A prospective, multicenter study of invasive fungal disease caused by molds in children and adults in Chile

Ricardo Rabagliati; Dona Benadof; Luis Thompson; Patricia Garcia; Tamara Gonzalez; Cecilia Vizcaya; Andres Soto; Catalina Gutierrez; Lorena Rodriguez; Yenis Labraña; Cecilia Tapia; Marcela Zubieta; Martin Lasso; Valentina Gutierrez; Veronica Contardo; Yocelyn Castillo; Karen Ducasse; Mario Calvo; Romina Valenzuela; Maria Elena Santolaya; on behalf of the Chilean Invasive Mycosis Network

doi:10.1371/journal.pone.0330426

Peer Review History

Original SubmissionJune 17, 2024
8 Aug 2024 Decision Letter - Nosheen Nasir, Editor Dear Dr. Rabagliati, 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. Please submit your revised manuscript by Sep 22 2024 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 plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Nosheen Nasir Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Additional Editor Comments (if provided): [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Invasive mold disease (IMD) is a severe complication which affects immunocompromised and immunocompetent patients. In this manuscript, the authors have investigated the epidemiological and clinical features of IMD in patients specifically from Chile between the time period of 2019 to 2021. Some suggestions regarding improving or modifying the manuscript is as follows : 1. Page 4: Please re write the abstract since it seems rather disconnected and abrupt. 2. Page 4: In the abstract, the words "The objective" is in italics. 3. Page 4: In the results --What is immunosuppression in the pediatric group, the result of? 4. Page 8: Could you explain in detail what the patient conditions were, for data analysis? 5. The numerical data is not consistent throughout the paper --in some places the numbers are given as digits and in other places, the numbers are spelt out. 6. Please provide the full forms of all the abbreviations mentioned. 7. Have you looked into Crytococcosis, considering that WHO has mentioned it as an emerging disease? Reviewer #2: Report on Review of "A prospective, multicenter study of invasive fungal disease caused by molds in children and adults in Chile" The submitted manuscript offers valuable insights into the epidemiology of IMDs in Chile. However, there are several areas where the manuscript could be improved to enhance clarity and comprehensiveness. Terminology: The authors should consistently use the plural form "Invasive mold diseases (IMDs)" throughout the manuscript, as IMDs encompass a broad spectrum of diseases caused by various mold species. Study Design: -Please clarify the composition of the control group in this prospective observational study. How were the control subjects selected and compared to the case group? -A detailed description of the inclusion and exclusion criteria for both groups would strengthen the study design. Methodology: -A more comprehensive description of the sample collection, processing, and culture techniques is needed. -The rationale for limiting antifungal susceptibility testing to Aspergillus Spp. should be explained. Results: -The clinical manifestations of IMDs should be presented separately for each type of infection to provide a clearer understanding of the disease spectrum. -The specific molecular technique used for the identification of mold species should be stated. -The results for children and adults should be presented separately, especially for the proven, probable, and possible categories. -A more detailed analysis of the antifungal treatment regimens would be beneficial. For each disease, please specify which antifungal agents were used and for what duration. Discussion: Although the manuscript centers on IMDs, it disproportionately emphasizes Aspergillus. The data, however, indicates that fusariosis and mucormycosis are prevalent infections among pediatric and adult populations. The discussion should give more weight to these findings and their implications for clinical management. ****** 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 #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. 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Revision 1
21 Feb 2025 Author Response RESPONSE TO REVIEWERS Dr. Nosheen Nasir Academic Editor PLOS ONE Dear Dr Nasir. Thank you for your letter referring to the revision of our manuscript PONE-D-24-19295. We also thank the reviewers for their diligent revision and comments that will certainly improve the manuscript. We will address the reviewer comments one by one, pointing out when changes to the original manuscript were made following the reviewers’ suggestions. Reviewers' comments: Reviewer #1: Invasive mold disease (IMD) is a severe complication which affects immunocompromised and immunocompetent patients. In this manuscript, the authors have investigated the epidemiological and clinical features of IMD in patients specifically from Chile between the time period of 2019 to 2021. Some suggestions regarding improving or modifying the manuscript is as follows: 1. Page 4: Please re write the abstract since it seems rather disconnected and abrupt. Response. We re wrote the manuscript in a more comprehensive manner. 2. Page 4: In the abstract, the words "The objective" is in italics. Response. We delete the italics 3. Page 4: In the results --What is immunosuppression in the pediatric group, the result of? Response. Thanks for this suggestion. We change the term immunosuppression by the following phrase in the abstract: Cancer, neutropenia and hematopoietic cell transplantation were the most frequently associated conditions in the pediatric group, and we added the same information in the Results section (page 12) 4. Page 8: Could you explain in detail what the patient conditions were, for data analysis? Response. The immunosuppression-related conditions were cancer, neutropenia and HCT, as was explained in the abstract and results. 5. The numerical data is not consistent throughout the paper --in some places the numbers are given as digits and in other places, the numbers are spelt out. Response. We change all numbers to digits, with the exception of numbers that are at the beginning of a paragraph or immediately after a period. 