Referee report. For: Case Report: Extensive digital gangrene as a primary manifestation of late-onset systemic lupus erythematosus [version 2; peer review: 2 approved]

This case report describes a 56-year-old man with late-onset systemic lupus erythematosus (SLE) who presented with digital gangrene as one of the initial symptoms, a rare occurrence. The patient exhibited symptoms such as joint pain, hair loss, photosensitivity, and digital pain, alongside laboratory findings of lymphocytopenia and elevated C-reactive protein. Despite initial treatment with hydroxychloroquine, methylprednisolone, cyclophosphamide, and calcium blockers, the lesions did not improve. However, after two infusions of rituximab, there was a marked improvement in vasculitis lesions and partial improvement in dyspnea. This case highlights digital gangrene as an uncommon primary manifestation of late-onset SLE.