Journal of Medical Case Reports BioMed Central Editorial Case

Background Brucellosis is a multi-system disease that may present with a broad spectrum of clinical manifestations. While hepatic involvement in brucellosis is not rare, it may rarely involve the kidney or display with cardiac manifestations. Central nervous system involvement in brucellosis sometimes can cause demyelinating syndromes. Here we present a case of brucella hepatitis, myocarditis, acute disseminated encephalomyelitis, and renal failure. Case presentation A 26-year-old man presented with fever, ataxia, and dysarthria. He was a shepherd and gave a history of low grade fever, chilly sensation, cold sweating, loss of appetite, arthralgia and 10 Kg weight loss during the previous 3 months. He had a body temperature of 39°C at the time of admission. On laboratory tests he had elevated level of liver enzymes, blood urea nitrogen, Creatinine, Creatine phosphokinase (MB), and moderate proteinuria. He also had abnormal echocardiography and brain MRI. Enzyme-linked immunosorbent assay for IgG and IgM was negative. Standard tube agglutination test (STAT) and 2-mercaptoethanol (2-ME) titers were 1:80 and 1:40 respectively. Finally he was diagnosed with brucellosis by positive blood culture and the polymerase chain reaction for Brucella mellitensis. Conclusion In endemic areas clinicians should consider brucellosis in any unusual presentation involving multiple organ systems, even if serology is inconclusive. In endemic areas low STAT and 2-ME titers should be considered as an indication of brucellosis and in these cases additional testing is recommended to rule out brucellosis.


Editorial
There has been a long descriptive history of case reporting in relation to cancer. In his book titled Clinical Case Reporting in Evidence-Based Medicine, Milos Jenicek eloquently describes case reports as the first line of evidence, where everything begins [1]. Some of the earliest case reports describing individual patients afflicted with cancer can be traced all the way back to the papyrus records of Ancient Egyptian medicine of approximately 1600 B.C.. These reports were the first recorded cases of incurable tumors of the breast [2]. Throughout the centuries physicians have continued the practice of writing case reports. Case reports of melanoma were described by Hippocrates in the fifth century B.C. and also by Rufus of Ephesus, a Greek physician, in the first century A.C. [3].
Another area where case reporting has provided significant advances in the knowledge of cancer has been in the identification of new types of cancer. For example, in January 1832, Thomas Hodgkin reported six cases to the Medical-Chirurgical Society of London, two of which were what we know today as Hodgkin's lymphoma [4]. In 1957, while in Uganda, Dennis P. Burkitt described a tumor that presented as a growth in the angle of the jaw of African children [5], later to be known as Burkitt's lymphoma. In 1960, Peter Nowell and David Hungerford published a report describing seven patients with chronic myeloid leukemia having the same "minute chromosome" later to be known Philadelphia chromosome [6]. In 1990, Farcet et al. described two patients with a new type of lymphoma, called Hepatosplenic T-Cell lymphoma [7], leading to more focused research of this new entity.
On the therapeutic front, the evolution of case reports to describe treatment entities is still evolving. To date the majority of reporting has been about adverse events. For example a case report about a patient with acute myeloid leukemia and nocardiosis revealed that high dose trimethoprim-sulfamethoxazole is a direct cause of significant myoclonus [8]. Another report revealed Aprepitant as a cause of Ifosfamide-induced encephalopathy [9]. 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 Waldenström's macroglobulinemia [10].
It is without question that case reports do not replace well designed randomized clinical trials in testing new therapeutics. However, in cancer therapeutics the numbers of patients to conduct such studies may not be always recruitable. The advancement of cancer knowledge relies on a multitude of factors including molecular studies and preclinical models in order to study disease mechanism and potential targeted therapy: the kind of clinical information that could be gained through a series of case reports [11].
Another area where case reports about oncological matters have a role in the progress of medical science is in medical education [12]. Journal of Medical Case Reports (JMCR) is an open access journal that is committed to publishing high quality case reports from anywhere in the world and making them accessible to all. Through promoting the role of case reports in oncology, we hope to build a large prospective database of online case reports that will add to the aspects of oncology described in the evidence-based medical literature. This database will be a future resource allowing researchers to ask specific questions and study characteristics of uncommon events. JMCR will feed into an associated searchable database of case reports, and this database will serve as a clearing house of good case reports from all around the world. For example, by publishing every case report about spontaneous regression of metastatic renal cell carcinoma after debulking nephrectomy, a specific search of the database would help researchers in studying this particular and interesting phenomenon [13]. The prospective nature, of course would be in the data collection not retrieval. The planned aggregation of case reports has the potential to contribute to the ability to study newer risk factors associated with cancer. We recognize that case reports can serve as a substrate to further research many years after an original publication. For example, in 1886, Felix Fränkel described the first case report of pheochromocytoma in an 18 year-old woman with bilateral adrenal tumor. In 2007, almost 121 years later, Neumann et al. studied four living relatives of the same patient reported by Fränkel in 1886 and found that the patient had RET mutation and that her family had multiple endocrine neoplasia (MEN-2) [14].
In Medicine, questions in "research" (looking back) almost always start with patient encounters. Well written case reports will always be a source of inspiration for clinicians and scientists about newer research directions.