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Health See other Health Articles Title: What's in a Hiccup? Crack the Case Medscape: Clinical Presentation A 78-year-old man complained of 1 week of dizziness and a tendency to fall to the right. He had headache with nausea and vomiting and developed hiccups. He denied dysarthria, dysphagia, sensory change, vertigo, and weakness. When the symptoms progressed so that he could no longer walk, he came to the hospital. Medical history was notable for hypertension, chronic obstructive pulmonary disease, hyperlipidemia, migraine, and depression. Medications on admission included aspirin 81 mg/day, atorvastatin 10 mg/day, lisinopril 30 mg/day, verapamil 240 mg/day, and escitalopram 20 mg/day. He has no allergies, doesn't smoke, but drinks 4 highballs/day. He is retired and lives in a mobile home. Review of symptoms included chronic upper extremity tremor, left greater than right. He normally walks with a cane. Family history was noncontributory. Physical exam revealed normal vital signs, a cardiac flow murmur, and no carotid bruits. Neurologic exam was remarkable for normal mental status, a small reactive right pupil, normal extraocular movements, a bilateral tremor with normal strength, symmetric reflexes and no Babinski sign, decreased pinprick in the left leg, past-pointing with finger to nose, worse on the right, and jerky heel-to-shin movements. He cannot walk without a walker and tends to fall to the right. He had trouble speaking because of intermittent hiccups. The most likely cause for this patient's constellation of symptoms that includes hiccups, dizziness, falling to the right, and headache -- with examination findings of anisocoria, normal strength, decreased pain sensation on the left leg, and ataxia -- is: Your Colleagues Responded: Alcoholic intoxication 8% Migraine 2% Hemispheric cerebrovascular accident 31% Brainstem cerebrovascular accident Correct Answer 59% Neuroimaging MRI of the brain revealed signal abnormality in the right medulla consistent with an acute brainstem stroke (Figure 1). On the T2 axial MR image, increased signal in the right lateral medulla and a partially thrombosed vertebral artery can be appreciated. Additional MRI findings included diffuse generalized atrophy, chronic ischemic white matter changes, and an old right basal ganglia lacunar infarction. On the 3-dimensional reconstructed angiogram, interruption of flow can be seen in the right vertebral artery (Figure 2, arrows). Figure 1. MRI T2 axial image with right lateral medullary infarct and thrombosed right vertebral artery. Figure 2. 3-dimensional reconstruction of angiogram with right vertebral occlusion. Additional Work-Up EKG had normal sinus rhythm. Transthoracic echocardiogram demonstrated an ejection fraction of 60%-65%, grade I diastolic dysfunction, mild aortic insufficiency, and mild aortic stenosis with a mean gradient of 12 mm Hg. Complete blood count showed a white cell count of 6.49 K/µL, hemoglobin of 12.3 g/dL, and platelets of 274 K/µL. Total protein was low at 6.2 g/dL and albumin low at 3.2 g/dL. Electrolytes, blood urea nitrogen, creatinine, metabolic panel, cholesterol, and triglycerides were normal. Clinical Course The patient complained of hiccups, which were intermittent but at times very distressing, interrupting speech, eating, and sleep. Hiccups improved after treatment with chlorpromazine 25 mg orally given up to 3 times/day. His ataxia and gait slowly improved with physical therapy, but he still needed a walker a week after admission. The most likely cause for the hiccups was: Your Colleagues Responded: Alcohol intoxication 4% Brainstem stroke Correct Answer 59% Parkinsonism 4% Diaphragmatic paralysis 33% Diagnosis The patient's symptoms of hiccups, dizziness, headache, and falling to the right associated with examination findings of anisocoria, normal strength, decreased pain on the left leg, and ataxia are most consistent with a diagnosis of lateral medullary (Wallenberg) syndrome. This is confirmed by the MR image (Figure 1) and supported by the angiogram demonstrating right vertebral occlusion. The lateral medullary syndrome is relatively uncommon, accounting for only 1.9% of all cerebral infarcts.