A Case Report of Discoid Lupus Erythematosus Mimicking Skin Infection

Round 1

Reviewer 1 Report (Previous Reviewer 4)

Comments and Suggestions for Authors

Main concern: Although the images are visually appealing, the presentation of DLE mimicking infection is well-known, and aside from the interesting images, the case offers no additional educational or scientific value. The case does not suggest a new mechanism, an extremely rare presentation, or a management challenge that would meaningfully contribute to the literature.

Additional comments: It remains unclear whether acid-fast bacilli staining was performed on the biopsy. If it has not been done, cutaneous tuberculosis is not definitively excluded, and TB may show an early, misleadingly favorable response to glucocorticoids.

Was a CD4 ly count was obtained? CD4 lymphopenia may predispose to tuberculosis and is relevant to the infectious differential.

Also, there is an unclear evaluation of other differentials. The manuscript does not specify whether additional possible differential diagnoses were systematically considered and excluded.

Author Response

Reviewer 1:

Main concern: Although the images are visually appealing, the presentation of DLE mimicking infection is well-known, and aside from the interesting images, the case offers no additional educational or scientific value. The case does not suggest a new mechanism, an extremely rare presentation, or a management challenge that would meaningfully contribute to the literature.

• Dear reviewer, the case report focuses on the presentation of the disease, and as seen by the path of the patient, the condition is difficult for recognition by non-dermatologists and non-dermatopathologists. In this regard, we hope that the manuscript can serve as a consultation and teaching aid, especially in Bulgaria, with regard to lacking data from this type of cutaneous lupus in epidemiological studies in our region.

 

Additional comments: It remains unclear whether acid-fast bacilli staining was performed on the biopsy. If it has not been done, cutaneous tuberculosis is not definitively excluded, and TB may show an early, misleadingly favorable response to glucocorticoids.

• We have since performed the Ziehl-Neelsen stain on the specimen, which did not show evidence of AFB.

 

Was a CD4 ly count was obtained? CD4 lymphopenia may predispose to tuberculosis and is relevant to the infectious differential.

• We have followed up with rheumatology in this regard, sadly no CD4 monitoring was performed by them

 

Also, there is an unclear evaluation of other differentials. The manuscript does not specify whether additional possible differential diagnoses were systematically considered and excluded.

• Differential diagnoses considered are the ones listed in the discussion section. They were excluded based on the morphological findings from the biopsy,

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Thank you for your work. You have improved the content. 

 

Overall Impression:

This case report presents a compelling and instructive account of discoid lupus erythematosus (DLE) with an atypical presentation that initially led to misdiagnosis as a skin infection, further complicated by the development of pulmonary tuberculosis during immunosuppressive therapy. The report effectively highlights the "great imitator" nature of DLE and the critical considerations when managing patients with chronic autoimmune conditions. The detailed clinical progression, histopathological findings, and eventual complication make this a valuable contribution to clinical knowledge.

 

Specific Review Points:

 

1. Clarity of "Mimicking Skin Infection" and Clinical Progression:

    The abstract and introduction effectively establish that the DLE presented atypically, mimicking a skin infection. However, in the "Case Presentation" section (lines 62-65), the initial description of "pustules" progressing to "dense blisters" could benefit from further clarification. It would be valuable to explicitly detail how these initial lesions were particularly misleading for an infection, perhaps by contrasting them more sharply with classical DLE features, or by explaining any rapid onset/spread that contributed to the initial misdiagnosis. This would strengthen the narrative around DLE's mimetic capabilities.

 

2. Emphasis on the Pulmonary Tuberculosis Complication:

    The development of pulmonary tuberculosis following immunosuppressive therapy is a highly significant and clinically relevant complication, serving as a critical teaching point. While mentioned in the abstract and thoroughly discussed, consider bringing this complication more prominently into the "Clinical Significance" section of the Introduction. This would immediately signal the unique and impactful aspect of this case report to the reader, reinforcing the importance of vigilant monitoring during DLE treatment.

