Reviewer's report 
 Invasive Pulmonary Aspergillosis in Patients with decompensated cirrhosis : case series Title: 
 1  7 August 2006 Version: Date: 
 saad nseir Reviewer: 
Reviewer's report: 
Discretionary Revisions (which the author can choose to ignore) 
Dr. Provanovic and colleagues report a case series of three patients with cirrhosis hospitalized in the ICU for ARDS, sepsis, and multiorgan dysfunction. Invasive pulmonary aspergillosis was diagnosed based on positive Aspergillus antigenemia in two patients, and positive Aspergillus selology in the third one. 
Bronchoalveolar lavage fluid grew Aspergillus fumigatus in all patients. Outcome was fatal in all patients. 
General comments: 
This is a well described case series of invasive pulmonary aspergillosis in patients with moderate 
immunosuppression. In fact, invasive pulmonary aspergillosis is an emerging infectious disease in these 
patients. Therefore, diagnosis should rapidly be raised, and prompt antifungal treatment should be given to these patients. In general, this case series is interesting and well written. However, some clarifications are needed. 
Specific comments: 
1. To my knowledge, according to EORTC criteria the three cases would be classified as probable invasive pulmonary aspergillosis. The authors sated that the first two cases would be classified as proven invasive 
pulmonary aspergillosis (Discussion section, page 6, line 12). However, no histopathologic examination 
from biopsy specimen was performed. 
2. Hemoptysis and bronchospasm are important clinical signs of invasive pulmonary aspergillosis. Were 
these clinical signs present in the studied patients? 
3. The authors stated that prompt empirical antifungal treatment should probably be considered in patients 
with severe cirrhosis and suspected invasive pulmonary aspergillosis. It would be of interest to add a 
comment on combined antifungal treatment in these patients. 
4. Corticosteroid treatment is an important risk factor for invasive pulmonary aspergillosis. Should this 
treatment be stopped in patients with invasive pulmonary aspergillosis? 
5. The three cases of invasive pulmonary aspergillosis were hospital-acquired. Were these cases 
diagnosed during the same period of time? 
6. Minor comment: 
-page 5, case 3, line 4: â€œthis complication occurredâ€¦â€  the sentence is incomplete. 
-page 6, Discussion, line 4: â€œhalo sign, considered of high diagnostic value in cancer patients was 
present or notâ€  should be replaced by â€œhalo sign, considered of high diagnostic value in cancer 
patients, was present or notâ€ 
Dr. Saad NSEIR 
 Accept after minor essential revisions What next?: 
 An article of limited interest Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
Reviewer's report 
 Invasive Pulmonary Aspergillosis in Patients with decompensated cirrhosis : case series Title: 
 1  7 August 2006 Version: Date: 
 saad nseir Reviewer: 
Reviewer's report: 
Discretionary Revisions (which the author can choose to ignore) 
Dr. Provanovic and colleagues report a case series of three patients with cirrhosis hospitalized in the ICU for ARDS, sepsis, and multiorgan dysfunction. Invasive pulmonary aspergillosis was diagnosed based on positive Aspergillus antigenemia in two patients, and positive Aspergillus selology in the third one. 
Bronchoalveolar lavage fluid grew Aspergillus fumigatus in all patients. Outcome was fatal in all patients. 
General comments: 
This is a well described case series of invasive pulmonary aspergillosis in patients with moderate 
immunosuppression. In fact, invasive pulmonary aspergillosis is an emerging infectious disease in these 
patients. Therefore, diagnosis should rapidly be raised, and prompt antifungal treatment should be given to these patients. In general, this case series is interesting and well written. However, some clarifications are needed. 
Specific comments: 
1. To my knowledge, according to EORTC criteria the three cases would be classified as probable invasive pulmonary aspergillosis. The authors sated that the first two cases would be classified as proven invasive 
pulmonary aspergillosis (Discussion section, page 6, line 12). However, no histopathologic examination 
from biopsy specimen was performed. 
2. Hemoptysis and bronchospasm are important clinical signs of invasive pulmonary aspergillosis. Were 
these clinical signs present in the studied patients? 
3. The authors stated that prompt empirical antifungal treatment should probably be considered in patients 
with severe cirrhosis and suspected invasive pulmonary aspergillosis. It would be of interest to add a 
comment on combined antifungal treatment in these patients. 
4. Corticosteroid treatment is an important risk factor for invasive pulmonary aspergillosis. Should this 
treatment be stopped in patients with invasive pulmonary aspergillosis? 
5. The three cases of invasive pulmonary aspergillosis were hospital-acquired. Were these cases 
diagnosed during the same period of time? 
6. Minor comment: 
-page 5, case 3, line 4: â€œthis complication occurredâ€¦â€  the sentence is incomplete. 
-page 6, Discussion, line 4: â€œhalo sign, considered of high diagnostic value in cancer patients was 
present or notâ€  should be replaced by â€œhalo sign, considered of high diagnostic value in cancer 
patients, was present or notâ€ 
Dr. Saad NSEIR 
 Accept after minor essential revisions What next?: 
 An article of limited interest Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
Please review this paper.
user
Reviewer's report 
 Invasive Pulmonary Aspergillosis in Patients with decompensated cirrhosis : case series Title: 
 1  7 August 2006 Version: Date: 
 saad nseir Reviewer: 
Reviewer's report: 
Discretionary Revisions (which the author can choose to ignore) 
Dr. Provanovic and colleagues report a case series of three patients with cirrhosis hospitalized in the ICU for ARDS, sepsis, and multiorgan dysfunction. Invasive pulmonary aspergillosis was diagnosed based on positive Aspergillus antigenemia in two patients, and positive Aspergillus selology in the third one. 
Bronchoalveolar lavage fluid grew Aspergillus fumigatus in all patients. Outcome was fatal in all patients. 
General comments: 
This is a well described case series of invasive pulmonary aspergillosis in patients with moderate 
immunosuppression. In fact, invasive pulmonary aspergillosis is an emerging infectious disease in these 
patients. Therefore, diagnosis should rapidly be raised, and prompt antifungal treatment should be given to these patients. In general, this case series is interesting and well written. However, some clarifications are needed. 
Specific comments: 
1. To my knowledge, according to EORTC criteria the three cases would be classified as probable invasive pulmonary aspergillosis. The authors sated that the first two cases would be classified as proven invasive 
pulmonary aspergillosis (Discussion section, page 6, line 12). However, no histopathologic examination 
from biopsy specimen was performed. 
2. Hemoptysis and bronchospasm are important clinical signs of invasive pulmonary aspergillosis. Were 
these clinical signs present in the studied patients? 
3. The authors stated that prompt empirical antifungal treatment should probably be considered in patients 
with severe cirrhosis and suspected invasive pulmonary aspergillosis. It would be of interest to add a 
comment on combined antifungal treatment in these patients. 
4. Corticosteroid treatment is an important risk factor for invasive pulmonary aspergillosis. Should this 
treatment be stopped in patients with invasive pulmonary aspergillosis? 
5. The three cases of invasive pulmonary aspergillosis were hospital-acquired. Were these cases 
diagnosed during the same period of time? 
6. Minor comment: 
-page 5, case 3, line 4: â€œthis complication occurredâ€¦â€  the sentence is incomplete. 
-page 6, Discussion, line 4: â€œhalo sign, considered of high diagnostic value in cancer patients was 
present or notâ€  should be replaced by â€œhalo sign, considered of high diagnostic value in cancer 
patients, was present or notâ€ 
Dr. Saad NSEIR 
 Accept after minor essential revisions What next?: 
 An article of limited interest Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
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