Persistent Hiccups as a Rare Presenting Symptom of Pulmonary Embolism
A search of the medical literature (search for PE and intractable hiccups through Medline, the Cochrane library database and Google search engine) did not reveal any case series of hiccups as a presenting symptom of PE, although a single citation describing this entity was identified in the lay literature and one case report.– In 2 of our 3 patients, recent surgery was a risk factor for PE.\nA 52-year-old African-American male without significant prior medical or surgical history presented to the emergency department (ED) with a 3-day history of hiccups. He had had progressively worsening dyspnea for 4 weeks, a dry cough and pain in the upper right back associated with inspiration and coughing. He had increasing leg edema for 2 weeks and was told he had congestive heart failure at another institution, where he was advised admission, but left against medical advice. The rest of his review of systems (ROS) was unremarkable and he had no risk factors for deep venous thrombosis (DVT), such as family history of clotting disorder or personal history of immobilization, long journeys, surgery or trauma. He had quit occasional smoking many years ago and did not use alcohol or narcotic drugs.\nPhysical examination revealed a well-built male in mild respiratory distress with a respiratory rate (RR) of 20 breaths/minute, pulse rate (PR) of 108 beats/minute and blood pressure (BP) 113/76 mmHg. His oxygen saturation was 89–91% on room air. His electrocardiogram (EKG) was normal except for sinus tachycardia, and a duplex ultrasound of his lower extremities was negative for DVT. His portable chest radiograph (CXR) was the first hint of abnormality (), showing a prominent pulmonary central artery (early Fleishner’s sign, red arrow heads) and a pruned tree /cut off of the pulmonary arteries (Westermark’s sign, black arrows). With the working diagnosis of PE, a computed tomography (CT) of the chest with intravenous (IV) contrast was performed which revealed a massive saddle embolus of the pulmonary artery (). Patient was heparinized and transferred to a tertiary center where pulmonary thrombectomy was performed. He made a full recovery with resolution of hiccups and dyspnea. His laboratory examination with complete blood count (CBC), complete metabolic panel (CMP), prothrombin time (PT)/international normalize ration (INR) and partial thromboplastin time (PTT) was essentially normal. Workup for a coagulation disorder failed to reveal a reason for his embolus.\nA 40-year-old Hispanic female came for her follow-up gynecology appointment after undergoing total abdominal hysterectomy for fibroids under general anesthesia 12 days earlier. She complained of severe left lower back pain of 1-day duration and was referred to the ED to rule out renal colic. Her postoperative course was uneventful and she had been ambulating on post-operative day #1 and discharged home shortly after surgery. In the ED she spoke in fragmented sentences due to persistent hiccups. ROS and past medical history were unremarkable\nPhysical examination revealed a young female with hiccups and mild lower abdominal tenderness, but no signs of rhonchi, rales or crepitations in the chest. She was given dilaudid and morphine for back pain, but her PR was 110–120 beats/minute and BP 112/78 mmHg. Temperature was 100.7° Fahrenheit and RR 20 breaths/minute. Based on the previous case of PE presenting with hiccups, a diagnosis of pulmonary embolism was entertained. CXR was unremarkable, but EKG revealed S1T3Q3 changes (). CT chest revealed a large left pulmonary embolus (). Bedside duplex ultrasound did not show DVT. Her laboratory examination with CBC, CMP, PT, INR, and PTT was essentially normal. Workup for a coagulation disorder failed to reveal a reason for his embolus. She was started on IV heparin infusion and warfarin and discharged home with resolution of hiccups and back pain.\nA 46-year old African-American male presented to the ED with persistent hiccups 2 days after having left inguinal herniorrhaphy under general anesthesia. Surgery was uncomplicated and performed as an ambulatory procedure. He had been ambulating at home, but one day after surgery developed hiccups. His past medical history was unremarkable, but he had undergone right inguinal herniorrhaphy in 2008 without any adverse events or symptoms. He was a nonsmoker and drank no alcohol and denied any other risk factors for DVT.\nPhysical examination revealed a middle-aged man in no apparent distress except for hiccups. At presentation his temperature was 98° Fahrenheit, PR 81 beats/minute, BP 128/77 mmHg and RR 18 breaths/minute. ECG showed normal sinus rhythm. He was given chlorpromazine, which resolved his hiccups, and he was discharged home. On his way home the hiccups returned and he came back to the ED. A second dose of chlorpromazine failed to resolve the hiccups this time. He also complained of feeling dizzy and his BP was found to be low. A chest CT was ordered and revealed a pulmonary embolus (). His laboratory examination with CBC, CMP, PT, INR, and PTT was essentially normal. Workup for a coagulation disorder failed to reveal a reason for his embolus.