IgG4-Related Disease (IgG4-RD) with Unique Combined Generalized Skin Rashes and Biliary Tract Manifestation: A Comprehensive Immunological Analysis
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
- The authors present an interesting case of IgG4-related disease with skin and billiary tract manifestations, with a comprehensive characterization of the inflammatory infiltrate, namely of the lymphocyte subsets.
- The word "pain" is missing from the sentence "male who presented with fever and right upper quadrant...."
- The description of the skin lesions should be more detailed in the text and/or in the figure legends (the type of lesions, their distribution, symmetry, etc)
- The histopathological picture 2C should have a higher magnification to better appreciate the composition of the infiltrate.
- Was any fibrosis detected on the skin biopsy?
Comments on the Quality of English Language
English language is good. Just minor corrections of typos are needed.
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for Authors
You have provided a unique and interesting case of IgG4 related disease with an extensive review of the immunophenotype of the infiltrate, which has not been reported before.
It would be helpful to educate the reader a little more about IgG4RD in the introduction. What is the typical dermatologic presentation (eg, commonly associated with salivary or parotid involvement). How is it diagnosed? What are the typical histopathologic findings? I would include the criteria for this condition in the introduction – you can consider using this reference: Umehara H, et al.; Research Program for Intractable Disease by the Ministry of Health, Labor and Welfare (MHLW) Japan.. The 2020 revised comprehensive diagnostic (RCD) criteria for IgG4-RD. Mod Rheumatol. 2021 May;31(3):529-533. I would also make sure that you have supplied enough information in your manuscript for the reader to confirm this diagnosis. From the data you have provided in your results, I do not think you have supplied enough information to confirm the diagnosis of IgG4-RD.
You say that there is a predominant infiltration of plasma cells, yet you are looking at the lymphocyte population. I see that in the discussion, you have included some information on prior literature on lymphocyte subsets and potential relationship with IgG4RD or plasma cells, but it would be helpful to give some brief background for the reader in the introduction regarding how the lymphocyte population is potentially related to the plasma cell infiltration, so he/she can understand why you have chosen pursue such an extensive evaluation of the lymphocyte population.
I have some additional comments below. Of note, there are many grammatical errors, some of which I have commented on below. The manuscript should be proof-read carefully for such errors:
Abstract:
Line 15: “…pruritic rashes”: I would replace the word rashes with eruption. I also suggest giving some specific findings for the reader who only has access to the abstract
Line 20-21: “…Skin punch biopsy showed lymphoplasmacytic infiltrates. with a 67% ratio of IgG4+:IgG+ plasma cells”: remove period after infiltrates
Introduction:
Line 42 : “There are limited studies on lymphocyte subsets in patients with IgG4-RD” : please supply a reference for studies that have been published
Material and Methods:
Line 54: age- and gender-matched healthy control. I believe you only had one control, so I would put “an” before “age”
Line 55-56: “Patient is a 55 years-old Korean male who presented with fever and right upper quadrant…”: please add “The” before patient. And the sentence is confusing-- right upper quadrant what? Pain? Tenderness? Please clarify.
Line 58: “he also reported a generalized macular pruritic rash” please give more details about the clinical presentation. You have given the complaint of the rash but not the physical examination or history. Distribution? Morphology? It looks like there were erythematous patches as well as post-inflammatory hyperpigmentation
Line 62:” Patient was treated with steroids…”: please add “The” before patient. And please clarify what type of steroid—oral, IV, topical?
Line 62-63:”… and normalization of serum IgG4 (from 448mg/dl to /dl).”: what was the level of IgG4 after improvement? This number is left blank.
Line 85 under flow cytometry: fix should be fixed
Line 89: “All fluorescence minus one controls…” controls should be singular (no ‘s’)if there is only one
Line 105:” Following cell surface markers…” put “The” before following
You have included referenced information in the method section. I suggest moving this educational information to the introduction, if the intention is to provide background information for the antibodies you discuss in the methods section.
Results
Line 117: “Skin punch biopsy and ampulla biopsy specimen were subjected to histological and
immunostaining examination.”: This is part of the methodology, so delete this line in the results section.
