Mucocutaneous Findings Highlighting Multisystem Inflammatory Syndrome in a Child Following SARS-CoV-2 Infection: A Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Manuscript presents a well-documented and clinically relevant case of multisystem inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection, with a particular emphasis on mucocutaneous manifestations. The clinical course, laboratory findings, management, and outcome are described in detail and are generally consistent with current diagnostic criteria and published literature.

The case is of interest, as mucocutaneous findings may serve as early diagnostic clues in MIS-C, and the authors appropriately highlight this aspect. The discussion is comprehensive and supported by relevant references.

However, several points could improve the clarity and overall quality of the manuscript:

Introduction

• 1st paragraph

The overview of MIS-C is appropriate; however, this paragraph could be slightly condensed, as epidemiology and post–SARS-CoV-2 timing are well established in the literature.

• 2nd paragraph

The description of mucocutaneous manifestations is relevant. The authors are encouraged to more clearly state the added value of this case compared with existing reports, particularly regarding severity, progression, or diagnostic challenges.

• Final paragraph

The aim of the case report could be stated more explicitly, for example by emphasizing early diagnostic recognition or differentiation from Kawasaki disease.

Case Presentation

• Οpening paragraph

The clinical presentation is clearly described; adding a brief timeline (e.g., days from symptom onset to PICU admission) would improve clarity.

• Paragraphs on neurological, respiratory, and cardiovascular findings

These findings are clinically important, but the sequence of deterioration would benefit from clearer chronological organization (initial presentation, clinical worsening, intensive care interventions).

• Table 1

Minor typographical errors and inconsistencies in units should be corrected.

Column headings (e.g., “3nd day”) should be revised, and laboratory terms such as Eritrosedimentation 1st h, Procalcitonine, Albumines, Presepsina, and Interleukne 6 should be corrected to standard English terminology.

Reference ranges should be checked for consistency.

Discussion

• 1st paragraph

This paragraph appropriately summarizes the MIS-C phenotype; minor language editing would improve flow.

• Laboratory findings and cardiac involvement

The discussion is well supported by the literature. Briefly contextualizing the severity of thrombocytopenia and shock relative to typical MIS-C presentations would strengthen this section.

• Differential diagnosis paragraph

The comparison with Kawasaki disease is appropriate; a concise statement highlighting the features favoring MIS-C would improve clarity.

• Final paragraph

The role of vaccination in reducing MIS-C incidence is well noted; linking this more directly to public health implications may enhance impact.

Overall, this is a solid case report that would be strengthened by major revisions aimed at improving clarity, structure, and presentation.

Comments on the Quality of English Language

Minor grammatical and stylistic issues are present throughout the manuscript (e.g. Table 1). Careful language editing by a fluent English speaker or professional editing service is recommended

Author Response

General Comment

Reviewer Comment:
The manuscript presents a well-documented and clinically relevant case of MIS-C following SARS-CoV-2 infection, with particular emphasis on mucocutaneous manifestations. However, several points could improve the clarity and overall quality of the manuscript.

Author Response:
We sincerely thank the reviewer for this positive and constructive evaluation. We have carefully revised the manuscript and addressed all comments in order to improve clarity, structure, and overall presentation.

 

Introduction

1st Paragraph

Reviewer Comment:
The overview of MIS-C is appropriate; however, this paragraph could be slightly condensed, as epidemiology and post–SARS-CoV-2 timing are well established in the literature.

Author Response: Pages 1, Paragraph 1, lines 39-43
We agree with this comment. The first paragraph of the Introduction has been condensed, with redundant epidemiological details and well-established post–SARS-CoV-2 timing information removed to improve conciseness.

 

2nd Paragraph

Reviewer Comment:
The description of mucocutaneous manifestations is relevant. The authors are encouraged to more clearly state the added value of this case compared with existing reports, particularly regarding severity, progression, or diagnostic challenges.

Author Response: Pages 2, Paragraph 2, lines 47-52
We appreciate this suggestion. The second paragraph has been revised to more clearly emphasize the added value of this case, particularly its severity, clinical progression, and the diagnostic challenges posed by the prominent mucocutaneous manifestations.

 

Final Paragraph

Reviewer Comment:
The aim of the case report could be stated more explicitly, for example by emphasizing early diagnostic recognition or differentiation from Kawasaki disease.

Author Response: Pages 2, Paragraph 4, lines 56-58
This point has been addressed by explicitly stating the aim of the case report, with emphasis on early diagnostic recognition and differentiation between MIS-C and Kawasaki disease.

 

Case Presentation

Opening Paragraph

Reviewer Comment:
The clinical presentation is clearly described; adding a brief timeline (e.g., days from symptom onset to PICU admission) would improve clarity.

Author Response: Pages 2, Paragraph 1, lines 60-65
We agree and have added a brief clinical timeline indicating the interval between symptom onset and PICU admission to improve clarity.

 

Neurological, Respiratory, and Cardiovascular Findings

Reviewer Comment:
These findings are clinically important, but the sequence of deterioration would benefit from clearer chronological organization.

