PNTD-D-25-00614Hematological diseases-Related Mucormycosis: A Retrospective Single Center StudyPLOS Neglected Tropical Diseases Dear Dr. Wei, Thank you for submitting your manuscript to PLOS Neglected Tropical Diseases. After careful consideration, we feel that it has merit but does not fully meet PLOS Neglected Tropical Diseases's publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript within 30 days Sep 01 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosntds@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pntd/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: * A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers '. This file does not need to include responses to any formatting updates and technical items listed in the 'Journal Requirements' section below.* A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes '.* An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript '.

If you would like to make changes to your financial disclosure, competing interests statement, or data availability statement, please make these updates within the submission form at the time of resubmission. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Ahmed Hassan Fahal, FRCS, FRCSI, FRCSG, MS, MD, FRCP(London)

Academic EditorPLOS Neglected Tropical Diseases

Marcio Rodrigues

Section Editor

PLOS Neglected Tropical Diseases

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-4304-636XX

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-1765-0002

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Reviewers' comments:Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: Line 69: was culture and nGS performed on all patients included, if not what percentage had either and both?

Additionally, the concordance rate for microbiologic confirmed infection would also be of interest to the reader.

Reviewer #2: Methods appear valid.

Reviewer #3: 1) objectives are clearly stated and the study design matches the objectives

2)population is clearly describes.

3) as far as sample size is concerned, with only 46 patients, subgroup analyses (e.g., multivariate Cox regression for multiple variables) may be underpowered, increasing the risk of type II error. However, given the rarity of hematologic mucormycosis, the sample size is reasonable for a single-center retrospective study, though this limitation should be more explicitly discussed.

4) statistical analyses used is also appropriate

4) yes concerns regarding ethical or regulatory requirements are met

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Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: Given the focus on COVID-19 and the impact on steroid use and thereby assumption of the correlation with Mucor rate of rise, it would be informative to capture the frequency of patient flagged for steroid exposure who also had concomitant COVID-19 diagnosed.

Figure 1 cold benefit from alternative data presentation such as a heatmap

Reviewer #2: Analysis presented matches the analysis plan, and the results are clearly presented.

Reviewer #3: 1) Table 1 (Mucor strain distribution) and Table 2 (patient characteristics) are useful and well-structured, though Table 1 includes redundant rows (e.g., mixed strain listings that are unclear) — this could confuse readers and needs cleanup.

2) Table 3 (Cox analysis) is detailed and informative, but there are formatting inconsistencies — e.g., irregular column alignment and missing confidence intervals in some entries.

3) Consider expanding discussion on treatment efficacy outcomes to provide more clinical interpretation.

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Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: The authors provide convincing analysis of the regional drivers of Mucor infection in hematologic patients, noting high dose steroid exposure, advanced age, and multiple Mucor infections as clear drivers of increased mortality risk. As noted above, commentary about COVID-19 is made without evidence of infection in captured patient base, this may be related to regional access to testing at this time, but if testing was available as a standard of care, commentary on the association of this diagnosis with steroid exposure in these patients would be of interest to support the complications offered in the conclusion.

Reviewer #2: The conclusions are justified and supported by the data.

Reviewer #3: The discussion lightly touches on some known limitations — e.g., challenges in histopathological diagnosis, limitations of traditional culture methods, and the value of mNGS in such contexts.

However, key limitations are not explicitly acknowledged, such as:

Small sample size (n=46) and its implications for statistical power.

Single-center design and retrospective nature, which may limit generalizability.

Potential selection bias (e.g., inclusion only of patients who underwent mNGS).

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Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: I would encourage the authors to define nGS for the reader within the manuscript with first reference as well as in the abstract.

line 319 potentially unintended space between Mucor and mycosis.

Would review Table for unnecessary periods, and consider standard italicized nomenclature in the manuscript where appropriate

Figure 2 grpahic appears blurry in my editorial review sample. Would provide high resolution alternative.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: The authors provide a regional assessment of Mucor infection in hematologic patients with descriptive statistical approach to the demographics and epidemiology of invasive mucor. The key points made appear supported by the data offered. The manuscript could be strengthened by commentary on concordance rates where standard microbiology techniques and nGS were performed on the same patient to allow for assessment of the non-commercial nGS approach described as it relates to "traditional" mycology workflows.

Reviewer #2: The paper is a retrospective review that describes the clinical characteristics of 46 cases of Mucormycosis diagnosed at the Affiliated Cancer Hospital of Zhengzhou. Using regression analyses, the authors conclude that age greater than 60 years old, prolonged neutropenia (> 10 days), and having two or more Mucor infections were independent risk factors for reduced survival due to Mucormycosis.

While the findings of the paper appear valid, the overall sample size for Mucormycosis is somewhat small and the findings reinforce what is already generally well recognized for infections with fungi in the order Mucorales.

Reviewer #3: (No Response)

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes:  Syeda Ilsa Aaq

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Dear Doctor Wei,

We are pleased to inform you that your manuscript 'Hematological diseases-Related Mucormycosis: A Retrospective Single Center Study' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

Should you, your institution's press office or the journal office choose to press release your paper, you will automatically be opted out of early publication. We ask that you notify us now if you or your institution is planning to press release the article. All press must be co-ordinated with PLOS.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Ahmed Hassan Fahal, FRCS, FRCSI, FRCSG, MS, MD, FRCP(London)

Academic Editor

PLOS Neglected Tropical Diseases

Marcio Rodrigues

Section Editor

PLOS Neglected Tropical Diseases

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-4304-636XX

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-1765-0002

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