Your case report is finished. The title reads "Spontaneous X of the Y: The First Reported Case", and it is the strongest sentence in the manuscript — which is also the only sentence a stranger with a browser can disprove in four minutes.
"First" is a claim about the entire published literature, in every language. You have made it on one PubMed search in English, run once, on a Tuesday.
The fix is not to soften the wording. It is to change what the sentence claims: not the state of the world, which you cannot verify, but the search you ran, which you can.
Why "the first reported case" is the one sentence in your manuscript a stranger can disprove
Everything else in the report is anchored to your patient, which a reader cannot look up and check. Novelty is the exception. It lives outside your data, in a literature anyone can query — a reader finds a 1987 report in a Japanese journal and has a citable objection, sitting in your title.
Claim your search, not the world: the reframe that turns novelty into something checkable
Compare two sentences about the same case.
This is the first reported case of [condition] in [population].
To our knowledge, and following a search of [databases] on [date] using the strings listed below, no previous report of [condition] in [population] has been published in the literature we were able to search.
The first is a claim about all publishing, everywhere; the second is a claim about a search — bounded, dated, and true if you ran it. A reader who finds an earlier report has not caught an error; they have extended a search whose limits you declared.
Run the search with free tools first: PubMed, Europe PMC, Google Scholar, OpenAlex and regional indexes
You do not need a subscription to run a defensible search. Record what each returns:
- PubMed — search MeSH terms and free text separately; they return different sets.
- Europe PMC — a wider net, including preprints, and it searches the full text of the articles it holds in full, not just their abstracts.
- Google Scholar — poor precision, good recall; it reaches theses and unindexed journals.
- OpenAlex — an open index covering far more journals than the subscription databases.
- Regional indexes — LILACS, SciELO, African Journals Online, KoreaMed, and WHO's Global Index Medicus, which searches its five regional indexes in one query. A claim never tested outside English is a weak claim.
- Citation chasing — read the reference lists of the closest reports, then what has cited them since; this finds cases keyword searching misses.
Search synonyms, eponyms and obsolete names: the 1980s literature is filed under the 1980s vocabulary, and choosing keywords and titles works in reverse here.
No database is complete — including for journals like ours that PubMed does not index
Every search protocol has a hole in it, and naming the hole is what makes the rest credible.
A PubMed search returns PubMed's index, and journals it does not index will not appear. That includes our own titles: Directive journals are not indexed in PubMed, PubMed Central, MEDLINE, Scopus or Web of Science. A report published with us surfaces through Crossref DOI metadata, OpenAlex, Google Scholar and plain web search — which is why those belong in your protocol.
Non-English journals, undigitised material and society journals outside the aggregators sit in similar blind spots. You cannot close them all; you can name them.
Write the four-line search statement: databases, exact strings, date run, language limits
Put this in the Discussion, immediately before the table it refers to. Fill every bracket.
We searched [list every database and index, by name] on [date, as DD Month YYYY] using the search strings [reproduce the exact strings, including Boolean operators and field tags], without language restriction [or: restricted to publications in English, which we note as a limitation of this review]. We did not search [name the subscription databases you had no access to — for example Embase, Scopus, Web of Science]. We identified [n] previously reported cases meeting [state your inclusion criterion in one clause], summarised in Table [X].
Four elements do the work: which databases, the exact strings, the date, and what you could not search. Without the date it is not reproducible.
Build the table of previously reported cases, and make each column earn its place
The table turns a novelty claim into an argument. Seven columns is the full version:
| Author, year | Country | Age/sex | Presentation | Intervention | Outcome | Follow-up |
|---|---|---|---|---|---|---|
| [Author] et al, [year] | [country] | [nn] / [M or F] | [presenting features, one clause] | [procedure or treatment] | [resolved / recurred / died] | [duration] |
| Illustrative row only — Doe et al, 2019 | Illustrative | 47 / F | Painless swelling, six months, no systemic features | Wide local excision | Resolved, no recurrence | 18 months |
| Present case | [country] | [nn] / [M or F] | [your presentation] | [your intervention] | [your outcome] | [your follow-up] |
The illustrative row is a fictional placeholder, not a real patient or a real published case. Delete it, keep your own case in the final row, and drop any column where every cell reads "not stated".
Fit the table inside 2,000 words, four display items and twenty references
Case reports are short. Our Author Guidelines set the limits for a case report — up to 2,000 words, up to four figures or tables and up to 20 references, with tables excluded from the word count but counted against the four display items — so a seven-column table of fifteen prior cases will not fit alongside your imaging. Use the trimmed five-column variant:
| Author, year | Age/sex | Presentation | Intervention | Outcome |
|---|---|---|---|---|
| [Author] et al, [year] | [nn] / [M or F] | [presenting features] | [procedure or treatment] | [resolved / recurred / died] |
| Present case | [nn] / [M or F] | [your presentation] | [your intervention] | [your outcome] |
Where the seven-column version adds something, place it as a supplementary file and cite it as "Supplementary Table S1"; see preparing supplementary materials for how to label it.
If the search will not support "first", climb down the ladder: four fallback claims ranked by the evidence each needs
Every rung below is a statement about the scope and date of your search, never a synonym for "first". A claim that cannot be phrased that way does not belong in the manuscript.
| Rung | Claim | What your search must support |
|---|---|---|
| 1 | No previously reported case anywhere | Multi-database, multi-language, citation-chased, with the gaps named |
| 2 | No previous report in this population, age group or anatomical variant | The same search narrowed by one stated attribute — far easier to defend |
| 3 | No previous report of this intervention or this outcome | Cases of the condition exist; you tabulate them and show what was not tried |
| 4 | A rare presentation adding to a small published series | A countable set of prior cases, tabulated, with your case as the next row |
| 5 | No novelty claim at all — teaching value only | Nothing beyond an accurate account of what happened |
A model sentence for each rung:
1. Following a search of [databases] on [date] without language restriction, we identified no previous report of [condition].
2. [n] cases of [condition] have been reported (Table [X]). Following the search described above, we identified none in [patients under 18 / this anatomical site / this population].
3. [n] previously reported cases were identified, of which [n] were managed by [alternative]. We identified no previous report of management by [your intervention].
4. [Condition] is uncommon, with [n] cases identified by the search described above. We report a further case presenting with [feature not described in the tabulated reports].
5. We report a case of [condition] in which [the diagnostic or management problem] delayed recognition, and describe how it was resolved.
A title that cannot support rung 1 belongs on rung 2: a smaller claim, defensible on the search you have already run.
A case with no defensible novelty claim can still be worth publishing on teaching value alone
A case is worth writing up when it changes what a clinician would do: a missed diagnosis and the feature that would have caught it; an adverse effect not on the differential; a decision taken under uncertainty, with the reasoning explicit and the outcome reported honestly.
Strip the novelty claim out. If the case still teaches something, build the Discussion around the lesson rather than the search.
Our standards for honest reporting are set out in Research Integrity, and the scope of each format in Article Types. See also our guides to writing a case report, writing a discussion section and preparing supplementary materials.