How hiccups revealed a life-threatening condition

After experiencing hiccups for over two weeks, a 55-year-old Japanese man visited a local clinic to seek treatment. At the time, he also reported having a persistent cough and insomnia.

At the clinic, initial laboratory and chest radiograph tests were "unremarkable," the researchers wrote. The man was given a short-acting beta-agonist inhaler, clarithromycin, and a traditional herbal treatment for his hiccups and other symptoms.

However, the man continued to experience hiccups for several days even though he saw improvement in his cough. He returned to the same clinic, and this time was prescribed vonoprazan for gastroesophageal reflux disease and the muscle relaxant dantrolone.

After seeing no improvement from the new treatments, the man was referred to the study's authors, Hikaru Sedogawa from Saiseikai Niigata Kenoh Kikan Hospital and Takeshi Ueda from Rakuwakai Marutamachi Hospital.

Although Sedogawa and Ueda noted that the patient had a history of dyslipidemia, most baseline tests showed no abnormal findings. The patient also did not report any chest pain, dyspnea, hemoptysis, syncope, lower extremity edema, or recent immobilization.

Due to the lack of findings, Sedogawa and Ueda scheduled the patient for an upper gastrointestinal endoscopy and contrast-enhanced CT scan of the torso. They also stopped all the patient's medications.

Although the endoscopy showed no abnormalities, the CT scan showed "filling defects," or areas of darkness that can indication an occlusion or blockage, in both pulmonary arteries. A Doppler ultrasound also showed thrombus formation in the right femoral vein.

Following the diagnosis, the man was given direct oral anticoagulation, and his hiccups went away within a week. Follow-up testing for other clotting disorders came back negative, and the man was told to continue taking anticoagulants. Since then, his hiccups have not returned, and he has not reported any other symptoms.

Commentary

LuLu Wang, an emergency physician at MedStar Health, said a case like the patient's is rare and that she has only seen one similar case in her decade-long career.

According to Wang, she wouldn't "jump to a CT as the first line of investigation" for hiccups unless they weren't responsive to initial treatment, lasted for an extended period of time, or the patient had other symptoms, such as chest pain, high heart rate, low oxygen, one-sided leg swelling or a recent surgery.

"What worked really well in this case was that the patient kept coming back," Wang said, nothing that the patient wasn't diagnosed until his third visit to a medical facility.

In the ED, "we always tell people, we're seeing you at a snapshot in time," she said. "If your symptoms aren't getting better, certainly if they're getting worse, or even if you're just concerned, come back. We're open 24/7."

Zubair Hasan, a pulmonologist and critical care physician at Long Island Jewish Medical Center, said that a "complex interplay" of nerve signaling between the lungs and brain could have been interrupted when the embolism disrupted blood flow to the lungs. This then could have irritated the vagus and phrenic nerves, which are responsible for breathing, cough, and hiccup reflexes — leading to the patient's persistent symptoms.

Hasan added that physicians need to "really listen" to patients and that patients should be open about any signs and symptoms they experience since "[t]he more detail you can give us, the better."

Sedogawa and Ueda also emphasized the importance of clinicians listening to patients and not dismissing their symptoms, saying that clinicians "should avoid trivializing persistent hiccups when respiratory symptoms coexist and should consider serious thoracic or cardiopulmonary disease."