Author Response: Pages 3, Paragraph 3, lines 72-81
The relevant sections have been reorganized to clearly reflect the chronological sequence of events, including initial presentation, clinical worsening, and subsequent intensive care interventions.

 

Table 1

Reviewer Comment:
Minor typographical errors and inconsistencies in units should be corrected. Column headings and laboratory terminology should be revised, and reference ranges checked.

Author Response: Pages 3, Paragraph 1, lines 83
Table 1 has been carefully revised. Typographical errors and unit inconsistencies have been corrected, column headings have been standardized, laboratory terms have been revised to standard English terminology, and all reference ranges have been checked for consistency.

 

Discussion

1st Paragraph

Reviewer Comment:
This paragraph appropriately summarizes the MIS-C phenotype; minor language editing would improve flow.

Author Response: Pages 4, Paragraph 1, lines 114-120
Minor language edits have been made to improve readability and flow while preserving the content of the paragraph.

 

Laboratory Findings and Cardiac Involvement

Reviewer Comment:
Briefly contextualizing the severity of thrombocytopenia and shock relative to typical MIS-C presentations would strengthen this section.

Author Response: Pages 4-5, Paragraph 1, lines 112-129
We have revised this section to contextualize the severity of thrombocytopenia and shock in comparison with typical MIS-C presentations reported in the literature, strengthening the clinical discussion.

 

Differential Diagnosis

Reviewer Comment:
A concise statement highlighting the features favoring MIS-C over Kawasaki disease would improve clarity.

Author Response: Pages 5, Paragraph 5, lines 145-152
A concise comparative statement has been added to clearly highlight the features supporting a diagnosis of MIS-C rather than Kawasaki disease.

 

Final Paragraph

Reviewer Comment:
Linking the role of vaccination in reducing MIS-C incidence more directly to public health implications may enhance impact.

Author Response: Pages 6, Paragraph 8, lines 162-168
The final paragraph has been revised to more explicitly link the protective role of vaccination against MIS-C with broader public health implications.

 

Closing Statement
We believe that these revisions have substantially improved the clarity, structure, and overall quality of the manuscript. We thank the reviewer for the insightful comments and valuable suggestions.

 

Reviewer 2 Report

Comments and Suggestions for Authors

This report presents a severe case of multisystem inflammatory syndrome in children (MIS-C) due to SARS-CoV-2 infection, highlighting prominent mucocutaneous findings as early diagnostic clues. The clinical presentation such as shock, myocardial dysfunction, severe thrombocytopenia, and markedly elevated inflammatory parameters are well-characterized and in line with previous descriptions of severe MIS-C phenotypes. The favorable response to IVIg and systemic corticosteroids also supports the diagnosis, and is consistent with the established standard management. The novelty of the case is limited, but the education it imparts is noteworthy. The manuscript requires greater consideration of distinguishing MIS-C from Kawasaki disease, as well as a brief contextual treatment of the frequency of cardiac involvement and the immunopathological correlates of MIS-C. In addition, there is a minor limitation in its lack of information on vaccination status and on circulating viral variants.

Author Response

 

Reviewer Comment: This report presents a severe case of multisystem inflammatory syndrome in children (MIS-C) due to SARS-CoV-2 infection, highlighting prominent mucocutaneous findings as early diagnostic clues. The clinical presentation such as shock, myocardial dysfunction, severe thrombocytopenia, and markedly elevated inflammatory parameters are well-characterized and in line with previous descriptions of severe MIS-C phenotypes. The favorable response to IVIg and systemic corticosteroids also supports the diagnosis, and is consistent with the established standard management. The novelty of the case is limited, but the education it imparts is noteworthy. The manuscript requires greater consideration of distinguishing MIS-C from Kawasaki disease, as well as a brief contextual treatment of the frequency of cardiac involvement and the immunopathological correlates of MIS-C. In addition, there is a minor limitation in its lack of information on vaccination status and on circulating viral variants.

Closing Statement
We believe that these revisions have substantially improved the clarity, structure, and overall quality of the manuscript. We thank the reviewer for the insightful comments and valuable suggestions.

We thank the reviewer for the thoughtful and constructive comments. In response, we have revised the manuscript to more clearly distinguish MIS-C from Kawasaki disease by emphasizing key clinical, laboratory, and demographic features favoring MIS-C ( Pages 5, Paragraph 3, lines 157-162 ). We have also added a brief contextual discussion on the frequency of cardiac involvement in MIS-C, supported by relevant literature, and expanded the discussion to include immunopathological correlates of the syndrome. In addition, we have clarified the patient’s COVID-19 vaccination status and acknowledged the absence of data on circulating viral variants as a minor limitation. We believe these revisions improve the clarity, completeness, and educational value of the manuscript ages. Paragraph 7, lines 181

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have satisfactorily addressed all the reviewer’s comments. The Introduction is now more concise and focused, the clinical timeline is clearer, and the discussion provides better contextualization of thrombocytopenia, shock, and cardiac involvement in MIS-C. The differential diagnosis versus Kawasaki disease is well articulated, and the public health relevance of vaccination is appropriately emphasized. Overall, the manuscript has improved in clarity, structure, and scientific presentation and is suitable for publication in its current form.