 

3. Detailed Explanation of Lab Parameters (Table 1) in Context:

    Table 1, detailing blood parameters, shows notably elevated Leukocytes (12.11 x10^9/L) and Neutrophils (10.25 x10^9/L) during the initial workup, which are values often indicative of an active bacterial infection. Given the initial suspicion of cutaneous infection, it would be highly beneficial to explicitly discuss these elevated values in the "Case Presentation" or "Discussion" sections, elaborating on how they either supported the initial infection hypothesis or were interpreted in the context of the evolving chronic inflammatory picture, especially leading up to the later tuberculosis diagnosis. This context would add depth to the diagnostic journey.

 

4. Discussion of Antiphospholipid Syndrome (APS) Criteria:

    The report identifies elevated antiphospholipid antibodies, leading to a suggestion of Antiphospholipid Syndrome (APS), but states that specific treatment was not initiated because "not all criteria for the syndrome were met" (lines 137-139). For completeness and to enhance the educational value, a brief mention of which specific criteria were missing for a definitive APS diagnosis would be helpful. This detail would clarify the clinical decision-making process for readers unfamiliar with APS diagnostic criteria.

 

5. Quality and Self-Explanatory Nature of Figures:

    For a dermatology case report, the visual documentation is paramount. Ensure that all figures (1, 2, 3, 4, 5) are provided in the highest possible resolution and that their legends are truly self-explanatory. For instance, in Figure 2, the legend could more specifically describe the key features visible in each panel (A, B, C) that are being referenced in the text (e.g., "A: Right lateral view showing erythematous plaques with indurated peripheral border"). Similarly, for the histopathology and immunofluorescence figures, ensuring that the specific positive staining or cellular features mentioned in the text are clearly discernible or highlighted in the images would be valuable.

 

6. Consistency in DLE Prevalence/Incidence Data:

    The Introduction states the reported incidence of isolated CLE ranges from 4.0 to 4.3 cases per 100,000 individuals, and DLE accounts for 50-85% of all CLE cases (lines 48-51). While these numbers provide good context, it would be beneficial to explicitly state whether DLE itself is considered a "rare" disease, as implied by the abstract's conclusion of "rarity and broad differential diagnosis of DLE." Clarifying if "rarity" refers to DLE overall or specifically its atypical presentations would improve precision.

 

7. Minor Editorial Enhancements:

    Several minor linguistic refinements could improve readability. For example, in the Abstract, "Immunosuppressive therapy her condition deteriorated" could be rephrased for smoother flow, perhaps as "during immunosuppressive therapy, her condition deteriorated." In the Conclusion, "rises for DLE" could be rephrased, for example, "the escalating prevalence of DLE" or "the rising incidence of DLE," depending on the intended meaning. A thorough proofread for grammar and sentence structure throughout would be beneficial.

Author Response

Reviewer 2:

Thank you for your work. You have improved the content.

 

 

 

Overall Impression:

 

This case report presents a compelling and instructive account of discoid lupus erythematosus (DLE) with an atypical presentation that initially led to misdiagnosis as a skin infection, further complicated by the development of pulmonary tuberculosis during immunosuppressive therapy. The report effectively highlights the "great imitator" nature of DLE and the critical considerations when managing patients with chronic autoimmune conditions. The detailed clinical progression, histopathological findings, and eventual complication make this a valuable contribution to clinical knowledge.

• Dear reviewer, thank you for these comments

 

 

Specific Review Points:

 

 

 

Clarity of "Mimicking Skin Infection" and Clinical Progression:

    The abstract and introduction effectively establish that the DLE presented atypically, mimicking a skin infection. However, in the "Case Presentation" section (lines 62-65), the initial description of "pustules" progressing to "dense blisters" could benefit from further clarification. It would be valuable to explicitly detail how these initial lesions were particularly misleading for an infection, perhaps by contrasting them more sharply with classical DLE features, or by explaining any rapid onset/spread that contributed to the initial misdiagnosis. This would strengthen the narrative around DLE's mimetic capabilities.