Figure 2A: the figure is sideways and needs to be rotated upright (clockwise rotation)
In general, the results should be reported separate from the figure legends and not bundled together in the result section (but I will defer to the editorial team for the format of this check this ***)
Figure 2 legend:” showed a dense perivascular (B) and periadnexal (C) lymphoplasmacytic infiltrates with eosinophils throughout the dermis and involving the subcutis. IgG4/IgG positive plasma cell ratio was 67% ratio (D, arrow).”: The legend does not describe what is on the image. The infiltrate is not dense and it is not present throughout the dermis, nor is there subcutis present on the image to highlight the subcutaneous involvement. It is not possible to discern the plasma cells and eosinophils on the magnification in the images. You also need to state the magnification of the photomicrographs. For image D, what immunostain is this? And how does this demonstrate the percentage of IgG4 with only one image? Please redo the legends in a way that demonstrates what is on the figures. I suggest including a high power image to demonstrate the plasma cells. and also include a photo that better demonstrates the increased IgG4 and IgG ratio. I suggest showing side-by-side images of IgG and IgG4 so the reader can confirm the ratio.
Figure 3: “Figure 3 shows ampullary tissue with focal mildly active chronic inflammation and mild reactive changes…” . Can you be more specific about the inflammatory infiltrate instead of saying active chronic inflammation? Was it mostly plasma cells? The infiltrate also appears to be diffuse, not focal, and not necessarily mild. What do you mean by reactive changes? Fibrosis? Edema? Please include the magnification and the stains in the figure legends. Are C and D showing the same thing? If so, I would eliminate one and replace it with a high power view of the infiltrate.
Figure 4A: Line 129-30: “show” needs an “s” if figure is plural and in the figure, you have the patient labeled CD Treg, but perhaps this should be CD4 Treg.
When you are reporting the results of the immunophenotyping of the lymphocytes, can you please indicate if the difference between the patient and control is significant. Additionally, it is not possible to accurately assess the relevance of the comparison, since there is only 1 control, so this needs to be discussed as a limitation of this study.
Discussion
In the first line, 158: you have not established that the skin eruption is IgG4RD with certainty.
In lines 160-163, you discuss pancreatitis as if it was a typical or classic association with IgG4RD, but you have not stressed this presentation in the introduction when you described this condition. I would leave this part out or include chronic pancreatitis as one of the common visceral presentations.
I suggest giving a differential discussion of your patient’s skin eruption (eg cutaneous lymphoid hyperplasia, marginal zone lymphoma,) and of IgG4RD in general
Conclusion
“ and associated with”: there should be an “is” between ‘and’ and ‘associated’
“…IgG4-RD are associated with alterations in phenotypically characterized subsets of…”: should “is” replace “are”? or are you referring to multiple cases?
I would emphasize that your results are an observation, since this is only one patient with one control (and you have not yet confirmed that the difference in their results are significant).
Comments on the Quality of English Language
There are scattered grammatical errors that will have to be corrected.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 2 Report
Comments and Suggestions for Authors
Thank you for making the suggested changes. The manuscript is much stronger and more educational. I have a few additional comments below.
Line 72-73 page 2: “The distribution of his skin lesion was on upper body.” I suggest changing this to “The eruption was distributed on his upper body and face.”
Lines 79-81: “… included secondary to cholestatic pruritus and mild atopic dermatitis. Other differentials included allergic vs irritant contact dermatitis, eczematous drug eruption, and cutaneous pseudolymphoma. “…included secondary to cholestatic…” doesn’t make sense. Based on the images, perhaps you could say something like “…included lichen simplex chronicus and excoriation secondary to…”. Also in this line, spell out” vs” as versus.
