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PONE-D-23-06572Clinical Manifestations and Outcome of Patients with Primary Amoebic Meningoencephalitis in Pakistan. A Single Center ExperiencePLOS ONE

Dear Dr. Farooq,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’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.

==============================The reviewers have made comments that will improve this manuscript. I agree that adding information on the patient that survived would be wonderful since there are so few reports of PAM survivors.

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. The scientific name of Naegleria fowleri should be correctly addressed as italics through the manuscript.

2. IRB approval number should be clearly provided.

3. Table 1: GCS means Glasgow Coma Scale? If yes, please describe it clearly.

4. In Treatment: Why only 37 patients, not 39? Detailed description for one survivor would be interesting.

5. Were there any specific reasons to classify the patients into two groups, 18-35 and over 35 years old, by age?

6. Tables 3 and 4: The numbers of patients based on the classification could be included.

7. Table 4: Few values such as infarction, lepto enhance, and tonsil herniation in combined imaging results showed differences between the two groups, even though the number of patients were not high. 8. Discussion on the differences in the discussion section would be appreciated.

9. Line 155: Proper references should be added.

10. Considering the main points of this manuscript were the clinical features in PAM patients, discussion could be improved further by comparing the previously reported clinical features in Pakistan and other global areas.

11. English could be improved. English editing is recommended.

Reviewer #2: According to my expertise, this article fulfills all the requirements mentioned in the PLOSOne guidelines.

The researchers of the article have done a rigorous analysis on their sample population and provided with the results in written and table forms as well which makes it easier to comprehend.

The method and material portion upheld the ethical code and was approved by IRB.

However, there are few changes that I would like to suggest.

1.Out of these 39 patients only one patient who survived received all

105 these treatment for total of 24 days and was stopped by infectious disease team.

Suggestion a: Please mention the clinical criteria used by the infectious disease team to decide when to stop treatment for this patient. This information can provide further insight into prognostic factors and recovery criteria that can be used by doctors managing this disease in future.

Suggestion b: Kindly also mention any demographic or clinical presentation factors that differ between this patient and the other deceased patients, as the mortality rate of this disease is high. Elaborating on why this particular patient may have survived could help the medical community identify potential factors that contribute to better outcomes. This information could inform further studies that could hypothesize about the causal relationship between these factors and disease severity.

2.Efforts should be made at government level to improve living infrastructure in provision

of clean and safe chlorinated water to all and to improve healthcare facilities.

Suggestion: kindly provide a reference for the claim that chlorinated water can reduce the spread of Naegleria, and if so, how? This information could provide guidelines for the prevention of this infection. Alternatively, could you mention any already-published guidelines used by developed countries to prevent the spread of this disease?"

3.

Reviewer #3: First of all, I want to thank to all of the authors of the manuscript. This study needs to be revised with more detailed and proper written language.

Naegleria fowleri, the causative agent of primary amoebic meningoencephalitis (PAM), is a free-living amoeba. It is a water-borne infection usually detected in children and young people with healthy immune systems who swim, dive and perform activities in fresh and hot springs. It is an important study in terms of addressing the Clinical Symptoms and Outcomes of Patients with Primary Amoebic Meningoencephalitis in Pakistan. The points mentioned below need to be considered in more detail.

- "Naegleria fowleri" or "Naegleria" needs to be corrected in italics throughout the manuscript.

- -In line 56, it is stated that the transmission route of N. fowleri can not only be through contaminated water, such as swimming in freshwater lakes, rivers, canals, and swimming pools, but also "dry infection" with dust in the air. It would be better to mention this transmission route here.

- In line 93, it should also mention the decrease in consciousness about the clinical symptoms that are the backbone of the study.

- The term "GCS" is not mentioned anywhere in the manuscript.

- In line 102, the spelling of "2 gm/day" should be corrected.

- In line 104, explaining the drug treatment complex administered for a surviving patient in more detail would be more beneficial.

- It is interesting t that 27 patients were positive by microscopy, while only ten were positive by PCR. Besides, the PCR method is more sensitive and specific, and PCR results are essential in confirming the microscopy. It would be better if you could explain how you evaluate this situation.

- Cerebral edema is 66.7% in line 114 and 66.6% in the table; whichever is correct should be corrected.

- Looking at the table, tonsil herniation (23.1%) is among the most common ones.

- "While imaging results showed higher tendency of cerebral edema among female patients with frequency of 60.6% vs. 100.0%; p=0.081 for female and male patients, respectively" in line 122 This sentence should be reviewed. Because while 100% cerebral edema is seen in women in table 3, it is expressed as 60.6% in men.

- In the discussion section, the clinical symptoms of the patients and the treatment options given should be discussed in more detail. For example, it should be discussed compared to clinical symptoms and treatments in a single case (https://doi.org/10.1007/s11686-021-00514-0).

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Reviewer #1: No

Reviewer #2: Yes: Syeda Maria Hassan

Reviewer #3: Yes: Mehmet AYKUR

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Attachments

Attachment

Submitted filename: Reviewer Comments to Author_02.05.2023.docx

Clinical Manifestations and Outcome of Patients with Primary Amoebic Meningoencephalitis in Pakistan. A Single Center Experience

PONE-D-23-06572R1

Dear Dr. Farooq,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Kelli L. Barr, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: (No Response)

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: (No Response)

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: (No Response)

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Syeda Maria Hassan

Reviewer #3: Yes: Mehmet Aykur

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