‘Science only advances when unexpected observations cause a frame shift in our previously held beliefs’.Karl Popper

Case reports are the best ways to start publishing and it can be a valuable tool for both the author and the reader. Though there are numerous ways for medical writing; case reports are the best ways to start publishing. From Hippocrates (460B.C. to 370 B.C.) to modern-day practice, physicians of all specialties have described interesting cases in their fields. ^{[1], [2]} More than 240000 case reports have been published in various journals from 1997-2002 as per Medline report. ^[3] Case reports have also been used as a teaching tool. Acquired Immunodeficiency Syndrome (AIDS) and Parkinson’s disease were first described in case study format. ^{[4], [5]} Retinopathy of prematurity (ROP) was originally described as Retrolental fibroplasia by Terry ^[6] in 1952, who related it with premature birth. Even though case reports are not the best scientific evidence still many authors believe that case reports are one of the few methods for bringing a new condition or new etiology to the attention of scientific community. ^{[7], [8]} The roles of case reports are diverse, which include recognition and description of new disease, detection of various side effects, study the mechanism of disease, rare manifestations of a disease and medical education. It should be kept in mind that a case report is to describe and discuss a clinical event and not to prove anything.

Case report study design

Case reports can be retrospective or prospective in nature. Retrospective design is the most common and simplest form of writing. In prospective case report the author plans out patient care and data collection ahead of time.

Who should write a case report?

Case reports are excellent opportunities for medical students, residents and practitioners, who want to start scientific writing. A case report requires a strong content to describe the case, a focused literature review and an understanding of relationship between the case and general practice. It should describe some recommendations for the improvement of clinical care in future. The experience of writing a case report can also improve author’s writing skills.

When to write a case report

Novelty is a criterion to write a case report

• To report an unusual or an unknown clinical entity.
• To illustrate an unusual etiology of a case.
• To cite, prompt, support or refute a clinical hypothesis.
• To provide new insights into pathogenesis of a disease.
• To describe unusual or new clinical features of an already known clinical condition.
• To report a unique or rare features observed during imaging.
• To report a novel therapeutic or interventional technique.
• To describe and report new adverse reactions to a drug already in use.
• To make readers aware of a new complication of a therapeutic procedure in vogue.
• To stimulate further research.

Guidelines for writings a case report

• Title- It should be short and catchy and should include the description of the patient under study. The word “case report” should be included in the title itself.

• Abstract- This is the most important and salient feature of the case report because this is what people will read in the database and will create interest and attract the reader for reading the full case report. It should be short and sweet, highlighting the salient points of the case and its clinical relevance. No references or abbreviations are to be used in the abstract. It should summarize the case and should end with a clear take home message for the reader. Some authors prefer writing abstract at the end as it flows in easily.
• Keywords- About 2- 5 keywords specific to the case report should be provided, so that it becomes easier for the reader to search for it. Use key words found in the Index Medicus database, which are called medical subheadings (MeSH). List of additional words that are unique to the case report can also be provided.
• Introduction- It should be brief review of the literature pertaining to the case and its contribution to the literature. It should describe why the case is unique. It should end with a purpose of documenting and reporting. The reader should be able to understand why this report is important and how it relates to common clinical practice.
• Case presentation- The case is started with the demographic profile of the patient, which includes age, gender, ethnicity and occupation. The chief presenting complaints should be mentioned. History is presented in a chronological order and clinical findings written clearly. Significant negative results should also be elaborated. Various imaging results and diagnostic test should be mentioned. Treatment and its outcome or any progress of the disease should also be mentioned. Follow up of the patient with favorable or unfavorable outcome should be explained. The description should end with author’s clinical diagnosis. This section also includes tables and figures which explain clinical findings.
• Discussion- Explain “How” and “Why” certain inferences were made. Reveal “What is known” and write “What is new” in the context of the case. It should compare the case with published literature. Any salient differences between the case and published literature should be explained. Logical management options should be explained in detail. Limitations of the case report and significance of each limitation must be discussed.
• Conclusion- The case report concludes with a brief summary of the case that is closely related to the central theme of the case and what new has been learned from the case report. It should not be the repeat of entire case. The most important part of the conclusion is the recommendations drawn from it for future treatment or further research.
• Acknowledgements- One may briefly acknowledge the work of the person who has helped the authors in writing a case report and it is not necessary to mention his name as one of the author. Most journals require a written consent from the people acknowledged for their name to appear in the print.
• References – Articles from peer reviewed journal should be included. Help and quotes should be taken from books. It is preferable to use the most recent references unless history is discussed in the case report. Magazines and newspapers are not be used as a source of evidence. Mostly there is no recommendation for number of references, however some journals impose a limit on the number of references. A long list of references sometimes indicates lack of author’s understanding for the publishing process. References should be formatted appropriately as per journal’s instructions. It is mandatory to go through the instructions before sending the case report to the journal for publication.
• Tables- Should be simple and self-contained, requiring no further explanation. Tables should not be used for small amount of information that can be conveyed in a sentence. Tables should have a proper title.
• Figures- Figures, graphs, and photographs make articles interesting. Figures should be properly marked with arrows as and when required. Legends should contain detail of how the clinical image was obtained. The format of figures should be checked in the instructions of the journal. The backbone of the case is GOOD PHOTOGRAPHS (clinical, imaging). If you don’t have photographs, forget about writing a case report.
• List of abbreviations- Whenever abbreviations are used in the text, they should be defined as text at first instance. A list of abbreviation can be provided in the end.
• Consent- It is mandatory for some journals to have patient’s informed consent for the case report to be published. It need not be sent routinely with manuscript, but some reviewers can request copies of the consent any time. It should be kept in mind that manuscripts will not be peer reviewed if a statement of patient’s consent is not presented.
• Going through a checklist provided by the CARE (CAse REport) group, will aid the authors not to miss on salient points before submitting the manuscript in the journal.^[9]

