Reviewer's report
Title:New foe treated with old guns - Role of steroids for the treatment of acute
severe hepatitis E
Version:3Date:23 September 2014
Reviewer: Henning Wolfgang Zimmermann
Reviewer's report:
In the present manuscript Sebode et al. report on a case of acute liver injury due
to acute autochthonus hepatitis E virus infection in a 63-year-old male caucasian
patient, which resolved under treatment with prednisolone. This report describes
an interesting case that may allude to potential novel therapeutic strategies in
potentially detrimental acute HEV infection. It hence may provide the rationale for
future trials investigating immunosuppressive approaches in this disease. In
general, this report is clear and very well written. However, there are some
concerns and open questions that need to be addressed prior to publication.
Major compulsory revisions:
1. Given the fact that this patient did not present with overt hepatic
encephalopathy as stated in the manuscript the diagnostic criteria of acute liver
failure are not met. The authors should use the term acute liver injury instead. Of
course, it may be speculated that the development of encephalopathy and hence
acute liver could be prevented due to the use of corticosteroids. On the other
hand, absence of encephalopathy is linked to a better prognosis per se which
might support the notion that the favourable clinical outcome described here is
the result of spontaneous resolution.
2. What is risk of chronic HEV infection in the course of acute HEV under
sustained corticosteroid treatment? In the discussion the authors should clearly
indicate why they thought from the very beginning that the potential benefits of
maintenance of steroid therapy outweighed the risks of HEV chronification and
also the infectious risks in the light of a clinical scenario in which patients are
highly susceptible to bacterial threats. In the present form it is not fully
comprehensive why this approach was chosen. Was Ribavirin considered once
the diagnosis of HEV was established? Please provide a more-depth rationale for
the use of steroids.
Minor essential revisions:
1. Are there any hints for the possible route of transmission and/or source of
infection in this case. Please comment on this.
2. Did the patient receive high-dose acetylcysteine as it may be applied in acute
liver injury / failure due to a non-acetaminophen cause (Lee et al.,
Gastroenterology, 2009)
Level of interest: An article of importance in its field
Quality of written English: Acceptable
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:New foe treated with old guns - Role of steroids for the treatment of acute
severe hepatitis E
Version:3Date:23 September 2014
Reviewer: Henning Wolfgang Zimmermann
Reviewer's report:
In the present manuscript Sebode et al. report on a case of acute liver injury due
to acute autochthonus hepatitis E virus infection in a 63-year-old male caucasian
patient, which resolved under treatment with prednisolone. This report describes
an interesting case that may allude to potential novel therapeutic strategies in
potentially detrimental acute HEV infection. It hence may provide the rationale for
future trials investigating immunosuppressive approaches in this disease. In
general, this report is clear and very well written. However, there are some
concerns and open questions that need to be addressed prior to publication.
Major compulsory revisions:
1. Given the fact that this patient did not present with overt hepatic
encephalopathy as stated in the manuscript the diagnostic criteria of acute liver
failure are not met. The authors should use the term acute liver injury instead. Of
course, it may be speculated that the development of encephalopathy and hence
acute liver could be prevented due to the use of corticosteroids. On the other
hand, absence of encephalopathy is linked to a better prognosis per se which
might support the notion that the favourable clinical outcome described here is
the result of spontaneous resolution.
2. What is risk of chronic HEV infection in the course of acute HEV under
sustained corticosteroid treatment? In the discussion the authors should clearly
indicate why they thought from the very beginning that the potential benefits of
maintenance of steroid therapy outweighed the risks of HEV chronification and
also the infectious risks in the light of a clinical scenario in which patients are
highly susceptible to bacterial threats. In the present form it is not fully
comprehensive why this approach was chosen. Was Ribavirin considered once
the diagnosis of HEV was established? Please provide a more-depth rationale for
the use of steroids.
Minor essential revisions:
1. Are there any hints for the possible route of transmission and/or source of
infection in this case. Please comment on this.
2. Did the patient receive high-dose acetylcysteine as it may be applied in acute
liver injury / failure due to a non-acetaminophen cause (Lee et al.,
Gastroenterology, 2009)
Level of interest: An article of importance in its field
Quality of written English: Acceptable
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:New foe treated with old guns - Role of steroids for the treatment of acute
severe hepatitis E
Version:3Date:23 September 2014
Reviewer: Henning Wolfgang Zimmermann
Reviewer's report:
In the present manuscript Sebode et al. report on a case of acute liver injury due
to acute autochthonus hepatitis E virus infection in a 63-year-old male caucasian
patient, which resolved under treatment with prednisolone. This report describes
an interesting case that may allude to potential novel therapeutic strategies in
potentially detrimental acute HEV infection. It hence may provide the rationale for
future trials investigating immunosuppressive approaches in this disease. In
general, this report is clear and very well written. However, there are some
concerns and open questions that need to be addressed prior to publication.
Major compulsory revisions:
1. Given the fact that this patient did not present with overt hepatic
encephalopathy as stated in the manuscript the diagnostic criteria of acute liver
failure are not met. The authors should use the term acute liver injury instead. Of
course, it may be speculated that the development of encephalopathy and hence
acute liver could be prevented due to the use of corticosteroids. On the other
hand, absence of encephalopathy is linked to a better prognosis per se which
might support the notion that the favourable clinical outcome described here is
the result of spontaneous resolution.
2. What is risk of chronic HEV infection in the course of acute HEV under
sustained corticosteroid treatment? In the discussion the authors should clearly
indicate why they thought from the very beginning that the potential benefits of
maintenance of steroid therapy outweighed the risks of HEV chronification and
also the infectious risks in the light of a clinical scenario in which patients are
highly susceptible to bacterial threats. In the present form it is not fully
comprehensive why this approach was chosen. Was Ribavirin considered once
the diagnosis of HEV was established? Please provide a more-depth rationale for
the use of steroids.
Minor essential revisions:
1. Are there any hints for the possible route of transmission and/or source of
infection in this case. Please comment on this.
2. Did the patient receive high-dose acetylcysteine as it may be applied in acute
liver injury / failure due to a non-acetaminophen cause (Lee et al.,
Gastroenterology, 2009)
Level of interest: An article of importance in its field
Quality of written English: Acceptable
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
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