Clinical Reasoning: A 44-year-old man with a 3-month history of hiccups

Abstract

A 44-year-old right-handed African American man with a 1-year history of seizures was admitted for further evaluation. During a previous hospitalization for status epilepticus, MRI revealed a brain lesion, but the patient refused biopsy. Over a 3-month period, he developed unrelenting hiccups which fluctuated in frequency. His only other symptom was headache relieved by acetaminophen. The patient denied photophobia, phonophobia, and visual changes associated with the headache. He had a history of hypertension and a left above-the-knee amputation (AKA) for osteosarcoma as a child. His general medical examination revealed the left AKA but was otherwise unremarkable. He was alert, oriented, and executive functions were intact. Vision was 20/20 in both eyes, extraocular movements were intact, and pupils were equal and reactive. There was no papilledema. He had a flattened right nasolabial fold. Motor, sensory, and cerebellar function were intact. Hiccups persisted throughout the interview. Their frequency remained relatively constant, and they often interrupted the patient's speech. ### Questions for consideration: 1. How are hiccups classified based on their time course? 2. How are hiccups generated and what is the pathophysiology in this patient? GO TO SECTION 2 Hiccups, or singultus, result from sudden closure of the glottis along with contraction of the inspiratory muscles.1 Bouts of hiccups lasting up to 48 hours are considered physiologic. However, persistent (lasting up to 2 months) or intractable (lasting greater than 2 months) hiccups have various etiologies.2 The pathophysiology of hiccups is not entirely clear, but …