Review for 10.1186/s12876-022-02133-z (2022)

Reviewer’s report
Title: 
Graves' disease overlapping with chronic hepatitis B and methimazole-
induced liver injury and autoimmune hepatitis: a case report
Version: 
0 
Date: 
28 Jun 2021
Reviewer's report:
In their case report entitled "Grave's disease complicated with chronic hepatitis B
and autoimmune-like methimazole-induced liver injury: a case report" Zheng et
al. report on a 35-year-old patient with acute-severe cholestatic hepatic injury
due to methimazole on pre-existing chronic hepatitis B infection. The patient had
a mild elevation of transaminases, an elevated ANA-titre of 1:320, an increased
serum IgG level and histological signs of autoimmune hepatitis (AIH). The
authors interpreted this case as an autoimmune-like DILI case due to
methimazole and treated this patient with steroids. This is an interesting case
however my major concern is that I am not convinced that the above-mentioned
parameters were necessarily caused by methimazole. 
Major concerns:
1) Increased ANA titres, elevation of transaminases and histological signs of
AIH such as interface hepatitis, rosettes etc are not AIH-specific and can also
occur during chronic or an acute flare of hepatitis B infection. In my opinion,
this a case of untreated chronic hepatitis B infection with additional acute
cholestatic liver injury due to methimazole. What is the authors' opinion on this
alternative interpretation of their case? Additionally, elevation of transaminases
could also be due to hyperthyroidism.
2) Can the authors report on previous liver enzymes, IgG-levels or ANA titres
before the acute liver injury due to methimazole? 
3) Selective IgG-elevation is very specific for AIH - can the authors report on
IgA and IgM levels in this patient. 
4) Liver biopsy was performed very late (about 40 days after admission). This is
an important limitation because all the new medication given to the patient in the
meantime could have had an impact on the histological picture. This limitation
should be discussed. Furthermore, what is the reason that the liver biopsy was
performed so late during the clinical course?
5) The combination of RUCAM and simplified AIH score are not validated to
make the diagnosis of autoimmune-like DILI. This should be mentioned. 
6) What was the total medication of this patient at the time of admission. 
Minor concerns
7) What do the authors mean by "The patient denied any history of alcohol, …
and HEPATITIS B" (p4, line 83)? He was not aware of his hepatitis B infection?
Or do you mean he denied risk factors for hepatitis B infection? 
8) What do the authors mean by "The liver and spleen were not touched." (p4,
line 85)? Liver and spleen were not palpable?
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