Drawback of case reports

• Most journals do not publish case reports for many reasons; abuse in authorship has been noted in the past, low level of application to practice in evidence based medicine, unreliability of information tendered for diagnosis, it add little to scientific knowledge, case reports are less citable and cannot be used as review of literature, limited page space in the journal and less impact factor of the journal publishing case reports.^[8]
• A single case report does not prove causation and observations of the case and it cannot be generalized to other patients.

• Off-label use of drugs is not allowed to be advertised in certain countries.
• Case reports are at the bottom of the evidence based health care where as randomized control trials top the hierarchy.^[8]
• Recently case reports have been downgraded due to new and more advanced methods of medical research.^[10]
• If a case does not add to any new knowledge it is unlikely that it will be accepted for publication.^[11]

Conclusion

A firm understanding of the message for creating a case report should be kept in mind before writing it. Writing a case report can be a fun and hobby both for novice and experienced author. Adherence to the journal guidelines is mandatory for its acceptance.

References:

1. Breasted JH: Historical Tradition and oriental Research. Proc Natl Acad Sci USA. 1924; 10:289-294.
2. Rison RA: Neurological case reporting: a call for all. J Med Case rep. 2011; 23;5:113. doi: 10.1186/1752-1947-5-113.
3. Sorinola O, Olufowowobi O, Coomarasamy A, Khan KS. Instructions to authors for case reporting are limited: A review of a core journal list. BMC Med Educ. 2004;25:4
4. Gottleib GJ, Rogoz A, Vogel JV, Friedman-Kien A, Rywlin AM,Weiner EA, et al: A preliminary communication on extensively disseminated Kaposi’s sarcoma in a young homosexual man. Am J Dermatopathol. 1981; 3:111-114.
5. Goetz CG: The history of Parkinson’s disease: early clinical descriptions and neurological therapies. Cold Spring Harb Perspect Med. 2011;1:a008862
6. Terry TL. Extreme prematurity and fibroblastic overgrowth of persistent vascular sheath behind each crystalline lens. I. Preliminary report. Am J Ophthalmol. 1942;25:203-204
7. Nissen T, Wynn R et al. The history of the case report: a selective review. JRSM Open. 2014;12:5:2054270414523410
8. Green BN, Johnson CD. How to write a case report for publication. J Chiropr Med. 2006;5:72-82.
9. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D; CARE Group. The CARE guidelines: consensus-based clinical case reporting guideline development. Headache. 2013;53:1541-1547
10. Rison RA. A guide to writing case report from the Journal of Medical Case Reports and BioMed Central Research Notes. J Med case rep.2013; 27: 239.
11. Carleton HA, Webb ML. The case report in context. Yale journal of biology and medicine. 2012;85:93-96.