Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

• In the patients history the data about eventual crack cocaine use should be mentioned, which, if present, could be relevant for hemorrhagic pulmonary presentation. If HIV status of the patient is known it should be mentioned.
• Rows 69-72, and Figure 1 should be omitted because detailed information about primary malignant disease are not relevant for this particular case of Strongyloides stercoralis hyperinfection description. It should only be mentioned as a reason for introduction of corticosteroid therapy.
• Table 1 and Table 2 can be merged in one table, and the timepoint of blood testing should be stated (at admission?)
• Table 1 and 2: the Title of the second column should be „Absolute value“ so the repeating words „absolute“ should be removed from the first column. If the full name of the laboratory finding is stated in the first column, it is not necessary to write the abbreviation. Abbreviations should be explained in the text of the article, where applicable. 
• The bronchoscopy finding should be quoted in full, and due to the presence of a focal lesion in the lower left lung lobe (metastases?) – it may be important to specify from which area the BAL sample was taken.
• Other relevant laboratory findings should be listed (i.e. the eosinophil and platelet count during hospital stay, coagulation parameters, blood cultures results during deterioration, et cet. Any laboratory finding to rule out vasculitis present? That should be stated.)
• Statement on the use of anticoagulants or antiplatelet agents should be included.
• Which antiparasitic therapy was applied, in which dose and how long (if not - why)?
• The used „broad spectrum antibiotic“ should be specified, dose and duration should be mentioned.
• Row 124 – it is unclear how can the BAL analysis identify the source of alveolar hemorrhage?
• Rows 128 -131: presented clinical, laboratory and microbiological findings can not exclude other possible causes of alveolar hemorrhage (unless other specific tests have been performed) therefore there is no exact basis for determination of probability. I suggest that this sentence be omitted.
• Figure 3: Figures a and b are redundant - the same image at different magnifications. I suggest that one of them be chosen. I have the same comment about images c and d. The larval type (stage) of shown larva should be specified.
• Table 3, first column: there is unnecessary repetition of „Day 25“ – once is enough.
• According to the information from Table 3, the result of BAL cytology was known four days after the bronchoscopy – this delay needs to be explained. Actually it is not clear what happened on Day 30 – the BAL result, or death, or both?
• Rows 142 – 143: This constatation is unnecessary – reactivation of strongyloidiasis following a single dose of corticosteroid therapy has been described.
• Discussion section: stating generally known facts should be avoided. Discussion should be case-orientated (for example: diagnostic problems – the absence of eosinophilia in the most severe cases, difficulties in conducting of prescreening et cet., unusual clinical presentation – comparison with previously described cases with pulmonary hemorrhage, discussion on the possible role of parasites in pathogenesis of pulmonary hemorrhage, possible factors which contributed to the lethal outcome (reasons for delayed diagnosis..) .. availability of antiparasitic drugs in your country/region...Awareness of the clinicians... The described case should be discussed in the context of current knowledge about strongyloidiasis in Colombia and/or specific region (some more recent local references and data should be mentioned and possibly discussed to provide the reader with a more complete picture of the epidemiology of strongyloidiasis in Colombia, its clinical presentations, treatment outcomes, diagnostic and therapeutic issues et cet.  How does the presented case fit into previous experiences?  What are the limitations of this case report?...
• In addition to three previous Colombian manuscripts cited (which could also be discussed), I recommend reading and discussing following papers:
•  
• Vinueza D, Collazos-Torres LA, Vallejo-Serna RA, Gómez-Gil BS, Quintero-Romero JM, Muñoz-Lombo JP. Strongyloides stercoralis: From chronic silent infection to fulminant catastrophe. Int J Infect Dis. 2026 Mar;164:108398. doi: 10.1016/j.ijid.2026.108398. Epub 2026 Jan 17. PMID: 41554402.

 

• Rivera A, Patiño M, Ocampo JM, Suárez J, López G, Salazar W. Strongyloides stercolaris hyperinfection in a young patient with HTLV-1 infection and ulcerative colitis. Rev Colomb Gastroenterol. 2021;36(3):408-413. https://doi.org/10.22516/25007440.688

Author Response

Review 1

1. Reviewer comment:
   In the patient’s history, data about crack cocaine use should be mentioned… If HIV status is known it should be mentioned.