• Dear reviewer, thank you for these suggestions. The presenting symptoms were described and defined by the patient as such; that is why we have placed them in brackets.

 

 

 

Emphasis on the Pulmonary Tuberculosis Complication:

    The development of pulmonary tuberculosis following immunosuppressive therapy is a highly significant and clinically relevant complication, serving as a critical teaching point. While mentioned in the abstract and thoroughly discussed, consider bringing this complication more prominently into the "Clinical Significance" section of the Introduction. This would immediately signal the unique and impactful aspect of this case report to the reader, reinforcing the importance of vigilant monitoring during DLE treatment.

• Dear reviewer, thank you for this suggestion.

 

 

 

Detailed Explanation of Lab Parameters (Table 1) in Context:

    Table 1, detailing blood parameters, shows notably elevated Leukocytes (12.11 x10^9/L) and Neutrophils (10.25 x10^9/L) during the initial workup, which are values often indicative of an active bacterial infection. Given the initial suspicion of cutaneous infection, it would be highly beneficial to explicitly discuss these elevated values in the "Case Presentation" or "Discussion" sections, elaborating on how they either supported the initial infection hypothesis or were interpreted in the context of the evolving chronic inflammatory picture, especially leading up to the later tuberculosis diagnosis. This context would add depth to the diagnostic journey.

• Dear reviewer, thank you for these suggestions. Relevant changes have been made.

 

 

Discussion of Antiphospholipid Syndrome (APS) Criteria:

    The report identifies elevated antiphospholipid antibodies, leading to a suggestion of Antiphospholipid Syndrome (APS), but states that specific treatment was not initiated because "not all criteria for the syndrome were met" (lines 137-139). For completeness and to enhance the educational value, a brief mention of which specific criteria were missing for a definitive APS diagnosis would be helpful. This detail would clarify the clinical decision-making process for readers unfamiliar with APS diagnostic criteria.

 

• Dear reviewer, thank you for this suggestion. Section has been expanded, and APS follow-up has been added.

 

Quality and Self-Explanatory Nature of Figures:

    For a dermatology case report, the visual documentation is paramount. Ensure that all figures (1, 2, 3, 4, 5) are provided in the highest possible resolution and that their legends are truly self-explanatory. For instance, in Figure 2, the legend could more specifically describe the key features visible in each panel (A, B, C) that are being referenced in the text (e.g., "A: Right lateral view showing erythematous plaques with indurated peripheral border"). Similarly, for the histopathology and immunofluorescence figures, ensuring that the specific positive staining or cellular features mentioned in the text are clearly discernible or highlighted in the images would be valuable.

• Dear reviewer, thank you for this suggestion. Relevant changes have been made.

 

 

 

Consistency in DLE Prevalence/Incidence Data:

    The Introduction states the reported incidence of isolated CLE ranges from 4.0 to 4.3 cases per 100,000 individuals, and DLE accounts for 50-85% of all CLE cases (lines 48-51). While these numbers provide good context, it would be beneficial to explicitly state whether DLE itself is considered a "rare" disease, as implied by the abstract's conclusion of "rarity and broad differential diagnosis of DLE." Clarifying if "rarity" refers to DLE overall or specifically its atypical presentations would improve precision.

• Dear reviewer, thank you for this suggestion, relevant changes will be made.

 

 

 

Minor Editorial Enhancements:

    Several minor linguistic refinements could improve readability. For example, in the Abstract, "Immunosuppressive therapy her condition deteriorated" could be rephrased for smoother flow, perhaps as "during immunosuppressive therapy, her condition deteriorated." In the Conclusion, "rises for DLE" could be rephrased, for example, "the escalating prevalence of DLE" or "the rising incidence of DLE," depending on the intended meaning. A thorough proofread for grammar and sentence structure throughout would be beneficial.

