A Protracted Course of Periorbital Oedema in Infectious Mononucleosis Caused by Epstein–Barr Virus

Round 1

Reviewer 1 Report

The manuscript describes a patient afflicted with prolonged bilateral periorbital edema, called the “Hoagland sign”, as a manifestation of infectious mononucleosis. The article is concise and straight-forward stating that the patient showed signs of periorbital edema at the start of the disease course and that although it was self-limiting the edema lasted 8 weeks. In the discussion there were brief mentions of rule-out differentials, thus presumptively associating the periorbital edema with the primary infectious mononucleosis.

There are portions of the manuscript that read fluidly, and other portions that are difficult to follow. The flow of objective data was difficult to follow between the case and discussion sections as well. The epidemiology of the particular clinical sign, especially in relation to infectious mononucleosis, being reported was not discussed. After reading the report, it seems that the intended importance was the duration of the periorbital swelling, however the typical duration of these signs is only highlighted at the very end. Considering the importance and the focus on the duration, it may be worth delineating in the introduction.

In the second paragraph of the “Case” section, was the lack of hepatomegaly and splenomegaly found via palpation or ultrasound or both? In the third paragraph, there is a redundancy of the confirmed diagnosis. In the same paragraph, the urine dipstick was performed for completeness, however the pertinence of the protein and blood being negative was not discussed. In the fourth paragraph of the same section, the patient had a good response to supportive treatment, however the details of this good response are lacking. The wording for the kickboxing comment makes it seem as though she practiced kickboxing during her treatment/recovery.

The second paragraph of the “Discussion” is difficult to read and follow. The discussion regarding rule-out differentials is confusing.

Overall, this manuscript shares important information regarding a case that had prolonged Hoagland signs. With mild improvement, this article will be helpful for others approaching similar clinical cases.

Author Response

Dear reviewer,

Thank you for your comments. I have clarified the points you mentioned as follows:

• The epidemiology of Hoagland sign has been mentioned briefly.
• I have stated in the introduction that the main purpose of this report is to highlight the duration of the oedema associated with IM.
• It has been specified that absence of hepatosplenomegaly was noted only on palpation.
• The redundancy of the diagnosis has been omitted
• The significance of absence of proteinuria and haematuria has been mentioned in the 'discussion' section.
• The response to supportive treatment has been specified
• She only practised kickboxing as a hobby and as she was revising for her GCSE exams at the time of her illness, she was not actively doing the sport
• I agree that the discussion about the rule out differentials was confusing This has been simplified at the end of the manuscript.

Thank you.

Reviewer 2 Report

Line 1: Replace "incited" with "caused."

Author Response

Dear reviewer,

Thank you for your comment. The word 'incite' has been changed to 'caused'.

Reviewer 3 Report

The case report entitled "A protracted course of periorbital oedema in infectious mononucleosis caused by Epstein-Barr virus" submitted by Ricardo et.al. focused on the other manifestations caused by the infection due to Epstein-Barr Virus  resulting in Infectious mononucleosis(IM). The authors reported the case study for a patient having IM showing periorbital oedema which started off early during the disease progression. Moreover this case had a longer than usual duration of periorbital tissue association which is not shown in the current literature making this case study an important finding.     

The repot has been written well with a brief introduction and giving the details about the vital, blood and clinical presentations. The discussion is well written refereeing to possible studies and cause of this periorbital oedema. However there are a few concerns which is as follows.

Although, the case of IM was confirmed by the Monospot test the CDC does not recommend this test to diagnosis the clinical IM does the auth has any comment over this or could they have performed any other test to confirm. The clinical presentation of certain CMV infection also shows IM could the author comment more why they considered it to be due the EBV origin.

Over all the work done by the authors is commendable and adds to the necessary information.

Author Response

Dear reviewer,

Thank you for your comments.

IM was diagnosed based on the clinical findings and the presence of heterophile antibodies. While I agree that EBV serology could have been done, we felt that there was enough evidence to confirm IM. With regards to CMV as a potential mimic of mononucleosis, the presence of heterophile antibodies (which is not a usual response seen in CMV) made CMV much less likely that EBV.