Response:
We thank the reviewer for this important and clinically relevant suggestion.

A history of crack cocaine use was specifically assessed and was not present in this patient. As the reviewer correctly highlights, cocaine use is a recognized cause of diffuse alveolar hemorrhage and should be considered in the differential diagnosis

Additionally, HIV testing was performed during hospitalization and was negative. This information has now been incorporated into the Case Presentation section

We appreciate the reviewer’s comment, which has helped to enhance the clinical rigor of the manuscript.

 

2. Reviewer comment:
   Rows 69–72, and Figure 1 should be omitted because detailed information about primary malignant disease are not relevant…

Response:
We thank the reviewer for this important and insightful comment. We agree that the focus of the manuscript should remain on Strongyloides stercoralis hyperinfection and its clinical implications.

Accordingly, we have revised the manuscript to reduce detailed oncological information and maintain only the essential elements required to contextualize the patient’s immunosuppressed status and corticosteroid exposure. The description of the malignancy has been simplified, and emphasis has been placed on its role as a predisposing factor for hyperinfection.

Regarding Figure 1, in line with the reviewers’ suggestions, we have revised the image by adding arrows to highlight the key radiological findings and have simplified the caption to improve clarity. The figure has been retained as it provides relevant clinical context supporting the indication for corticosteroid therapy, which is central to the pathophysiology of hyperinfection in this case.

We believe that these modifications improve the clarity, focus, and overall quality of the manuscript.

3. Reviewer comment:
   Table 1 and Table 2 can be merged… Title of the second column should be “Absolute value”… abbreviations…

Response:
We thank the reviewer for this helpful and detailed suggestion.

Accordingly, Tables 1 and 2 have been merged into a single table to improve clarity and readability. The timepoint of laboratory testing has been explicitly specified in the table title (hospital day 25, corresponding to clinical deterioration).

In addition, the column heading has been revised to “Absolute value”, and redundant use of the term “absolute” within the table has been removed. Laboratory parameters are now presented using their full names, and abbreviations have been omitted from the table for clarity and consistency with journal guidelines.

We believe these changes significantly improve the presentation and interpretability of the data.

 

4. Reviewer comment:

The bronchoscopy finding should be quoted in full, and due to the presence of a focal lesion in the lower left lung lobe (metastases?) – it may be important to specify from which area the BAL sample was taken

 

Response:
We thank the reviewer for this important and clinically relevant suggestion.

The bronchoscopic findings have been expanded to provide a complete description of the airway evaluation. Additionally, the exact site of bronchoalveolar lavage has now been specified. BAL was performed in the lateral basal segment of the left lower lobe (LB9), corresponding to the area where alveolar hemorrhage was identified during bronchoscopy.

These modifications have been incorporated into the Case Presentation sectio

 

5. Reviewer comment:
   Statement on the use of anticoagulants or antiplatelet agents should be included.

Response:
We thank the reviewer for this important and clinically relevant suggestion.

A detailed medication history was reviewed, and the patient was not receiving anticoagulant or antiplatelet therapy at the time of presentation. This information has now been incorporated into the Case Presentation section

 

 

6. Reviewer comment:
   Row 124 – it is unclear how BAL analysis can identify the source of alveolar hemorrhage?

Response:
We thank the reviewer for this important clarification. We agree that bronchoalveolar lavage (BAL) does not allow identification of the underlying etiology of alveolar hemorrhage.

The manuscript has been revised to clarify that BAL findings confirmed the presence of diffuse alveolar hemorrhage—based on hemorrhagic return and the presence of hemosiderin-laden macrophages—but do not determine its cause. The etiological diagnosis in this case was established by the identification of Strongyloides stercoralis larvae in the BAL fluid.

 

 

7. Reviewer comment:
   Which antiparasitic therapy was applied, in which dose and for how long?

Response:
We thank the reviewer for this important comment.

The patient received oral ivermectin at a dose of 200 µg/kg (equivalent to approximately one drop per kg in the formulation used), administered once daily for two consecutive doses.