• Dear reviewer, thank you for these suggestions. Relevant changes have been made

Reviewer 3 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

Although much improved, I still think that the Introduction and Discussion are exceedingly long. I do understand, however, the authors conundrum as another reviewer suggest enlarging them whereas I suggested to shorten them.

Abbreviations are not used consistently. For example, SLE, DLE and CLE are noted early in the manuscript, but they are again written in full in later paragraphs. And it is not systemic lupus but systemic lupus erythematosus. This reflects lack of attention to detail by the authors

Finally, as I stated before, the tables with the laboratory data are unnecessary; presenting them in the text suffices. 

Comments on the Quality of English Language

Still deficient

Author Response

Reviewer 3:

Although much improved, I still think that the Introduction and Discussion are exceedingly long. I do understand, however, the authors conundrum as another reviewer suggest enlarging them whereas I suggested to shorten them.

• Dear reviewer, thank you for the feedback and understanding.

 

Abbreviations are not used consistently. For example, SLE, DLE and CLE are noted early in the manuscript, but they are again written in full in later paragraphs. And it is not systemic lupus but systemic lupus erythematosus. This reflects lack of attention to detail by the authors

• Dear reviewer, thank you for these comments. Relevant changes will be made to the text.

 

Finally, as I stated before, the tables with the laboratory data are unnecessary; presenting them in the text suffices.

• Dear reviewer, thank you for these comments. If allowed by the editor, the table will be removed, as the other reviewers have not stated intent for the tables in this round of review.

Round 2

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

The manuscript has been improved.

Author Response

The manuscript has been improved.

• Dear reviewer, thank you for these comments.

Reviewer 3 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

Dear authors

The revised version of your manuscript represents a substantial improvement over the earlier submissions, and I would like to acknowledge the quality of the work that you now present. The case is clearly described, and the differential diagnostic reasoning is well structured, demonstrating a thoughtful and clinically grounded approach. Importantly, the manuscript now benefits from an excellent set of clinical and histopathological images, which considerably strengthens the educational value and clarity of the report.

I commend the authors for expanding and refining the discussion, which now more appropriately contextualizes the case within the broader spectrum of potential diagnoses. The diagnostic possibilities are reviewed in a balanced and comprehensive manner, and the updated narrative enhances the coherence between the clinical findings, pathology, and final interpretation.

I have only a few minor recommendations for further optimization. First, I suggest increasing the display size of clinical Figures 1, 2, and 6, as the current resolution limits full appreciation of key morphological details. Enlarging these images would further enhance the didactic usefulness of the report. Second, regarding the description of the condition as a “great imitator,” this term should not be reserved solely for cutaneous lupus. Other diseases—such as syphilis, tuberculosis, and sarcoidosis—are also widely recognized as major mimickers. I therefore recommend rephrasing this as “one of the great imitators.” Finally, I would temper the emphasis placed on antiphospholipid antibody titers, which may be transiently elevated in infections or under certain treatments, and require confirmation at least 12 weeks apart to carry true clinical significance.

Overall, the manuscript is very close to being suitable for publication after these minor adjustments.

Author Response

Dear authors

 

The revised version of your manuscript represents a substantial improvement over the earlier submissions, and I would like to acknowledge the quality of the work that you now present. The case is clearly described, and the differential diagnostic reasoning is well structured, demonstrating a thoughtful and clinically grounded approach. Importantly, the manuscript now benefits from an excellent set of clinical and histopathological images, which considerably strengthens the educational value and clarity of the report.

• Dear reviewer, thank you for these kind comments.

 

I commend the authors for expanding and refining the discussion, which now more appropriately contextualizes the case within the broader spectrum of potential diagnoses. The diagnostic possibilities are reviewed in a balanced and comprehensive manner, and the updated narrative enhances the coherence between the clinical findings, pathology, and final interpretation.

• Dear reviewer, thank you for these comments.