Results section
Figure 1. “Figure 1. Generalized skin rashes. Pigmented generalized macular rashes on the back.’ I would say Generalized skin eruption and not rashes. And “generalized pigmented eruption on the back
Figure 2:” Skin punch biopsy shows epidermal squamous cells and subcutis component (A); dermis tissue shows patchy dense chronic inflammation with lymphoplasmacytic infiltrates throughout the dermis and involving the subcutis, most plasma cells around were in perivascular (B, arrows) and in periadnexal gland (C, arrows).” The wording doesn’t make sense for specimen A. And the infiltrate is not throughout the dermis and subcutis. I suggest saying something like: Punch biopsy taken from??? (say which lesion was biopsied from the image if possible or say what kind of morphology the lesion was). A: Scanning view showing an inflammatory infiltrate concentrated around the deep eccrine glands and small vessels (x 50). B: Higher power view demonstrating a dense infiltrate of lymphocytes and numerous plasma cells around the peri-eccrine small vessels and eccrine glands
Figure 3: “…ampullary tissue shows actively chronic inflammation diffusely infiltrated by lymphoplasmacytic cellularity, with most of in which are plasmacytes” . This sentence does not make sense. Perhaps say “…ampullary tissue shows a dense infiltrate composed mostly of plasma cells”
Figure 3:” immunostains shows…” should be show
Lines 165-66:” Subsets of CD4+ and CD8+ cells, based upon expression of chemokine receptors, 1homing properties, and functions have been divided into distinct subpopulations”. It would sound better with a comma after functions. Please put a period after subpopulations.
Line 167:” Figure 4 A show data—should be shows, not show
Line 204:” 27multiple” put space after 27
Line 207: “In 2012, recommendation regarding…” put an s after recommendation
Regarding the IgG4-RD involving the skin—can you please elaborate more about the specific skin findings such as how it differs from organ disease. I would also emphasize that even if there are high IgG4+ cells on tissue sections without fulfilling the criteria on H&E, the diagnosis of IgG4-RD should not be made
Line 214: “…skin IgG4-RD appear to be underestimated” change to appears
Line 215: “Katerji and Smoller [10} recently 215 reviewed skin manifestations in IgG-RD.” please elaborate more about the histology of skin involvement with IgG4RD. For example, in addition to lymphocytes and plasma cells, there are admixed histiocytes and eosinophils, and variable germinal centers, with two different histopathologic patterns, including a plasma cellular mass and a non-mass presentation. And the criterium of serum IgG4 being higher than 135 mg/dL, is not entirely specific, as many systemic diseases may show elevation in IgG4 levels, and other diseases such as pemphigus show a similarly high ratio in > 40% of cases. It would also be helpful for the reader to know that the histologic features of IgG4-RSD are not specific, but the diagnosis should be considered in a dense polytypic plasma cell infiltrate admixed with eosinophils with background fibrosis, especially when arising in a patient with lacrimal or salivary gland symptoms.
Line 223-224: “Our patient is unique in that he has diffused generalized rashes…” I would change to “… a diffuse generalized eruption”
Line 227: “ The evidence that IgG4 itself causing pathology of IgG4-RD is lacking.” I think it would sound better to say “ evidence of IgG4 itself causing…” or “evidence that IgG4 is causing pathology…”
Line 259: “next gen sequencing” change gen to generation
Line 269: “The number of CD4 Treg in biliary tissue correlate with…” I believe it should be correlates, not correlate
Line 270: “sclerosing cholangitis and circulating CD4 Treg correlate with serum IgG4” put a comma after “and”
Line 286: “our observations” Capitalize “Our”
Line 289: “IgG4-RD may present with generalized skin rashes and associated with …” I would change to “present with a generalized skin eruption and be associated with”
Line 290-292: “Alterations in phenotypically characterized subsets of CD4+, CD8+, TFH, B cells, and regulatory lymphocytes, and regulatory lymphocytes in our patient with IgG4-RD suggest their role in the pathogenesis of IgG4-RD manifestations.” This sentence is confusing. Perhaps clarify it this way: ” IgG4 -RD is associated with alterations in phenotypically…..B-cells, and regulatory lymphocytes. Our patient was found to have regulatory lymphocytes that could potentially be playing a role in the pathogenesis of his IgG4-RD manifestations. “
Line 293: “However, more patients need to be studied before a definitive conclusion can be made”. “I would replace definite conclusion can be made with something like “ a definite conclusion regarding the role of T-cell subsets in IgG4-RD can be made”
Comments on the Quality of English Language
The paper in general is well written, but there were still several places where the sentence structure was confusing. See comments for examples
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