However, due to the rapid clinical deterioration and subsequent death of the patient, it was not possible to complete a full course of antiparasitic therapy, which is typically required in cases of hyperinfection.

This information has now been incorporated into the Case Presentation section

 

8. Reviewer comment:

The used „broad spectrum antibiotic“ should be specified, dose and duration should be mentioned.

Response:
We thank the reviewer for this important comment.

The antimicrobial regimen has now been specified in the revised manuscript. The patient received empirical broad-spectrum antibiotic therapy consisting of meropenem, linezolid, and trimethoprim–sulfamethoxazole, initiated on hospital day 25 at the time of clinical deterioration.

These agents were administered until the patient’s death, which occurred shortly after initiation of therapy, precluding completion of a longer treatment course.

These details have been incorporated into the Case Presentation section

9. Reviewer comment:

Rows 128 -131: presented clinical, laboratory and microbiological findings can not exclude other possible causes of alveolar hemorrhage (unless other specific tests have been performed) therefore there is no exact basis for determination of probability. I suggest that this sentence be omitted.

 

Response:
We thank the reviewer for this important and insightful comment. We agree that the available clinical, laboratory, and microbiological findings do not allow for a definitive exclusion of alternative causes of diffuse alveolar hemorrhage or for the estimation of their relative probability without additional specific testing.

Accordingly, the sentence has been removed from the revised manuscript to avoid overinterpretation of the findings and to improve methodological rigor.

 

 

10. Reviewer comment:
    Figure 3: Figures a and b are redundant - the same image at different magnifications. I suggest that one of them be chosen. I have the same comment about images c and d. The larval type (stage) of shown larva should be specified.

 

Response:
We thank the reviewer for this valuable and detailed suggestion.

In accordance with the recommendation, we have revised Figure 3 to eliminate redundant images. Specifically, only one representative image has been retained from each pair (a–b and c–d), selecting those with the best quality and diagnostic clarity.

Additionally, the figure legend has been updated to specify the larval stage observed. The larvae identified in the bronchoalveolar lavage correspond to filariform (L3) larvae, which are consistent with autoinfective stages typically observed in hyperinfection syndrome.

 

 

11. Reviewer comment:
    Table 3, first column: unnecessary repetition of “Day 25”.

Response:
We thank the reviewer for this helpful suggestion.

Table 3 has been revised to eliminate repetition of “Day 25” by grouping all events occurring on the same day into a single row. This modification improves clarity and readability of the clinical timeline.

 

12. Reviewer comment:
    According to the information from Table 3, the result of BAL cytology was known four days after the bronchoscopy – this delay needs to be explained. Actually it is not clear what happened on Day 30 – the BAL result, or death, or both?

 

Response:
We thank the reviewer for this important observation.

The interval between bronchoscopy and the final BAL cytological result reflects the time required for pathological processing and analysis of the specimen. In clinical practice, while bronchoalveolar lavage samples are obtained immediately, cytological evaluation and identification of parasitic elements may require additional processing time depending on laboratory workflow and staining procedures.

Importantly, prior to obtaining the BAL cytology result, strongyloidiasis was not clinically suspected, and antiparasitic therapy was not initiated. The diagnostic result confirming Strongyloides stercoralis was available on hospital day 30 (morning), at which point ivermectin therapy was started.

Despite treatment, the patient experienced rapid clinical deterioration and died during the early hours of hospital day 31, having received only two doses of ivermectin.

To improve clarity, Table 3 has been revised to clearly distinguish the timing of diagnostic confirmation, treatment initiation, and death.

 

13. Reviewer comment:
    Rows 142–143: This constatation is unnecessary—reactivation after a single dose has been described.

Response:
We thank the reviewer for this important and insightful comment. We agree that strongyloidiasis hyperinfection may occur even after short courses or a single dose of corticosteroids, as previously reported.

Accordingly, the statement has been removed from the revised manuscript to avoid unnecessary generalization and to improve scientific accuracy.

