What are the essential steps to prepare a case report for publication, including a summary photo, while maintaining patient anonymity and contributing to the medical community?

Preparing a Case Report with Patient Photography for Publication

You must obtain written informed consent from the patient before publishing any case report, especially when including photographs, regardless of whether identifying features are masked. 1

Critical First Step: Informed Consent

Obtain explicit written consent that specifies all intended uses of the patient's information and images, including worldwide electronic distribution. 1 The consent process must address:

• Publication in medical journals (print and online formats) 1
• Worldwide distribution through electronic media and the Internet 1
• Educational presentations to colleagues and students 1
• Potential for permanent accessibility once published 1

The American College of Medical Genetics emphasizes that with Internet proliferation, it has become particularly important to obtain permission for all uses that will be made of medical images, including worldwide distribution through various electronic media 1. The BMJ survey found that 90% of editors (completely or partly) agreed that informed consent should be obtained when presenting photographs or other material making identification possible 1.

Protecting Patient Anonymity

Remove all identifying information from the case report and photograph:

• Mask the eyes in facial photographs 1
• Remove superfluous social details (specific occupation, accommodation details, exact dates) 1
• De-identify demographic information while retaining clinically relevant details (age, sex, ethnicity, BMI if relevant) 2, 3

Important caveat: Most editors oppose altering factual medical information to prevent recognition, as this compromises editorial credibility 1. However, non-essential social details can and should be removed 1.

Essential Components of Your Case Report

The International Journal of Surgery and CARE guidelines provide the structural framework 2, 3, 4, 5:

Title and Keywords

• Include "case report" in the title along with the specific focus area (presentation, diagnosis, technique, or outcome) 2, 3
• Select 3-6 keywords that identify key areas covered, always including "case report" as one keyword 2, 3

Abstract

• Provide 1-2 paragraphs explaining why the case is unique or educational 2, 3
• Reference relevant medical literature and current standards of care 2

Patient Information Section

• De-identified demographics (age, sex, ethnicity, occupation if relevant, BMI if relevant) 2, 3
• Relevant past medical/surgical history and outcomes from previous interventions 3
• Present information chronologically to avoid confusing readers 3

Clinical Presentation

• Relevant physical examination findings and significant clinical findings 2
• Timeline of events in chronological order (consider using a table or figure) 3
• All diagnostic methods used (physical exam, laboratory testing, imaging, histopathology) 2, 3

Intervention and Outcomes

• Describe interventions performed (pharmacologic, surgical, etc.) and reasoning behind treatment choices 3
• Report clinician-assessed and patient-reported outcomes with specific time periods 2, 3
• Document complications or adverse events in detail, including how they were managed 2, 3

Discussion and Analysis

• Analyze strengths, weaknesses, and limitations in your approach to this case 2
• Include the patient's perspective on the treatments received when appropriate 2, 3

Mandatory Declarations

• State explicitly that informed consent was obtained from the patient 2, 3, 4, 5
• Include conflicts of interest, funding sources, and ethics committee approval when required 2
• Submit a completed SCARE checklist with the manuscript if reporting a surgical case 3

Common Pitfalls to Avoid

Never publish without consent, even if you believe the patient cannot be identified. The combination of demographic details (sex, age, occupation, location) and clinical information can often identify patients even without photographs 1. The BMJ found that patients and relatives have reacted negatively to publications despite longstanding policies of masking eyes and removing social details 1.

Do not alter factual medical information to protect anonymity, as this compromises scientific integrity 1. Instead, remove non-essential social details while maintaining medical accuracy 1.

Avoid presenting information non-chronologically, which confuses readers 3.

The Patient's Right to Refuse

Respect the patient's decision if they refuse publication, even if the case is well-anonymized. 1 The BMJ survey showed that 36% of editors (completely or partly) agreed that a case report should never be published if the patient refuses, regardless of anonymization efforts 1.