Detection of SARS-CoV-2 in Ascitic Fluid of Cirrhotic COVID-19 Patients: Case Series and Literature Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Caci G. and colleagues report three cases of cirrhotic patients with COVID-19 who tested positive for SARS-CoV-2 in ascitic fluid and review the existing scientific literature on the topic.

While the subject is not novel, as several case reports and literature reviews have already been published, the relatively recent emergence of COVID-19 makes these cases valuable. They provide an opportunity to reassess data collected during the pandemic and draw more concrete conclusions regarding the clinical presentation and outcomes of SARS-CoV-2 infection.

However, the study's main limitation is the lack of adequate context for the case reports. The introduction and discussion are somewhat unclear and difficult to follow. Given that all reported cases involve patients with chronic liver disease, I recommend structuring the introduction and discussion to focus specifically on the relationship between SARS-CoV-2 infection and liver disease.

Additionally, the references are redundant and should be streamlined.

 

Comments on the Quality of English Language

The English could be improved.

Author Response

We thank the Reviewer for the insightful comments that helped us improve our paper.

We have rewritten the introduction and discussion to provide an adequate context for the case reports. We focused the discussion to better explain the relationship between SARS-CoV-2 infection and liver disease.

We also added a table to provide the reader with an immediate and clear summary of every study assessing SARS-CoV-2 detection in peritoneal and abdominal samples.

We have updated our references accordingly.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

The study presents an interesting case series of three cirrhotic COVID-19 patients with SARS-CoV-2 detected in ascitic fluid, alongside a review of the literature on the presence and clinical significance of the virus in peritoneal fluid. The topic is clinically relevant, particularly given the potential implications for disease progression, patient management, and healthcare worker safety. However, I have several suggestions to improve the clarity, rigor, and impact of the manuscript listed below as major and minor revisions:

Major Revisions:

Expand the literature review:

1. Conduct a more systematic review of the literature to identify all reported cases of SARS-CoV-2 in peritoneal/ascitic fluid. This will provide a stronger foundation for your discussion and help contextualize your findings.
2. Include a table summarizing previous studies (e.g., sample size, patient characteristics, methods, and results) to highlight the novelty of your case series.

Clarify the methodology:

Provide more details on the RT-PCR protocol used for SARS-CoV-2 detection in ascitic fluid, including the limit of detection, validation, and whether the assay was optimized for this type of sample.

Strengthen the discussion:

1. Discuss potential mechanisms by which SARS-CoV-2 reaches the peritoneal cavity (e.g., hematogenous spread, lymphatic drainage, or direct viral shedding from the gastrointestinal tract).

1. Address conflicting findings in the literature (e.g., studies reporting negative results for SARS-CoV-2 in peritoneal fluid) and propose explanations for these discrepancies.

Include imaging or pathological findings:

If available, add radiological (e.g., CT or ultrasound images) or pathological findings (e.g., histopathology of liver or peritoneal tissue) to support your observations.

Minor Revisions:

Title: Revise the title to better reflect the focus of the study. For example: "Detection of SARS-CoV-2 in Ascitic Fluid of Cirrhotic COVID-19 Patients: A Case Series and Literature Review."

Abstract:

Make the abstract more concise and avoid repetition (e.g., "peritonitis" is mentioned twice in the keywords). Include a brief statement on the clinical significance of your findings.

Introduction:

Add a sentence or two about the significance of studying SARS-CoV-2 in cirrhotic patients, given their increased risk of severe COVID-19.

Case descriptions:

Streamline the case descriptions to focus on the most relevant clinical details and avoid redundancy (e.g., repeated mentions of comorbidities and medications). Include more information on the timeline of SARS-CoV-2 detection in nasopharyngeal swabs versus peritoneal fluid.

Discussion:

Add a paragraph discussing the potential role of the gut-liver axis in SARS-CoV-2 dissemination to the peritoneal cavity. Discuss whether the presence of SARS-CoV-2 in peritoneal fluid could be a marker of disease severity or a predictor of poor outcomes.

Conclusion:

Avoid speculative statements and focus on the evidence from your case series. Suggest specific areas for future research (e.g., larger cohort studies, mechanistic studies on viral dissemination).

By addressing above cited major and minor revisions, the authors can significantly enhance the quality, clarity, and impact of their paper.

Comments on the Quality of English Language

The English language quality of the manuscript is generally good, but minor improvements are needed. Grammatical errors (e.g., "the pathogens was named") and overly complex sentences should be revised for clarity. Repetition, such as redundant terms in keywords and case descriptions, should be streamlined. Ensure consistent terminology and define abbreviations at first use. Some phrases could be more formal and precise, particularly in the conclusion. Proofreading by a native English speaker or professional editor is recommended to enhance readability and polish the language. Overall, the manuscript is well-written but would benefit from these refinements.

Author Response

Please find our point by point response to your insightful comments that helped us improving our paper in attachments.

Kind regards

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors satisfactorily addressed all points. In this version the paper is substantially improved.    

Reviewer 2 Report

Comments and Suggestions for Authors

N/A