Review for 10.1186/s12876-020-01567-7 (2020)

Reviewer’s report
Title: 
Development of amoebic liver abscess in early pregnancy years after
initial amoebic exposure – A Case Report.
Version: 
0 
Date: 
28 Sep 2020
Reviewer's report:
Diagnosis of Amebic liver abscess (ALA) in the present case was based on
indirect evidence of the causing pathogen Entamoeba histolytica. A positive
serology and the absence of bacteria in the abscess fluid supported the diagnosis.
Polymerase Chain Reaction (PCR) is a highly specific and sensitive test to detect
E. histolytica in abscess fluid and stool samples. Today it is a well established
method and should be applied to diagnose intestinal and extraintestinal E.
histolytica infection in order to proof the diagnosis through direct detection of
the pathogen.
An ultrasound guided fine needle puncture soon after admission would have
confirmed the diagnosis within 3 days with direct evidence of E. histolytica to be
the responsible pathogen. 
Drainage could have been avoided too. The abscess was relatively small (< 5cm)
and well surrounded by liver tissue with a very low risk of rupture. 
Ultrasound is the diagnostic method of choice for ALA and provided all
necessary information in this case. CT and MRI are usually dispensable.
A PCR for E. histolytica from a stool sample would have confirmed the presence
of the parasite in the intestinal tract and the need for treatment with
Paromomycin.
Pregnancy and ALA:
There is now evidence that testosterone increases the susceptibility to develop
ALA. (Lotter et al. 2013, PLoS One, 
Testosteron increases the susceptibility of
amebic liver abscess in mice and mediates inhibition of IFN gamma secretion in
natural killer T-cells, 
Sellau et al. 2020, Nature Communications, Androgens
predispose males to Monocyte-mediated immunopathology by inducing the
expression of leukocyte recruitment factor CXCL1.) Men have a significantly
higher risk to develop ALA. Male:Female relation for all age groups is 4:1 and
in the age group of 20-40 years, Male:Female relation is approx. 9:1. The effect
of androgens on the immune system is most likely the principle reason. 
Serum Testosterone levels are increasing during pregnancy and this might be the
triggering factor to develop ALA during pregnancy. 
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