6. Please provide the full forms of all the abbreviations mentioned. Response. The full forms were provided previous to abbreviations throughout the manuscript 7. Have you looked into Crytococcosis, considering that WHO has mentioned it as an emerging disease? Response. Thanks for this suggestion. We don’t inform about Cryptococcus because this paper aimed to describe infections caused by molds, not yeasts. Reviewer #2: Report on Review of "A prospective, multicenter study of invasive fungal disease caused by molds in children and adults in Chile" The submitted manuscript offers valuable insights into the epidemiology of IMDs in Chile. However, there are several areas where the manuscript could be improved to enhance clarity and comprehensiveness. 1.Terminology: The authors should consistently use the plural form "Invasive mold diseases (IMDs)" throughout the manuscript, as IMDs encompass a broad spectrum of diseases caused by various mold species. Response. We changed IMD to IMDs throughout the manuscript 2.Study Design: Please clarify the composition of the control group in this prospective observational study. How were the control subjects selected and compared to the case group? Response. This study only included IMDs cases. Controls were not included 3. A detailed description of the inclusion and exclusion criteria for both groups would strengthen the study design. Response. We incorporated a IMD case definition in the Patients and methods section, to better describe the cases included (Page 10) 4. Methodology: A more comprehensive the sample description of collection, processing, and culture techniques is needed.-The rationale for limiting antifungal susceptibility testing to Aspergillus Spp. should be explained. Response. Thanks for these important suggestions. We improve the Laboratory procedures paragraph including collection, culture, identification (Page 9-10), and the explanation that not all the Aspergillus strains were viable for the susceptibility test (Page 17), also we include a commentary that it is a limitation of our study (Page 24) 5. Results: The clinical manifestations of IMDs should be presented separately for each type of infection to provide a clearer understanding of the disease spectrum. Response. Thanks again for the commentary. We include a new table (Table 3) with more information about the clinical manifestation in aspergillosis, mucormycosis and fusariosis cases, describing in the manuscript the more relevant clinical differences among them (Page 15) 6. The specific molecular technique used for the identification of mold species should be stated. Response. We include these specifications 7. The results for children and adults should be presented separately, especially for the proven, probable, and possible categories. Response. The outcomes for children and adults, in general and for aspergillosis, mucormycosis and fusariosis are detailed in Table 5 8. A more detailed analysis of the antifungal treatment regimens would be beneficial. For each disease, please specify which antifungal agents were used and for what duration. Response. We include these data, in special we include the antifungal therapy for aspergillosis, mucormycosis and fusariosis. (Page 18) 9. Discussion: Although the manuscript centers on IMDs, it disproportionately emphasizes Aspergillus. The data, however, indicates that fusariosis and mucormycosis are prevalent infections among pediatric and adult populations. The discussion should give more weight to these findings and their implications for clinical management. Response. Thanks for this suggestion. We consider that inclusion of clinical manifestations and therapy in the results section (Commentaries 5 & 8), we answer this comment. In addition, we include in the discussion to consider the differential diagnosis of IMD in the clinical approach and therapeutic decision-making process (Page 19-20). We truly hope that our responses to the reviewers and the modifications made to our manuscript make our paper suitable for publication in your Journal. Sincerely yours, Ricardo Rabagliati Attachments Attachment Submitted filename: Response to Reviewers Feb 2025.docx https://doi.org/10.1371/journal.pone.0330426.r002
27 May 2025 Decision Letter - Nosheen Nasir, Editor Dear Dr. Rabagliati, 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. ACADEMIC EDITOR: Please address reviewer comments. Please submit your revised manuscript by Jul 11 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 plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Nosheen Nasir Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #3: (No Response) Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #3: Partly Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #3: No Reviewer #4: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Yes ****** Reviewer #1: (No Response) Reviewer #3: Rabagliati and colleagues collected data from over 100 pediatric and adult patients across 11 hospitals in Chile to expand the understanding of invasive mold disease (IMD) in the region. This study helps address the current gap in data regarding the severity and characteristics of IMD in Chile. That said, I have a few comments: Major comments: 1. Missing methods: 1.1 The conditions under which “fungal culture” was performed should be clearly described. 1.2 The source (commercial or in-house) for the “lactophenol blue stain” should be specified. 1.3 More detailed information should be provided regarding the “tube protein extraction method.” 2. The authors list the percentages of various diseases or infections among the patient cohort. It would add value to conduct hypergeometric tests comparing these frequencies to those of all hospital admissions, to determine whether these conditions are significantly enriched or associated with IMD cases. 3. In discussion: 3.1 In the sentence, “We interpreted that the frequency of fusariosis… poorly controlled diabetes in this group,” a mechanistic explanation would strengthen the argument. Providing a biological or pathophysiological basis for the association would be more informative. 