The Value of Prospective Case Reports in Occupational Respiratory Allergy

To the Editor: A case report is written for different reasons including the description of an unusual disease and to document unrecognized potential associations between a particular agent and a disease (ie, new etiology) among others. Although case reports are considered the lowest level of evidence, often they constitute the basis and motivation for conducting further research using more complex study designs such as cohort studies, case-control studies, and clinical trials to provide stronger scientific evidence.1 Every year, specialized journals publish case reports describing cases of occupational rhinitis (OR) and occupational asthma (OA). Between 2009 and 2010, there were about 40 published case reports and case series reported new causative agents of OA.2 Ideally, if similar findings are found and published in case report format, the logical next step should be to further strength the evidence by conducting well-planned experimental and/or occupational epidemiology studies. Nevertheless, one of the key criteria to accept a case report for publication is its originality, which means that case reports with similar findings are possibly rejected by journals. Therefore, it is likely that isolated publications of case reports (ie, without further confirmation of findings by similar case reports or case series) will not contribute significantly to advance knowledge on OR and OA. From a clinical practice point of view, moving from a retrospective to a prospective case report approach may be more advantageous.3 In the prospective case report approach, a clinician first reviews the literature to learn about recent advances in the diagnosis and management of a particular health condition seen frequently in his/her medical practice. The next step is extracting the most relevant information on diagnostic tools and methods from published guidelines.3 A prospective case report approach will allow researchers to prospectively evaluate potential new cases from their practice according to recommended guidelines and thus, reporting new cases of these diseases will more effectively contribute to the literature. Nevertheless, there are barriers to implement evidence-based clinical practice in the field of occupational respiratory allergy. Often, it is not feasible to implement current guidelines into clinical practice.4 For example, according to current international recommendations, a challenge test with objective monitoring of nasal responses is required to confirm the diagnosis of OR,5 whereas a challenge test with objective monitoring of bronchial responses is required to confirm the diagnosis of OA.6 We recently published a case report where specific inhalation challenge with parallel assessment of nasal and bronchial responses was conducted to confirm the diagnosis of OA and OR in patients complaining of work-related rhinitis and asthma symptoms.7 Unfortunately, objective but sophisticated tests, such as induced sputum and specific inhalation tests, are not always available to confirm the diagnosis. Thus, a lot of case reports describing cases of OR and/or OA solely based their diagnosis on the reported work-related rhinitis and asthma symptoms and the presence of specific sensitization. This approach could be sufficient to consider a case as probable OR and OA, but not to confirm the diagnosis. Despite its limitation, awareness of the advantages of the prospective case report approach would be an important step that leads to better and useful case reports. Roberto Castano, MD, PhD Division of Otolaryngology—Head and Neck Surgery, University of Montreal, and Chronic Disease Research Division Hôpital du Sacré-Coeur de Montréal Montreal, Canada Eva Suarthana, MD, PhD Chronic Disease Research Division Hôpital du Sacré-Coeur de Montréal Montreal, Canada

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