[1] Classically, the lateral medullary syndrome is characterized by vertigo, dizziness and nystagmus (vestibular nucleus), nausea and vomiting (vestibular nucleus), dysphagia and dysarthria (cranial nerve X), and hiccups (imprecise localization). Ipsilateral symptoms include Horner's syndrome (sympathetic tract), loss of pain and temperature in the face (trigeminal tract), and ataxia (spinocerebellar tract). The only contralateral finding is impaired pain and temperature sensation due to involvement of the spinothalamic tract, which decussates in the spinal cord. Occlusion of the vertebral artery or its largest branch, the posterior inferior cerebellar artery (PICA), is the usual etiology. In this patient, the MRI shows a lateral medullary lesion and an accompanying thrombosis in the right vertebral artery, which is also seen on the reconstructed 3-dimensional angiogram. This patient had many features of the classic Wallenberg syndrome. However, he had only a partial Horner syndrome (small pupil, but no ptosis or anhydrosis) and no decreased facial sensation or vertigo. On exam, he did not have decreased sensation on the ipsilateral face or nystagmus. He had full strength bilaterally consistent with the lateral medullary localization that spares the pyramids (corticospinal tracts). Hiccups Hiccups may be defined as "repeated involuntary, spasmodic, and temporary contractions of the diaphragm accompanied by sudden closure of the glottis, producing a distinguishing 'hic' sound."[1] The physiologic purpose of hiccups is unknown. However, hiccups are not unimportant, particularly when persistent (> 48 hours) or intractable (> 2 months). Hiccups may cause patients considerable discomfort, as in this patient. Hiccups may be responsible for aspiration pneumonia, depression, esophagitis, respiratory depression, sleep deprivation, and weight loss.[1] Hiccups occur in 14%-26% of patients with lateral medullary syndrome.[1] The exact anatomic lesion responsible for the hiccups is unknown but appears to be in the medulla. Because of the extensive reflex arc for hiccups involving peripheral phrenic, vagal, and sympathetic pathways and midbrain, a wide variety of causes may be responsible, depending upon localization of the lesion (Table 1). Table 1. Causes of Persistent or Intractable Hiccups Central Nervous System Peripheral Other Brain trauma Abdomen (gynecologic tumors) Chemotherapy Herpes infection Cancer Drugs (antiparkinsonism treatment, azithromycin, morphine, psychiatric medications) Neuromyelitis optica and multiple sclerosis Chest (diaphragmatic tumors, lymphadenopathy, mediastinal diseases) Instrumentation (atrial pacing, bronchoscopy, catheter ablation, central venous catheterization, esophageal stent, shaving, tracheostomy) Parkinsonism Gastrointestinal (esophageal tumors, gastroesophageal reflux diseases, volvulus, Helicobacter pylori) Miscellaneous (chronic renal failure, electrolyte disturbance, ethanol, tuberculosis) Seizures Myocardial ischemia Steroids Tumor Surgery (anesthetics, postoperative complications) Vascular disease (aneurysm, stroke, systemic lupus erythematosis) From Chang FY, et al. J Neurogastroenterol Motil. 2012;18:123-130.[2] Treatment Most cases of hiccups are self-limited. Chlorpromazine is the only US Food and Drug Administration-approved treatment for intractable hiccups. Other commonly used drugs include baclofen, gabapentin, and metoclopramide. Many other drugs have been used including amantadine, antidepressants, calcium channel blockers, and intravenous lidocaine.[3] A multitude of nondrug therapies have also been tried, including acupuncture, breath holding, intranasal vinegar, and vagus nerve stimulation. Conclusions Another possible cause of this patient's hiccups is his excessive alcohol consumption, but the onset of hiccups in temporal association with his acute brainstem stroke implicates the latter. As of this writing, his gait was improving and the hiccups occurred less frequently. Because this patient had an ischemic stroke while taking aspirin, he was switched to another antiplatelet agent, clopidogrel. Post Comment Private Reply Ignore Thread
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