Writing Case Reports

Abstract

Case report is a common feature of general medical journals. In Med J Malaysia and Singapore Med J, case reports constitute a quarter to a third of all articles published. However, in the high impact medical journals, such as N Engl J Med, Lancet and BMJ, this proportion has shown a marked reduction in recent years (Figure 1). Figure 1: Case Reports In General Medical Journals What kind of case report is worth publishing? The reasons for publishing case reports vary somewhat between one journal and another. A case report is more likely to gain entry to the high impact medical journals if it is truly unique and has the potential to open up a whole new area of scientific enquiry. Two kind of case reports fall into this category: Case reports that are hypothesis generating. An example of such case report is the description of Nipah virus infection from Malaysia: the investigators postulated the emergence of a new “Hendra-like” virus transmitted from pig to man causing outbreak of encephalitis in the pig farmers.1 Another example is the discovery of Enterovirus 71 as the cause of hand-foot-and-mouth disease in children with sudden cardiopulmonary collapse attributed to brainstem involvement.2 Such case reports stimulated new research to elucidate the epidemiology, aetiology, and clinical characteristics of the newly emergent diseases. Case reports that refute previous hypothesis. The case report by Lum LCS et al is an example of case report in this category.3 They documented five children with dengue having evidence of microbiological and imaging changes suggestive of encephalitis, thus refuting previous assertion that dengue virus could not invade the brain directly.3 Case report in this category are not new diseases but may highlight new, unusual or unexpected presentation, or new association or variation in disease processes. The above two kinds of case reports are original works that can stimulate further scientific research, thus extending the boundary of knowledge. Occasionally, we do see other kinds of case reports: Case reports highlighting the “first case” in Malaysia. Such case reports emphasise that this clinical problem can occur in our country and serve an educational function and encourage other clinicians to look out for the same.4-8 They are more likely to be publishable if the clinical problem is of major public health significance.8 To the international journals, however, “first case report” in a particular country is of little interest unless the case report illuminates some aspect of the aetiology or pathogenesis of the clinical problem on account of the unique biological (e.g. genetic) or cultural differences. The “teaching” case reports. These types of case reports document the diagnostic and therapeutic triumphs, near misses or catastrophes of the clinicians. After successfully (or unsuccessfully) diagnosing or managing uncommon cases, there are many lessons learnt that are worth sharing with other practitioners, e.g. diagnostic pitfalls in atypical childhood tuberculosis;9 a unique way to repair lower oesophagealperforation;10 the danger of unplugging a bronchial obstruction;11 and diagnostic laparoscopy may miss duodenal perforation in trauma patient.12 What kind of case report does MFP looks for? The answer is “all of the above”, although at the moment, we are getting almost entirely the fourth category in the above list.