 

I have only a few minor recommendations for further optimization. First, I suggest increasing the display size of clinical Figures 1, 2, and 6, as the current resolution limits full appreciation of key morphological details. Enlarging these images would further enhance the didactic usefulness of the report. Second, regarding the description of the condition as a “great imitator,” this term should not be reserved solely for cutaneous lupus. Other diseases—such as syphilis, tuberculosis, and sarcoidosis—are also widely recognized as major mimickers. I therefore recommend rephrasing this as “one of the great imitators.” Finally, I would temper the emphasis placed on antiphospholipid antibody titers, which may be transiently elevated in infections or under certain treatments, and require confirmation at least 12 weeks apart to carry true clinical significance.

• Dear reviewer, thank you for these suggestions. The figure size has been increased to the maximum allowed by the template without compromising resolution. The section regarding the great imitator has been expanded, as many diseases, not only inflammatory but also some tumors, fit within this description. Section on antiphospholipid syndrome has been expanded upon.

 

Overall, the manuscript is very close to being suitable for publication after these minor adjustments.

• Thank you for these encouraging comments.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The study highlights a case of complicated cutaneous lupus in a young woman. The research has been done nicely and merits publication.

1. Provide data about the epidemiology of this pathology in your country.
2. Any experience with treating discoid cutaneous lupus with intravenous immunoglobulins?
3. Refer to the immunopathology of it in detail.
4. Provide recent references to improve the overall manuscript.

Author Response

Reviewer 1:

The study highlights a case of complicated cutaneous lupus in a young woman. The research has been done nicely and merits publication.

• Dear reviewer, thank you for this kind comment.

 

Provide data about the epidemiology of this pathology in your country.

• Dear reviewer, such data is not available for our region. As such, the introduction section of the manuscript already states “In Bulgaria, there is a lack of accurate epidemiological data on the prevalence of DLE; however, clinical practice suggests the presence of a number of cases, which warrants increased attention among specialists in dermatology and general medicine”

Any experience with treating discoid cutaneous lupus with intravenous immunoglobulins?

• The authors are dermatologists and pathologists, involved in the diagnostic process of the condition and not its treatment, which, as per local legislature, falls strictly within the jurisdiction of rheumatology. In this aspect, we are sadly unable to respond to this query; furthermore, such data would be out of place and difficult to incorporate into the case report.

Refer to the immunopathology of it in detail.

• A relevant section has been added to the discussion part of the manuscript.

Provide recent references to improve the overall manuscript.

• Dear reviewer, out of the 21 references used in total, 11 are from the previous 10 years (52%), 6 are from the previous 20 years (29%), and four are older than 20 years (19%), making the references a list of an amalgamation of past and present without omitting older seminal works on the topic. As this is a single case report, artificially increasing the number of recent references will only add to the total number of works, without specifically adding value. If your request is specifically involves expanding a section that is not well-developed in its current form, please let us know, and we will implement further changes.

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting and well-prepared case report on cutaneous lupus with an intricate differential diagnosis. The manuscript is strengthened by the excellent iconography provided, both in terms of clinical images and histopathological findings, which significantly enhances the scientific value of the work. The discussion of the differential diagnosis is comprehensive and well-argued, highlighting the complexity of the case, particularly the important consideration of mycobacterial infection as a confounding factor.

However, there are certain aspects that should be improved for consistency and readability. Specifically, the manuscript text formatting requires attention, as there appear to be noticeable font size variations, particularly between Sections 2 and 3 (Discussion). Furthermore, the formatting of the laboratory values table should be adjusted to ensure clarity, uniformity, and alignment with journal standards. Addressing these issues will improve the overall presentation and professionalism of the article.

Recommendations to the Authors

1. Maintain the excellent use of clinical and pathological iconography, which is a clear strength of the manuscript.

2. Ensure uniform formatting of the text throughout the manuscript, with special attention to font size consistency, particularly between Sections 2 and 3.

3. Revise the formatting of the laboratory values table to improve clarity, readability, and adherence to the journal’s style guidelines.