14. Reviewer comment:

Discussion section: stating generally known facts should be avoided. Discussion should be case-orientated (for example: diagnostic problems – the absence of eosinophilia in the most severe cases, difficulties in conducting of prescreening et cet., unusual clinical presentation – comparison with previously described cases with pulmonary hemorrhage, discussion on the possible role of parasites in pathogenesis of pulmonary hemorrhage, possible factors which contributed to the lethal outcome (reasons for delayed diagnosis..) .. availability of antiparasitic drugs in your country/region...Awareness of the clinicians... The described case should be discussed in the context of current knowledge about strongyloidiasis in Colombia and/or specific region (some more recent local references and data should be mentioned and possibly discussed to provide the reader with a more complete picture of the epidemiology of strongyloidiasis in Colombia, its clinical presentations, treatment outcomes, diagnostic and therapeutic issues et cet.  How does the presented case fit into previous experiences?  What are the limitations of this case report?..

Response:
We thank the reviewer for this insightful and constructive comment.

In response, the Discussion section has been carefully reorganized to improve its focus on the clinical aspects of the present case, including diagnostic challenges, unusual presentation, and factors contributing to the outcome.

While general statements have been reduced, we have intentionally preserved key elements and references that provide essential pathophysiological and epidemiological context. These have been integrated more closely with the case to enhance clarity and clinical relevance, rather than presented as standalone background information.

Additionally, regional data and previously reported Colombian cases have been incorporated to better contextualize this case within the current understanding of strongyloidiasis in endemic settings.

We believe these modifications improve the overall coherence, scientific rigor, and case-oriented focus of the Discussion

 

 

15. Reviewer comment:

In addition to three previous Colombian manuscripts cited (which could also be discussed), I recommend reading and discussing following papers:

 

Vinueza D, Collazos-Torres LA, Vallejo-Serna RA, Gómez-Gil BS, Quintero-Romero JM, Muñoz-Lombo JP. Strongyloides stercoralis: From chronic silent infection to fulminant catastrophe. Int J Infect Dis. 2026 Mar;164:108398. doi: 10.1016/j.ijid.2026.108398. Epub 2026 Jan 17. PMID: 41554402.

 

 

Rivera A, Patiño M, Ocampo JM, Suárez J, López G, Salazar W. Strongyloides stercolaris hyperinfection in a young patient with HTLV-1 infection and ulcerative colitis. Rev Colomb Gastroenterol. 2021;36(3):408-413. https://doi.org/10.22516/25007440.688

 

Response:

We thank the reviewer for this important  comment. Following this recommendation, we have incorporated both suggested references into the Discussion section. The work by Vinueza et al. (2026) was discussed in the context of corticosteroid-triggered hyperinfection, illustrating how iatrogenic immunosuppression even when clinically justified, can precipitate fatal disseminated strongyloidiasis in endemic settings, as evidenced by a comparable Colombian case in which the diagnosis was only established post-mortem. The report by Rivera et al. (2021) was incorporated to highlight the role of underlying immune dysregulation, specifically HTLV-1 infection combined with corticosteroid exposure, as a catalyst for rapid larval dissemination with pulmonary and gastrointestinal involvement. Both references were also used to reinforce two key points discussed in our manuscript: first, that the absence of eosinophilia should not be used to exclude strongyloidiasis in at-risk patients, as this finding was consistently absent across all three Colombian cases; and second, empiric ivermectin therapy has not yet been systematically implemented in Colombian institutions, underscoring the need to prioritize this as a public health measure in endemic regions.

Reviewer 2 Report

Comments and Suggestions for Authors

Comments and Suggestions for Authors

 

In this article, the authors report a case of Strongyloides stercoralis hyperinfection syndrome in a 70-year-old immunocompromised patient with urothelial carcinoma who was being treated with corticosteroids. The clinical presentation was characterised by progressive respiratory failure associated with diffuse alveolar hemorrhage, with bilateral ground-glass opacities on radiography. The diagnosis was confirmed by the detection of numerous larvae in the bronchoalveolar lavage. Despite treatment, the clinical course highlights the severity of this parasitic infection in the context of immunosuppression. The authors emphasise the need for early screening and preventive strategies, particularly the use of ivermectin in patients prior to any corticosteroid therapy.

 

This article is interesting and deserves to be accepted following revision.

