Persistent hiccups followed by cardiorespiratory arrest

Abstract

In January, 2011, a 78-year-old man was referred to us with syncope and persistent hiccups. He had had nausea and continuous hiccups 9 days earlier, and had fainted while visiting a local clinic. At our hospital, he had an immediate reduction in systolic blood pressure of 40 mm Hg and loss of consciousness after standing up after lying in a supine position for 5 min. Neurological evaluation showed a right hypoglossal nerve palsy, but MRI of the brain and spinal cord and cerebrospinal fl uid were normal. Chest radiography, gastroendoscopy, ECG, and echocardiography showed no abnormalities. Metoclopramide was prescribed for hiccups and amezinium metilsulphate for orthostatic hypotension. He was discharged because his symptoms improved. 2 weeks later he developed muscle weakness, and after 3 days could not walk. On readmission, he had dysarthria and dysphagia. Ophthalmoscopy showed no abnormalities. He had severe muscle weakness in his upper and lower limbs. CSF white blood cell count was 78 μL (99% lymphocytes) and protein concentration 1·03 g/L. MRI of the brain showed lesions in the medulla oblongata. We suspected acute disseminated encephalomyelitis, herpes simplex virus encephalitis, or neuromyelitis optica (NMO) spectrum disorder, and he was given methylprednisolone pulse therapy (1 g per day) and acyclovir 1500 mg per day. Despite treatment, his muscle weakness worsened. 1 week after completion of methylprednisolone pulse therapy, he had dyspnoea. Arterial blood gas fi ndings were unremarkable while on 2 L oxygen, so we planned MRI of the spinal cord the same day. His blood saturation level started decreasing, while he was in the