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Editor's Choice

Interactive case reports

BMJ 2009; 338 doi: (Published 11 March 2009) Cite this as: BMJ 2009;338:b1012
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    You’ll find the outcome of our latest interactive case report in this week’s journal (doi:10.1136/bmj.b247). Congratulations to Petros Rafailidis in Athens for reaching the correct diagnosis after we published the second part of the case a few weeks ago. The 38 year old woman who suffered recurrent collapses with the onset of menstruation did not have adrenal insufficiency as many of you thought. Our expert commentator Paul van Daele was also drawn to that diagnosis by the patient’s rapid response to steroids and lack of response to vasoactive drugs, which seemed to rule out anaphylaxis (doi:10.1136/bmj.b846). But anaphylaxis it was, caused by systemic mastocytosis.

    This is a rare case. Indeed, the authors believed it to be the first report of menstruation triggering the release of mast cell mediators. But one rapid respondent, Robert Berstein, found two other reports by Googling “hypotensive menstruation.” Google, that great diagnostic decision aid, strikes again (BMJ 2006;333:1143-5, doi:10.1136/bmj.39003.640567.AE).

    Educationalist Ed Peile warns us that when diagnosing complex cases “it is tempting to prioritise the information that fits more readily into our existing illness scripts and disregard that which does not fit” (doi:10.1136/bmj.b796). Gerhard Molderings reminds us that systemic mast cell activation is probably common in daily practice but is seldom considered (doi:10.1136/bmj.b799), maybe because it is largely a clinical diagnosis that relies on recognising the “complex variable and often changing pattern of symptoms.” The fact that our interactive case reports are real cases means we can hear directly from the patient. Mrs Barroso gives a vivid account of the terror and intensity of each attack (doi:10.1136/bmj.b867). She praises her medical team. “They did not make me feel like a rare case but like a woman with a problem.”

    If you would like to send us an interactive case report about a real patient, take a look at the guidance on ( and send us an outline. Ideally, the case should be sufficiently complex to raise clinical, investigative, diagnostic, ethical, and management questions, but not so rarefied that it will be useful to only a minority of BMJ readers.

    So to our cluster of research articles on the long term effects of tobacco (doi:10.1136/bmj.b462, doi:10.1136/bmj.b496, doi:10.1136/bmj.b349, doi:10.1136/bmj.b480). Do we really need more evidence of the dangers of active and passive smoking? Yes we do, for lest those of us in the developed world think the fight against tobacco is nearly won, in large parts of the world the lack of effective public health policies means easy pickings for the tobacco industry. Next year tobacco will kill six million people worldwide, nearly three quarters of them in low and middle income countries according to a new atlas on tobacco published this week (see, doi:10.1136/bmj.b981). The authors say that if households in Bangladesh bought food instead of tobacco, more than 10 million people would no longer be malnourished, potentially saving the lives of 350 children each day. There is no room for complacency.


    Cite this as: BMJ 2009;338:b1012

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