Importance of Reading and Publishing Case Reports

Dear Editor,

Medical case reports are generally considered not to have a high scientific impact and are ranked as class 3, just one step above the bottom, that is, the evidence from experts and clinical practice, in the evidence-based medicine classification [1]. The majority of high-impact journals does not publish a case report unless it reports a unique case with unique features. Although the number of the journals that publish case reports has recently increased [2], several reasons discourage scientists to publish case reports. During my entire medical career, I have been told that writing a case report is a waste of time and is not considered as an important scientific activity by any medical council or authority, in addition to its difficulty of acceptance for publication.

On the other hand, a case report is the best type of research to start with for young scientists because of many reasons. A case report is easy to write; it has no time or budget restriction; and it could be very beneficial for educational purposes because one needs to review the literature and write the case in a systematic order including epidemiology, etiology, clinical presentation, differential diagnosis, diagnostic methods, treatment, and discussion.

One of my very first articles was a case report of a pregnant woman with pulmonary artery aneurysm who was diagnosed with Behcet disease [3]. I learned a lot from this case report. It was first accepted as Oral Communication in the European Respiratory Society (ERS) Congress. This was the first abstract that I had sent to an international congress; on top of that, I also received a travel grant from ERS to attend that congress in Florence. Then, I submitted it to a high-impact rheumatology journal, and it was quickly accepted for publication. As I had reviewed almost all the existing medical literature, I had acquired enough knowledge to even give a lecture on Behcet disease and differential diagnosis of pulmonary artery aneurysms.

I have recently started private practice after 28 years of public service in a government-owned university hospital. One of my initial cases in the private practice was a 64-year-old Armenian woman brought in a wheelchair by her daughters-in-law without any hope for her survival. They were just seeking a comfort of trying their best before their mother-in-law dies. The patient had consulted several pulmonologists and was prescribed prednisolone treatment following bronchoscopic transbronchial biopsy performed 9 months ago because her lung biopsy indicated bronchiolitis obliterans organizing pneumonia (BOOP). However, her condition quickly deteriorated, and her oxygen saturation was 88% on 5 L/min of nasal oxygen upon her presentation to my clinic. On reviewing her test results, I noticed that the findings of high-resolution computed tomography (HRCT) were not compatible with BOOP but with diffuse panbronchiolitis (DPB). I had learned about the latter when I wrote my second case report that was about a young lady with juvenile rheumatoid arthritis who presented with severe progressive dyspnea and was diagnosed with bronchiolitis obliterans [4]. At that time, when thoroughly reviewing the medical literature before writing the case report, I came across a disease called DPB [5]. Even though this disease is predominantly seen in Asian populations and only few cases have been reported in Caucasians, the HRCT findings in my case were similar to the unique radiological presentation of DPB. I also remembered that a pathologist might confuse the histology of DPB with that of BOOP because DPB is very rare in our country. I discussed my thoughts with my patient and her daughters-in-law. Although they did not seem to believe me, they all agreed to gradually discontinue her prednisolone and instead start taking clarithromycin tablets. We scheduled a control visit 2 weeks later. When my secretary called to tell me that they are present in the clinic, my heart started beating very fast. I was staring at the door. When the door opened, I saw my patient walking on her own without oxygen and with her daughters-in-law by her side. My diagnosis was correct, and the happiness that I experienced was priceless.

In summary, I believe that case reports have many advantages, especially for those in the beginning of their medical career: it is relatively easy to write a case report, and one can learn a lot during the literature search. It is also a very useful method of teaching a medical trainee about how to approach a patient in a systematic manner. A case report may even lead to important epidemiological studies that may change a government’s health policy, such as reporting of silicosis in denim workers [6]. I would humbly recommend all my faculty colleagues to encourage their medical students, residents, and fellows to read and publish medical case reports.