I have a few comments for the authors :

 

Lines 33–34 :"Its estimated global prevalence is 8.1%, representing approximately 613.9 million individuals. "

- Please provide the relevant reference.

Lines 51–52 : Can the authors provide further details on the occurrence of alveolar hemorrhage as a complication ?

Lines 53–54 : "In endemic settings such as Colombia, where transmission favoring socioeconomic conditions persist ……….".

- I suggest you provide more information on these socio-economic factors.

Line 67–80 : Please highlight the lesions on the spine in Figure 1 (using small arrows). Add these details to the caption for Figure 1.

Lines 83 – 85 : "Histopathological analysis demonstrated a poorly differentiated carcinoma with morphological and immunophenotypic features consistent with urothelial origin."

- Could the authors provide an illustrative photograph of the carcinoma identified ?

Line 116 : Please use arrows to indicate the key elements in Figure 2 (a,b,c,d).

 

The conclusions are supported by the data presented.

 

Lines 251- 253 : "This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the Fundación Cardioinfantil — Instituto de Cardiología in Bogotá, Colombia."

Did the authors receive an approval number ? Please provide it.

 

Best regards,

Comments for author File: Comments.pdf

Author Response

We sincerely thank the reviewer for this thoughtful and encouraging assessment of our work. We are pleased that the clinical presentation, diagnostic approach, and discussion were considered relevant and well documented.

We appreciate the reviewer’s positive recommendation and the recognition of the potential clinical impact of this case.

 

Reviewer comment:
Lines 33–34: “Its estimated global prevalence is 8.1%, representing approximately 613.9 million individuals.”
Please provide the relevant reference.

Response:
We thank the reviewer for this important observation. The statement has now been appropriately referenced. This estimate is based on a comprehensive global modeling study by Buonfrate et al., which reported a prevalence of 8.1%, corresponding to approximately 613.9 million individuals worldwide. The corresponding reference has been added to the manuscript

 

Reviewer comment:
Lines 51–52: Can the authors provide further details on the occurrence of alveolar hemorrhage as a complication?

 

Response:
We thank the reviewer for this valuable suggestion. The manuscript has been revised to further elaborate on diffuse alveolar hemorrhage (DAH) as a complication of Strongyloides stercoralis hyperinfection.

Although pulmonary involvement is common in hyperinfection syndrome, alveolar hemorrhage is an uncommon but well-documented manifestation, typically associated with severe disease and high mortality. Previous reports and case series have described DAH in the context of disseminated strongyloidiasis, often in immunocompromised patients, particularly those receiving corticosteroids.

The underlying mechanism is thought to involve direct larval invasion of the alveolar–capillary membrane, leading to mechanical disruption, inflammatory injury, and bleeding. Importantly, the presence of pulmonary hemorrhage has been associated with advanced disease and poor outcomes, with several reported cases demonstrating high mortality rates.

These aspects have now been incorporated into the Discussion section to better contextualize the severity and clinical relevance of this complication

 

Reviewer comment:
Lines 51–52: “In endemic settings such as Colombia, where transmission favoring socioeconomic conditions persist…”
I suggest you provide more information on these socio-economic factors.

Response:
We thank the reviewer for this valuable suggestion. The manuscript has been revised to further specify the socioeconomic factors associated with Strongyloides stercoralis transmission in endemic settings.

These include poor sanitation and hygiene, inadequate access to safe water, rural living conditions with frequent soil exposure, overcrowding, and limited access to healthcare services. These conditions are well-recognized determinants of strongyloidiasis transmission, particularly in tropical and resource-limited setting

 

Reviewer comment:
Line 67–80: Please highlight the lesions on the spine in Figure 1 (using small arrows). Add these details to the caption for Figure 1.

Response:
We thank the reviewer for this helpful suggestion. Figure 1 has been revised to include arrows highlighting the spinal lesion, improving the clarity and interpretability of the imaging findings.

 

Reviewer comment:
Could the authors provide an illustrative photograph of the carcinoma identified?

Response:
We thank the reviewer for this valuable suggestion. We agree that histopathological images can provide additional illustrative value in case reports.

