His Hiccups Signaled a Life-Threatening Problem

A middle-aged man’s persistent hiccups were a sign of a much more severe problem, clinicians wrote in a case report.

The 55-year-old man first went to a local clinic seeking help for hiccups that lasted more than 2 weeks, as well as nonproductive cough and insomnia that followed, according to Hiraku Sedogawa, MD, of Saiseikai Niigata Kenoh Kikan Hospital in Niigata, Japan, and Takeshi Ueda, MD, of Rakuwakai Marutamachi Hospital in Kyoto.

He initially was given a short-acting beta-agonist inhaler, clarithromycin, and a traditional Japanese herbal treatment, but his symptoms persisted, they reported in the Annals of Internal Medicine: Clinical Cases.

When his symptoms persisted for several more days, he went back to the clinic. This time he was given vonoprazan for presumed gastroesophageal reflux disease, along with the muscle relaxant dantrolene.

Without any additional improvement, he was referred to the authors, who wrote that most baseline tests turned up normal — though the patient did have a history of dyslipidemia.

Given the lack of findings, they scheduled an upper gastrointestinal endoscopy and contrast-enhanced CT scan of the torso for 1 week later. They also stopped all of his medications.

The CT scan revealed “filling defects” — areas of darkness on the scan that can signal occlusion or blockage — in both pulmonary arteries. Doppler ultrasound also revealed thrombus formation in the right femoral vein.

With no abnormalities on endoscopy, the authors diagnosed deep vein thrombosis (DVT)-associated pulmonary embolism and immediately started the man on direct oral anticoagulation.

His hiccups went away within a week, and after follow-up testing for other clotting disorders came back negative, was told to continue on his anticoagulants. He remains asymptomatic and his hiccups haven’t returned, the authors reported.

Lulu Wang, MD, an emergency physician at MedStar Health in Washington, D.C., who wasn’t involved in the case report, noted that a case like this is rare; she’s only seen one similar case in her decade-long career.

Wang said she wouldn’t “jump to a CT as the first line of investigation” for hiccups unless they weren’t responsive to first-line treatment, lasted for an extended period of time, or the patient had co-occurring 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 told MedPage Today. It wasn’t until the patient’s third visit to a medical facility that he received a diagnosis, she pointed out.

In the emergency department, “we always tell people, we’re seeing you at a snapshot in time. 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, MD, a pulmonologist and critical care physician at Long Island Jewish Medical Center in New Hyde Park, New York, offered a potential explanation as to why pulmonary embolism could have triggered the hiccups. It’s likely that the “complex interplay” of nerve signaling between the lungs and the brain was interrupted when the embolism disrupted blood flow to the lungs.

That could have irritated the vagus and phrenic nerves in particular, which are responsible for breathing and cough and hiccup reflexes, Hasan said.

He added that physicians need to “really listen” to the patient, and that patients should be open to sharing any signs and symptoms they experience — nothing is too small. “The more detail you can give us, the better,” he said.

Sedogawa and Ueda emphasized that clinicians “should avoid trivializing persistent hiccups when respiratory symptoms coexist and should consider serious thoracic or cardiopulmonary disease.”