2019 Research Forum

Applicant: Phillip Aguìñiga-Navarrete RA Principal Investigator: Rachel O’Donnell MD

A Rare Case of Hiccups as the Only Presenting Symptom of an Underlying Pneumomediastinum

Rachel O’Donnell MD, Sean Sayani MD R3, Daniel Quesada MD, Kieron Barkataki DO, Phillip Aguìñiga-Navarrete RA

INTRODUCTION Hiccups (singultus) are often considered a benign condition however, as presented in this case, on rare occasions, it can be associated with more serious underlying pathologies.

PURPOSE We illustrate a case of a 36-year-old Hispanic male with a history of depression, anxiety and alcohol abuse presented to the emergency department secondary to persistent hiccups for 3 days. He expressed numerous singultous episodes per minute, resulting in an associated shortness of breath. He denied taking any medications. Social history consisted of drinking roughly six 24 ounce beers per day. He denied any history of previous/recent retching or vomiting. This patient’s vitals were stable, afebrile and no there were no other significant findings on exam (other than the patient’s repeated singultus). Labs were only significant for mildly elevated liver enzymes and an elevated D-dimer of 2267. Patient did not have an elevated white count and troponin was negative. Chest roentgenogram and electrocardiography (EKG) were performed and both were within normal limits. He was initially treated with chlorpromazine and his symptoms resolved. Before the patient was made aware of the lab findings and further workup could be ordered he left our department. He was then subsequently contacted and made aware of the results and he arrived the next day for further evaluations. Singultus had resolved and had not relapsed on the second presentation. Computed tomography (CT) angiogram of the chest was ordered due to concern of pulmonary embolism. CT angiogram was significant for right-sided pneumomediastinum extending into the neck. (Figure 1) Thoracic surgery was consulted and recommended a barium esophagram, which did not show any esophageal pathology. The patient was discharged with a follow up chest roentgenogram in one week, which did not show any signs of pneumomediastinum. DISCUSSION Numerous triggers can cause activation of the hiccup reflex pathway. These can range from etiologies that are benign such as gastric distention to more acute scenarios. The underlying mechanism is that of an increase of intrathoracic pressure caused by the singultus leading to alveolar rupture. This in turn may cause SPM. CONCLUSION In terms of managing and treating singultus and SPM a thorough workup must be initially done to identify possible underlying etiologies. Treatment in both cases are multimodal and in rare instances require more invasive procedures

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