4. Retain and emphasize the comprehensive discussion of the differential diagnosis, especially the consideration of mycobacterial infection, as it adds significant depth and clinical relevance to the report.

Author Response

Reviewer 2:

This is an interesting and well-prepared case report on cutaneous lupus with an intricate differential diagnosis. The manuscript is strengthened by the excellent iconography provided, both in terms of clinical images and histopathological findings, which significantly enhances the scientific value of the work. The discussion of the differential diagnosis is comprehensive and well-argued, highlighting the complexity of the case, particularly the important consideration of mycobacterial infection as a confounding factor.

• Dear reviewer, thank you for these comments.

 

However, there are certain aspects that should be improved for consistency and readability. Specifically, the manuscript text formatting requires attention, as there appear to be noticeable font size variations, particularly between Sections 2 and 3 (Discussion). Furthermore, the formatting of the laboratory values table should be adjusted to ensure clarity, uniformity, and alignment with journal standards. Addressing these issues will improve the overall presentation and professionalism of the article.

• Dear reviewer, thank you for these suggestions. Relevant changes will be made to the formatting of the text.

 

Recommendations to the Authors

 

Maintain the excellent use of clinical and pathological iconography, which is a clear strength of the manuscript.

• Thank you for this comment.

 

Ensure uniform formatting of the text throughout the manuscript, with special attention to font size consistency, particularly between Sections 2 and 3.

• Thank you for this comment. Changes have been incorporated in the text.

 

Revise the formatting of the laboratory values table to improve clarity, readability, and adherence to the journal’s style guidelines.

• Thank you for this comment. Changes have been incorporated in the text.

 

Retain and emphasize the comprehensive discussion of the differential diagnosis, especially the consideration of mycobacterial infection, as it adds significant depth and clinical relevance to the report.

• Dear reviewer, thank you for this comment. The discussion section will be expanded even further than this recommendation, as per the requests of other reviewers as well.

Reviewer 3 Report

Comments and Suggestions for Authors

Although this case of severe Discoid Lupus is of interest, the presentation is deficient. No data are provided as to whether there were clinical manifestations suggestive of systemic lupus from the outset and whether the patient met criteria for it, being that the EULAR/ACR or the SLICC criteria. In addition, standard methods of evaluating the patient in toto, such as the application of an activity index (such as the SLEDAI) and the damage index are lacking. Clearly, the input from Rheumatology is lacking in this presentation. In addition, please note that the write up is exceedingly long; it can be substantially summarized without compromising the intended message; this applies to the introduction and discussion sections of this manuscript. In addition, there is no need to present the laboratory data in a tabular format; text should suffice. 

Comments on the Quality of English Language

Could be improved

Author Response

Reviewer 3:

Although this case of severe Discoid Lupus is of interest, the presentation is deficient. No data are provided as to whether there were clinical manifestations suggestive of systemic lupus from the outset and whether the patient met criteria for it, being that the EULAR/ACR or the SLICC criteria. In addition, standard methods of evaluating the patient in toto, such as the application of an activity index (such as the SLEDAI) and the damage index are lacking. Clearly, the input from Rheumatology is lacking in this presentation. In addition, please note that the write up is exceedingly long; it can be substantially summarized without compromising the intended message; this applies to the introduction and discussion sections of this manuscript. In addition, there is no need to present the laboratory data in a tabular format; text should suffice.