However, in this case, representative pathology images are not available for inclusion, as the material was not retained in a format suitable for publication. The diagnosis was established based on standard histopathological evaluation and immunophenotypic analysis, which are considered the gold standard for the diagnosis of urothelial carcinoma

We have ensured that the relevant histopathological findings are clearly described in the manuscript.

 

Reviewer comment:
Line 116: Please use arrows to indicate the key elements in Figure 2 (a,b,c,d).

Response:
We thank the reviewer for this helpful suggestion. Figure 2 has been revised to include arrows highlighting the key radiological findings in each panel (a–d), improving clarity and facilitating interpretation.

The figure legend has also been updated to explicitly describe the annotated findings, ensuring that all visual markers are clearly explained and the figure remains self-explanatory.

 

Reviewer comment:
Did the authors receive an approval number? Please provide it.

Response:
We thank the reviewer for this important observation. The study was approved by the Institutional Ethics Committee of Fundación Cardioinfantil—Instituto de Cardiología, Bogotá, Colombia (Approval Code: CEIC-128-2026; Approval Date: 25 March 2026).

 

We are grateful for the insightful and constructive comments, which have significantly contributed to improving the clarity, quality, and scientific rigor of our manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

This case report underscores the severity of Strongyloides hyperinfection syndrome and emphasizes the critical importance of early recognition. It provides valuable insights for clinical practice, particularly in screening and prophylactic strategies before initiating immunosuppressive therapy. The case is thoroughly documented and discussed, and I recommend publication.

Author Response

We sincerely thank the reviewer for this insightful and encouraging comment. We agree that Strongyloides stercoralis hyperinfection syndrome represents a severe and often under-recognized condition, particularly in immunocompromised patients, with reported mortality rates exceeding 60–80% in some series when diagnosis is delayed .

We also concur with the importance of early recognition and preventive strategies. As highlighted in the revised manuscript, screening and timely treatment prior to the initiation of immunosuppressive therapy are critical measures to reduce the risk of hyperinfection and its associated high mortality .

We appreciate the reviewer’s positive assessment of the case and its potential contribution to clinical practice.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

• HIV status should be mentioned before the MR result.
• Row 100: The blood culture result should be mentioned.
• The abbreviation “BAL” was introduced in row 107 and should be used consistently throughout the following text.
• Row 130: At the first mention of the term “diffuse alveolar hemorrhage,” the abbreviation should be placed in brackets: diffuse alveolar hemorrhage (DAH). The abbreviation should then be used consistently throughout the following text.
• Table 3 is still graphically unclear. The day designation in the left column should be aligned with the corresponding text in the right column for that day.
• Rows 148 and 149 should be omitted, as the information is obvious.
• Discussion section, rows 152–183: The assumptions about the mechanism of action of corticosteroids in causing Strongyloides hyperinfection are common knowledge, and your case report does not provide any new insights into this topic. Therefore, these rows should be removed from the Discussion section, and the content should be briefly mentioned in the Introduction instead. I already suggested in my previous review of your case report that generally known facts should be avoided and that the Discussion should be case-oriented.
• Rows 185–198: The gold standard in Discussion writing is to begin with the most interesting or most important point of the report. I suggest that you start the Discussion with this text about the rare clinical presentation of Strongyloides hyperinfection.
• Rows 200–214: This content should be reformulated. The Discussion section should focus on discussion. What does it mean that you “considered” DAH in the differential diagnosis? Similarly, what does it mean that “non-immune causes were evaluated”? Did you perform any diagnostic tests or therapeutic interventions related to the diseases or conditions mentioned in the differential diagnosis in your patient? I suggest that you simply mention the differential diagnosis of DAH, including specification of possible infectious causes, and perhaps discuss the “pro et contra” elements in your patient for the mentioned diseases and conditions. Alternatively, according to your present experience, you could suggest a diagnostic algorithm for DAH, which should include early bronchoscopy with BAL analysis, at least in Strongyloides stercoralis endemic regions.
• Rows 216–219: Was there a delay in diagnosis in other published strongyloidosis cases in Colombia? You could comment that, and make a correlation with the disease outcomes.
• Rows 246–248: This sentence is unnecessary and should be removed.
• Row 250: Did your patient have ileus? Did he have a nasogastric tube placed? Why were the therapeutic options limited?
• Rows 251–263: These are well-known facts. Could you discuss them from the perspective of your patient? For example, could a double dose of oral ivermectin, or concomitant oral and subcutaneous or rectal administration, have increased his chances of survival? You could consult published literature about that.
• Rows 278–283: In my opinion, the key limitations would be the lack of local epidemiological studies (insight), the lack of early clinical suspicion (awareness) despite the endemicity, and the relatively long period between bronchoscopy and the cytology result of BAL.