3.2 The statement, “The high frequency of viral pneumonia should be highlighted… in the adult population,” would benefit from a statistical test (e.g., hypergeometric test) to assess whether this frequency is significantly associated with IMD. Since the focus of the study is on IMD, such analysis would better support the relevance of this observation. Reviewer #4: This curret study provides readers with a vivid analysis and description of real-world data on invasive fungal infections in both adults and children in Chile. The study holds significant academic value and merits publication in PLOS ONE. However, certain aspects of the manuscript warrant further discussion and refinement. 1. What are the clinical implications of statistically comparing age-related differences between adult and pediatric populations? 2. Based on the statistical results of the length of stay parameter in table 4, the median and interquartile range (IQR)might be the more appropriate choices. 3. why so few of BDG test were performed in the current study� 4. Why there are so many letter “a” in table 3 ? 5. �Page 10 ,line 1st � Please describe the diagnostic criteria for fungal infections in detail within the text, rather than simply citing references. ****** 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 #1: No Reviewer #3: No Reviewer #4: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: review opinion.docx https://doi.org/10.1371/journal.pone.0330426.r003
Revision 2
10 Jul 2025 Author Response Dear Dr. Nasir, Thank you for accepting to review once again our manuscript entitled: "A prospective, multicenter study of invasive fungal disease caused by molds in children and adults in Chile." We greatly appreciate the insightful comments and suggestions provided by the four reviewers, which have helped us improve the quality of our manuscript. Below, we provide our detailed responses to the reviewers’ major comments: Major Comments 1. Missing Methods 1.1 Fungal culture conditions Reviewer comment: The conditions under which “fungal culture” was performed should be clearly described. Response: We have added more detail to the Methods section: “Fungal cultures were incubated at 30 °C on plates containing 2% Sabouraud dextrose agar and potato dextrose agar (Merck®, Germany). Incubation was maintained for up to 30 days, with daily macroscopic evaluations to monitor fungal growth and morphological characteristics.” (Page 8) 1.2 Source of lactophenol blue stain Reviewer comment: The source (commercial or in-house) for the “lactophenol blue stain” should be specified. Response: We clarified that the stain was commercially sourced: “Microscopic observation was performed using commercial lactophenol cotton blue stain (Merck®, Germany), applied between a slide and coverslip, and examined under light microscopy at 40X magnification.” (Page 8) 1.3 Tube protein extraction method Reviewer comment: More detailed information should be provided regarding the “tube protein extraction method.” Response: We included the following clarification: “Protein extraction was performed following the Bruker protocol for filamentous fungi, with minor modifications.” (Page 8) 2. Statistical comparison of disease frequencies Reviewer comment: Consider conducting hypergeometric tests comparing disease frequencies to hospital admission data. Response: We fully agree that this analysis would add value. However, data on the total number of patients with each condition (e.g., diabetes, leukemia, transplantation, etc.) at each participating hospital were not collected as part of the study design and are currently unavailable. We have acknowledged this limitation in the Discussion section and will consider including such data in future epidemiological studies. (Page 24) 3. Discussion 3.1 Mechanistic explanation for fusariosis and diabetes Reviewer comment: Provide a biological or pathophysiological explanation for the observed associations. Response: We expanded the discussion to include epidemiological associations between fusariosis and neutropenia, and between mucormycosis and poorly controlled diabetes. We also added a new reference to support the association of fusariosis in pediatric patients. (Pages 19–20) 3.2 Statistical support for viral pneumonia frequency Reviewer comment: Consider statistical testing to assess the significance of viral pneumonia frequency. Response: As mentioned above, we lack comprehensive data on viral pneumonia cases across all centers. We have acknowledged this limitation in the Discussion and emphasized the need to address it in future studies. (Page 24) Reviewer #4 Comments 1. Clinical implications of age-related differences Response: We aimed to explore differences between pediatric and adult populations and identified variations in associated conditions, fungal species, and survival rates. These findings support the need for age-specific diagnostic and therapeutic approaches. 2. Length of stay – statistical reporting Response: We have updated Table 4 to include the median and interquartile range (IQR) for the length of stay variable. 3. Limited use of BDG testing Response: BDG testing was not part of the standard diagnostic protocol and was only performed upon specific request by the treating team. We clarified this in the Methods (Page 9) and Results sections (Page 14). 4. Table 3 formatting – letter “a” Response: We reviewed Table 3 and removed any unintended symbols or formatting artifacts that may have appeared as the letter “a.” 5. Diagnostic criteria description Response: We expanded the description of the diagnostic criteria for fungal infections in the Methods section, rather than relying solely on references. (Page 10) We hope that the revised manuscript and our responses adequately address the reviewers’ concerns. We sincerely thank you and the reviewers for your valuable feedback and consideration. Sincerely, Dr. Ricardo Rabagliati Corresponding Author Attachments Attachment Submitted filename: Response_to_Reviewers_Feb_2025_auresp_2.docx https://doi.org/10.1371/journal.pone.0330426.r004
1 Aug 2025 Decision Letter - Nosheen Nasir, Editor A prospective, multicenter study of invasive fungal disease caused by molds in children and adults in Chile PONE-D-24-19295R2 Dear Dr. Rabagliati, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Nosheen Nasir Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0330426.r005
Formally Accepted
Acceptance Letter - Nosheen Nasir, Editor PONE-D-24-19295R2 PLOS ONE Dear Dr. Rabagliati, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Nosheen Nasir Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0330426.r006

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