concern regards the diagnosis, since on the basis of jejunal ulcers refractory
celiac disease and ulcerative jejunoileitis should have been excluded. Indeed,
celiac antibodies, such as anti-transglutaminase and anti-endomysial, have not
been included among the serum antibody panel, and there is no histologic
information concerning the degree of villous flattening and intraepithelial
lymphocyte infiltration both at duodenal and jejunal level. Based on the
localization of intestinal ulcers (jejunum) the esclusion of celiac disease and its
complications is mandatory, as Behcet’s ulcers are mainly located in the
ileocecal tract. Moreover, though rare, the association of Behcet’s disease and
celiac disease has been already reported in literature. The clinical improvement
observed could be explained by the fact that refractory celiac disease has been
shown to respond to anti-TNF treatment.
Minor points:
- Page 5, line 11: How “the possibility of intestinal lymphoma was excluded”? No
investigation have been done to esclude an enteropathy-associated T-cell
lymphoma (entero-TC or entero-RM).
- Page 6, line 7: The use of CDAI does not make sense in this case. It is even
low appropriate to assess efficacy of anti-TNFs in Crohn’s disease (endoscopic
scores evaluating mucosal healing are more accurate).
- The language should be improved.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests
assistant