P.s. I still feel that Figure 1 is unnecessary, because this case report does not explore the correctness of indication for the introduction of corticosteroids, but if you insist, and if publisher agree – lets keep them!

 

Author Response

We would like to extend our deepest gratitude for the time, effort, and expertise devoted to the careful review of our manuscript. Your thoughtful and constructive comments have been invaluable in strengthening the scientific quality and clarity of our work.

 

Reviewer comment:
HIV status should be mentioned before the MR result.

Response:
We thank the reviewer for this valuable observation. We agree that the HIV status should be presented prior to imaging findings to maintain a logical and clinically consistent narrative. Accordingly, the text has been revised, and the HIV serology result has been repositioned in the Case Presentation section before the description of the MRI findings.

 

Reviewer comment:
Row 100: The blood culture result should be mentioned.

Response:
We thank the reviewer for this helpful comment. The result of blood cultures has now been included in the Case Presentation section. Blood cultures were obtained during the evaluation of the patient and remained negative.

 

Reviewer comment:
The abbreviation “BAL” was introduced in row 107 and should be used consistently throughout the following text.

Response:
We thank the reviewer for this helpful comment. The abbreviation “BAL” has now been used consistently throughout the manuscript after its first definition, and all subsequent instances of “bronchoalveolar lavage” have been replaced accordingly

 

Reviewer comment:
Row 130: At the first mention of the term “diffuse alveolar hemorrhage,” the abbreviation should be placed in brackets: diffuse alveolar hemorrhage (DAH). The abbreviation should then be used consistently throughout the following text.

Response:
We thank the reviewer for this helpful comment. The abbreviation has now been introduced at its first occurrence as “diffuse alveolar hemorrhage (DAH)” and has been used consistently throughout the remainder of the manuscript.

 

Reviewer comment:
Table 3 is still graphically unclear. The day designation in the left column should be aligned with the corresponding text in the right column for that day.

Response:
We thank the reviewer for this helpful comment. Table 3 has been revised to improve clarity and alignment. Events occurring on the same day have been consolidated into a single row to ensure that each timepoint corresponds clearly to its associated clinical events. We believe this modification enhances the readability and overall structure of the table.

 

Reviewer comment:
Rows 148 and 149 should be omitted, as the information is obvious.

Response:
We thank the reviewer for this comment. The indicated sentences have been removed from the revised manuscript to improve conciseness and avoid redundancy.

 

Reviewer comment:
Discussion section, rows 152–183: The assumptions about the mechanism of action of corticosteroids in causing Strongyloides hyperinfection are common knowledge…

Response:
We thank the reviewer for this insightful and important comment. We agree that the detailed discussion of corticosteroid-related mechanisms represents general knowledge and does not directly contribute to the case-oriented focus of the manuscript.

Accordingly, this section has been removed from the Discussion to improve conciseness and relevance. A brief and more focused description of these mechanisms has been incorporated into the Introduction to provide appropriate background context.

We believe that these changes have strengthened the Discussion by making it more clinically oriented and aligned with the purpose of a case report

 

Reviewer comment:
The gold standard in Discussion writing is to begin with the most interesting or most important point of the report…

Response:
We thank the reviewer for this valuable and insightful suggestion. In accordance with this recommendation, the Discussion section has been reorganized to begin with the most relevant and distinctive aspect of the case—its presentation as diffuse alveolar hemorrhage. We believe this modification improves the clarity and impact of the manuscript and better aligns the Discussion with a case-oriented approach.