• Dear reviewer, thank you for these comments.
• EULAR/ACR and SLICC criteria are used as a diagnostic algorithm for systemic lupus erythematosus only, as seen in the definition of discoid lupus and the introductory section of the manuscript, discoid lupus is a limited cutaneous condition. Hence, application to the criteria is impossible as per the criteria definition. The case description will be expanded with additional data to convince the reviewer that the condition is not systemic and these criteria are non-applicable.
• SLEDAI criteria are once again used only in systemic lupus and are not applicable to cutaneous forms, as seen in the presented case. The case description will be expanded with additional data to convince the reviewer that the condition is not systemic and these criteria are non-applicable.
• Furthermore, yes, the input from rheumatology may be lacking in the text; however, the text focuses on the diagnostic process and the patient's path. Prior to presenting to rheumatology for treatment, the patient needs to be diagnosed. As seen in the case description of the text, it is often a prolonged and complicated path due to misdiagnosis, with the goal of our manuscript being to raise awareness and underline conditions (as predominantly seen in the discussion) where cutaneous lupus needs to be considered.
• As other reviewers require expansion of the introduction and discussion sections of the manuscript, as well as reforming of the tables, we sadly cannot comply with this request.

Reviewer 4 Report

Comments and Suggestions for Authors

The main concern regarding this manuscript is the lack of novelty and clear scientific contribution. The report presents a rather vague and insufficiently defined clinical scenario, without offering new insights. Moreover, the investigations toward possible systemic lupus erythematosus are insufficiently detailed and not clearly presented, which limits the diagnostic reliability of the case. The diagnosis of antiphospholipid syndrome is also questionable, as the reported antibody titers are very low and there is no mention of any thrombotic events, which are essential for establishing the diagnosis according to current criteria. Also, the case outcome (development of tuberculosis) is mentioned abruptly, without clear linkage to the initial diagnosis or therapeutic implications.

Given these limitations, I suggest that the authors consider reformatting the submission as a brief “Medical Image” or “Interesting Image” report, as the provided clinical images appear specific and atypical and could be valuable in that format.

Author Response

Reviewer 4:

The main concern regarding this manuscript is the lack of novelty and clear scientific contribution. The report presents a rather vague and insufficiently defined clinical scenario, without offering new insights. Moreover, the investigations toward possible systemic lupus erythematosus are insufficiently detailed and not clearly presented, which limits the diagnostic reliability of the case. The diagnosis of antiphospholipid syndrome is also questionable, as the reported antibody titers are very low and there is no mention of any thrombotic events, which are essential for establishing the diagnosis according to current criteria. Also, the case outcome (development of tuberculosis) is mentioned abruptly, without clear linkage to the initial diagnosis or therapeutic implications.

 

Given these limitations, I suggest that the authors consider reformatting the submission as a brief “Medical Image” or “Interesting Image” report, as the provided clinical images appear specific and atypical and could be valuable in that format.

• Dear reviewer, thank you for these comments.
• We do not claim novelty with the presentation of the case, but rather present a rare form (manifestation) of a disease, which can be mimicked by many other conditions and as seen within the text, often misdiagnosed as well. Furthermore, as seen in the path of the patient, diagnosis is often not straightforward and a long and painful process for the patient.
• Case description will be expanded, as per some requests of the other reviewers, as well as to better underline that this is a chronic cutaneous form of lupus and not a systemic form of the disease.
• Data on antiphospholipid syndrome will also be expanded upon in the case presentation. No treatment was initiated based on the clinical condition of the patient, and the case report does not state that it was diagnosed, nor that there was a presence.
• The case presentation section regarding the development of treatment-related complications of a possible coexisting condition from the point of presentation will also be expanded upon.
• Regarding the last request, we would like to keep the case report nature of the report and are not sure is the Report accepts just case image type manuscripts. Furthermore, the other reviewers are requesting expansion of some aspects of the manuscript. We would also like some feedback from the respected editor on whether such a radical change of manuscript format would be acceptable.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have improved their work through revision.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors

 

After your changes, your work now is much better

 

Congratulations and good luck in your future projects

 

