Case Report Prof. of Clinical Neuroscience Department of Psychiatry Shahin Akhondzadeh Ph.D., FBPharmacolS., D.Sc. Prof. of Clinical Neuroscience Department of Psychiatry TUMS

Introduction ‘…Any patient that goes through the door of this hospital is a potential case report…’ Anonymous (The Montreal General Hospital)

Definition Case reports are brief reports describing an isolated clinical case or a small number of cases. They may describe new or uncommon diagnoses, unusual outcomes or prognosis, new or infrequently used therapies and side effects of therapy not usually discovered in clinical trials. (Khalid Khan, Peter Thompson)

Example of case report. A 64-year old woman presented with diffuse musculoskeletal pain. At the age of 58, she had undergone gastric bypass surgery because of severe obesity. At the age of 59, she underwent modified radical mastectomy for an estrogen receptor-positive T1N0M0 right breast carcinoma and received tamoxifen postoperatively.

Initial diagnosis. 16 months after mastectomy, she presented with low back pain, myalgias, and fatigue. Alkaline phosphatase was 231 U/L (normal 39-117 U/L). Bone scan revealed areas of increased activity in the right hip, right inferior pubic ramus, and multiple left ribs, interpreted as consistent with metastases.

Blood test. Serum calcium was 7. 8mg/dL Phosphorus 3 Blood test. Serum calcium was 7.8mg/dL Phosphorus 3.1mg/dL Creatinine 0.7mg/dL Albumin 4.0g/dL Alkaline phosphatase 220 U/L (normal less than 130 U/L) Serum 25-hydroxyvitamin D was undetectable (less than 4ng/ml) Parathyroid hormone(PTH) was elevated (338pg/ml; normal 10-65 pg/mL)

Treatment. Ergocalciferol dose was increased to 50,000 IU twice weekly Treatment. Ergocalciferol dose was increased to 50,000 IU twice weekly. Four months later, her 25-hydroxyvitamin D level was still low (15ng/mL), but she remained pain-free. Khokhar et al.

Case reports describing new diagnosis

Case Reports describing unusual treatment response

Case report-unusual response to treatment Case report-unusual response to treatment. More recently researchers have used the case report format to share unusual treatment combinations or responses. For example, Treon et al reported in 2004 about an interesting clinical response to sildenafil in Waldenstrom’s macroglobulinemia.

Rare Cases

Rare cases. In rare cases, a series or more definitive study may be impossible. The reporting of similar rare cases, affords the clinician an opportunity to read this discontinuous “case series” and inform a rational approach to disease.

Report. A well-written case report or small uncontrolled series of cases is often the first step in the discovery of new diseases and treatments.(Albrecht et al, Ruben RJ) A good case report has the element of surprise

Are Case reports important in the era of evidence based medicine?

Potential roles of case reports and case series

Potential roles of case reports and case series Potential roles of case reports and case series. Recognition and description of new diseases. Detection of drug side effects (adverse and beneficial). Study of mechanisms of disease. Medical education and audit. Recognition of rare manifestations of disease. (Vandenbroucke J)

Impact of case report on medical research

Impact of case reports on medical research (Lancet)

How to write a good case report

Types of case reports Full case reports Images (with legends) Quiz Letter to editor

Anatomy of a case report Background/Introduction/Abstract Case report Discussion Summary/Learning points References

Case presentation Include relevant details Be concise yet comprehensive Remember the difference between “spoken” and “written” language Make a logical chronologic sequence

Submission process Write a good cover letter Attempt online submission, when possible - quicker turnaround time and cheaper Check specific journal requirements and comply Figures - check format required - .jpeg, .tiff