Reviewer comment:

Rows 200–214: This content should be reformulated. The Discussion section should focus on discussion. What does it mean that you “considered” DAH in the differential diagnosis? Similarly, what does it mean that “non-immune causes were evaluated”? Did you perform any diagnostic tests or therapeutic interventions related to the diseases or conditions mentioned in the differential diagnosis in your patient? I suggest that you simply mention the differential diagnosis of DAH, including specification of possible infectious causes, and perhaps discuss the “pro et contra” elements in your patient for the mentioned diseases and conditions. Alternatively, according to your present experience, you could suggest a diagnostic algorithm for DAH, which should include early bronchoscopy with BAL analysis, at least in Strongyloides stercoralis endemic regions.

 

Response:
We thank the reviewer for this insightful and constructive comment. We agree that the previous wording was not sufficiently specific regarding the diagnostic approach.

The section has been revised to explicitly describe the differential diagnosis of diffuse alveolar hemorrhage, including both immune and non-immune causes, and to discuss the clinical features in our patient that supported or argued against these etiologies.

 

Reviewer comment:

Rows 216–219: Was there a delay in diagnosis in other published strongyloidosis cases in Colombia? You could comment that, and make a correlation with the disease outcomes.

Response:
We thank the reviewer for this important and insightful comment. We have expanded the Discussion to address the issue of delayed diagnosis in previously reported cases of strongyloidiasis in Colombia.

Available reports suggest that diagnosis is frequently delayed, often occurring after advanced clinical deterioration or even post-mortem, and this delay appears to be associated with poor outcomes

 

Reviewer comment:
Rows 246–248: This sentence is unnecessary and should be removed.

Response:
We thank the reviewer for this comment. The indicated sentence has been removed from the revised manuscript to improve clarity and conciseness of the Discussion.

 

Reviewer comment:
Did your patient have ileus? Did he have a nasogastric tube placed? Why were the therapeutic options limited?

Response:
We thank the reviewer for this important clarification. The patient did not present with ileus, nor was a nasogastric tube required, and there was no evidence of impaired enteral absorption. Accordingly, oral ivermectin was considered appropriate in this case.

We have revised the Discussion to clarify that alternative routes of administration, such as rectal ivermectin, are described in patients with gastrointestinal dysfunction and are mentioned only as general considerations rather than reflecting the clinical condition of our patient.

 

Reviewer comment:

Rows 251–263: These are well-known facts. Could you discuss them from the perspective of your patient? For example, could a double dose of oral ivermectin, or concomitant oral and subcutaneous or rectal administration, have increased his chances of survival? You could consult published literature about that

 

Response:
We thank the reviewer for this insightful comment. We have revised the Discussion to incorporate available evidence regarding ivermectin dosing strategies.

Current data, including randomized trials in uncomplicated strongyloidiasis, do not demonstrate improved efficacy with intensified dosing regimens, and evidence in severe disease is limited to case reports and small series without proven survival benefit.

Accordingly, we have clarified that delayed diagnosis and advanced disease stage likely played a more significant role in the outcome than the specific ivermectin regimen used.

 

Reviewer comment:

Rows 278–283: In my opinion, the key limitations would be the lack of local epidemiological studies (insight), the lack of early clinical suspicion (awareness) despite the endemicity, and the relatively long period between bronchoscopy and the cytology result of BAL.

 

Response:
We thank the reviewer for this valuable and insightful comment. We have revised the limitations section to explicitly address the points raised, including the lack of local epidemiological data, the absence of early clinical suspicion despite endemicity, and the time interval between bronchoscopy and BAL cytology results. We believe this addition improves the clinical relevance and transparency of the manuscript

 

Reviewer comment:
P.s. I still feel that Figure 1 is unnecessary…

Response:
We sincerely thank the reviewer for this thoughtful comment and for their openness to retaining the figure. We fully agree that the main focus of the case is not the indication for corticosteroid therapy itself. However, we chose to include Figure 1 to provide additional clinical context, particularly to illustrate the underlying condition that led to corticosteroid use, which ultimately played a key role in the development of hyperinfection.

Our intention was to offer a more comprehensive understanding of the patient’s clinical course and contributing factors. We greatly appreciate the reviewer’s consideration in allowing the figure to be retained.