Kind regards

Author Response

Reviewer 3:
Rather than shortened the presentation of this case report, it is even longer. Input from rheumatology is lacking and such omission is poorly justified. The lab data is presented in a tabular format which is unnecessary (and was recommended against it). The entire manuscript needs to be reviewed by a Native English Speaker or a Professional Editing Service as the new paragraphs added to the manuscript are poorly worded.
- Dear reviewer, thank you for these comments. As seen in our previous point-by-point response, the "lack" of rheumatology input and the lack of the requested point-systems for evaluating lupus in not present in the manuscript because rheumatology scores are used to determine systemic lupus activity, while as the manuscript states in multiple places, discoid lupus is a localized cutaneous form and not a systemic form of lupus.
- At the same time, while requesting additional rheumatology and activity scores data that would not add to the manuscript, as the scores are 0 due to this being a skin-only type of lupus, the reviewer also asks for the manuscript to be shortened.
- English has once again been reviewed and corrected.

Reviewer 4:
In my opinion, the manuscript in its current form remains unsuitable for publication. As I mentioned earlier, I had suggested to the authors that they might consider reworking the submission into a more appropriate format, such as a medical image or a similar type of contribution.
- As with our response to the previous reviewer, we are unable to shorten the manuscript. Furthermore, we have already responded to this comment from the reviewer, stating that the decision to transform the manuscript into an “images in” type of manuscript lies solely with the respected journal editor, who have not signaled to us that such a transformation is possible.

We hope the performed changes are satisfactory and will allow our manuscript to be processed further.
We would also like to declare that, since the decision to reject and resubmit has been issued, the manuscript has not been published, nor is it currently under consideration elsewhere. All authors have read and agree with the changes and the submitted version of the manuscript.
With respect,
George S. Stoyanov, MD, PhD
Corresponding author
Sofia, Bulgaria
29.10.2025

       

Reviewer 3 Report

Comments and Suggestions for Authors

Rather than shortened the presentation of this case report, it is even longer. Input from rheumatology is lacking and such omission is poorly justified. The lab data is presented in a tabular format which is unnecessary (and was recommended against it). The entire manuscript needs to be reviewed by a Native English Speaker or a Professional Editing Service as the new paragraphs added to the manuscript are poorly worded.

Comments on the Quality of English Language

Already noted

Author Response

Reviewer 3:
Rather than shortened the presentation of this case report, it is even longer. Input from rheumatology is lacking and such omission is poorly justified. The lab data is presented in a tabular format which is unnecessary (and was recommended against it). The entire manuscript needs to be reviewed by a Native English Speaker or a Professional Editing Service as the new paragraphs added to the manuscript are poorly worded.
- Dear reviewer, thank you for these comments. As seen in our previous point-by-point response, the "lack" of rheumatology input and the lack of the requested point-systems for evaluating lupus in not present in the manuscript because rheumatology scores are used to determine systemic lupus activity, while as the manuscript states in multiple places, discoid lupus is a localized cutaneous form and not a systemic form of lupus.
- At the same time, while requesting additional rheumatology and activity scores data that would not add to the manuscript, as the scores are 0 due to this being a skin-only type of lupus, the reviewer also asks for the manuscript to be shortened.
- English has once again been reviewed and corrected.

Reviewer 4 Report

Comments and Suggestions for Authors In my opinion, the manuscript in its current form remains unsuitable for publication. As I mentioned earlier, I had suggested to the authors that they might consider reworking the submission into a more appropriate format, such as a medical image or a similar type of contribution.

Author Response

Reviewer 4:
In my opinion, the manuscript in its current form remains unsuitable for publication. As I mentioned earlier, I had suggested to the authors that they might consider reworking the submission into a more appropriate format, such as a medical image or a similar type of contribution.
- As with our response to the previous reviewer, we are unable to shorten the manuscript. Furthermore, we have already responded to this comment from the reviewer, stating that the decision to transform the manuscript into an “images in” type of manuscript lies solely with the respected journal editor, who have not signaled to us that such a transformation is possible.

We hope the performed changes are satisfactory and will allow our manuscript to be processed further.
We would also like to declare that, since the decision to reject and resubmit has been issued, the manuscript has not been published, nor is it currently under consideration elsewhere. All authors have read and agree with the changes and the submitted version of the manuscript.