PLOS Neglected Tropical Diseases

Dear Dr. Tongsengkee,

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 by Jan 25 2026 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,

Felix Bongomin, MB ChB, MSc, MMed, FECMM

Academic Editor

PLOS Neglected Tropical Diseases

Joshua Nosanchuk

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

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

1) Please ensure that the CRediT author contributions listed for every co-author are completed accurately and in full.

At this stage, the following Authors/Authors require contributions: Sorawit Chittrakarn, Siripen Kanchanasuwan, Nattapat Sangkakul, and Nonthanat Tongsengkee. Please ensure that the full contributions of each author are acknowledged in the "Add/Edit/Remove Authors" section of our submission form.

The list of CRediT author contributions may be found here: https://journals.plos.org/plosntds/s/authorship#loc-author-contributions

2) We have noticed that you have uploaded Supporting Information files, but you have not included a list of legends. Please add a full list of legends for your Supporting Information files after the references list.

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: The authors report a case series of mycetoma in Thailand. The article is well-written and interesting. The results are relevant for these NTD. The statistical analysis is appropriate for the article.

No concerns noted regarding ethical or regulatory requirements.

Reviewer #2: The methodology is well described, although it acknowledges the limitations of a retrospective study.

Reviewer #3: As the authors mention, this is a pretty small sample size. The authors may choose to keep this article strictly descriptive and remove the statistical comparisons since the confidence intervals were so wide anyways

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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: Due to the sample size, the analysis and information on table 6 may be omitted.

Figure 2 could be deleted.

Reviewer #2: The presentation of the results could be improved. The tables could be better presented with the column containing the total number of cases in the rightmost column.

In Table 1, the rows containing the locations “Thigh”, “Buttock”, “Back”, “Perineum”, and “Abdominal Wall” do not need to be included in the table, since there were no cases of mycetoma of any type in these locations. Perhaps a note could be added to the legend.

Similarly, in Table 4, the rows referring to posaconazole and amikacin or gentamicin also do not need to be included in the table; it would suffice to note in the legend that no case used these medications.

Figure 2, which shows the overlap of diagnostic approaches, was not immediately clear: 21 patients underwent culture, but in the figure, the number 21 also identifies the 21 patients who underwent only histopathology, which can be confusing. Perhaps a stronger colored line could be added around the circles corresponding to the tests with numbers in the legend.

Reviewer #3: (No Response)

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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 conclusions and limitations are adequate. The authors also discuss potential ways to improve care.

Reviewer #2: The conclusions are based on the data presented and the limitations of the research are described. The authors highlight that the etiological profile of the disease identified in the country, different from other areas, may demand strategic control actions and differentiated therapies with great relevance to public health.

Reviewer #3: Lines 337-338: Is it necessary to identify to species level to guide therapy? In most settings, eumycetoma (for example) will be treated with itraconazole, regardless of causative fungus. While species level identication can be helpful, it may not be critical in managing a patient. Rather distinguishing between bacteria and fungi is vital.

Lines 360-361: Phialophora jeanselmei is just an older, updated name for Exophiala jeanselmei

Lines 383-385: The mycetoma belt incldues parts of central and south America in which other organisms other than M. mycetomatis almost predominate. Perhaps the authors should point out that the epi differs from high incidence areas on the African continent instead.

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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: Minor review.

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 manuscript is well-written.

Please include in the abstract the IQR ranges.

Please detail the culture media used in the center.

Please detail if any patients had a combination antibiotic or antifungal treatment.

Table 6 could be deleted.

Figure 2 could be deleted.

Reviewer #2: This is a relevant study that fills a knowledge gap regarding mycetoma in Southeast Asia, focusing on Thailand. Due to the rarity of the disease and its status as a Neglected Tropical Disease, prospective controlled studies are difficult to conduct. Within the methodological possibilities, the authors managed to extract important information, identifying the peculiar profile of the etiological agents in the country, which may contribute to new therapeutic approaches. The authors provided a good analysis of the research limitations. For these reasons, I would strongly recommend publication with minor adjustments to the presentation of the results.

Reviewer #3: Thank you for the opportunity to review this retrospective study on mycetoma in Southern Thailand. These data are critical to better understand the epidemiology this NTD in Southeast Asia. Some comments and thoughts below:

- Lines 78-79: While it could be unique regional patterns, it might also be due to gaps in reporting. Consider adding a note about publication bias.

- Lines 80-83: The authors mention eumycetoma causative agents from the large literature review, but what about actinomycetoma? Consider listing common agents from that review as well

- Lines 85: Is identification of causative agent essential? Or just etiology? Eumycetoma is likely to be treated the same regardless of causative fungi and same with actinomycetoma. The most important aspect is differentiating between fungi vs bacteria. Consider clarifying

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Dallas Smith

Figure resubmission:

While revising your submission, we strongly recommend that you use PLOS’s NAAS tool (https://ngplosjournals.pagemajik.ai/artanalysis) to test your figure files. NAAS can convert your figure files to the TIFF file type and meet basic requirements (such as print size, resolution), or provide you with a report on issues that do not meet our requirements and that NAAS cannot fix.

Reproducibility:

To enhance the reproducibility of your results, we recommend that authors of applicable studies deposit laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. Additionally, PLOS ONE offers an option to publish peer-reviewed clinical study protocols. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

Dear Mr Tongsengkee,

We are pleased to inform you that your manuscript 'Clinical presentation, etiology, and treatment outcomes of mycetoma: A 25-year retrospective study in Southern Thailand' 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,

Joshua Nosanchuk, MD

Section Editor

PLOS Neglected Tropical Diseases

Joshua Nosanchuk

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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