Intractable Hiccups Research Articles

Vagal Nerve Stimulation for Intractable Hiccups

Vagal Nerve Stimulation for Intractable Hiccups

Unusual neurological cause of intractable hiccups: A case report

Unusual neurological cause of intractable hiccups: A case report

Neuromyelitis optica spectrum disorder with acute brainstem manifestations as initial symptoms

ObjectiveTo explore the clinical features and prognosis of patients with neuromyelitis optica spectrum disorder (NMOSD) initially presenting with acute brainstem symptoms. MethodsThe clinical data of NMOSD patients admitted to two medical centers were collected. The clinical characteristics, laboratory data, neuroimaging features and prognoses of patients with NMOSD with acute brainstem manifestations as initial symptoms (NMOSD-BSMIS) were analyzed. The clinical features and prognosis of patients with NMOSD-BSMIS and patients with NMOSD with other manifestations as initial symptoms (NMOSD-OMIS) were compared. ResultsFifty-two patients (18.37 %, 52/283) initially presented with acute brainstem symptoms. Intractable nausea, vomiting or hiccups, diplopia, vertigo, headache, and facial hypoesthesia were the initial symptoms in most of the patients. The percentage of patients who were positive for serum aquaporin 4 (AQP4)-IgG antibodies was 81.63 % (40/49). MRI revealed that the lesions were usually located in the postrema, dorsal medulla oblongata, pons and other areas around the fourth ventricle. The early-stage misdiagnosis rate was 46.15 %. Compared with those in the non-misdiagnosed group, the age of onset of patients in the NMOSD-BSMIS group was older, and the proportion of patients admitted to the neurology department as the first department was lower in the misdiagnosed group. The annual relapse rate of patients who underwent NMOSD-BSMIS was significantly greater than that of patients who underwent NMOSD-OMIS (P < 0.01). ConclusionsNMOSD patients can initially present with different brainstem symptoms. The early misdiagnosis rate of NMOSD-BSMIS is high. Moreover, if patients are older or initially admitted to nonneurological departments, they are more likely to be misdiagnosed. Moreover, the annual recurrence rate of NMOSD-BSMIS is greater in the early stage.

Hiccups Should Not Be a Hiccup in Patient Care: Utilizing Inhaled Lidocaine for Intractable Hiccups

Hiccups Should Not Be a Hiccup in Patient Care: Utilizing Inhaled Lidocaine for Intractable Hiccups

Intractable cough and hiccups after resuscitation and acute coronary syndrome treatment successfully treated using the Kampo medicine bukuyoingohangekobokuto: A case report

BackgroundEven in patients who survive resuscitation through multidisciplinary treatment, minor persistent symptoms can make hospital discharge difficult. Herein, we report a case of myocardial infarction with intractable symptoms following resuscitation, which were successfully treated using Kampo medicine. Case presentationA 71-year-old man experienced intractable cough and hiccups following resuscitation for acute myocardial infarction. Despite successful invasive treatment for his cardiac condition, the patient's persistent symptoms hindered his recovery and discharge from hospital. The patient was diagnosed with qi and blood deficiency, qi stagnation, and fluid retention, before being prescribed the Kampo medicine “bukuryoingohangekobokuto (BRIHK)”. Within days of treatment initiation, his symptoms notably improved, allowing him to be discharged. ConclusionThis case highlights the potential of Kampo medicine for addressing post-resuscitation symptoms that are refractory to conventional treatments, and emphasizes the importance of integrating Kampo medicine with Western medical practices to enhance patient care and quality of life.

Intractable Singultus: Causes, diagnosis and treatment. A case report

IntroductionHiccups are involuntary, spasmodic contractions of the diaphragm and intercostal muscles that cause inspiration and are interrupted by closure of the glottis. Most sources define the term “persistent hiccups” as lasting more than 2 days and “intractable” as lasting more than 1 month. Both are most likely associated with a pathologic process. “Intractable hiccups” should lead to investigation of organic pathology. If it does not improve, it can interfere with the patient’s ability to eat, socialize and sleep, leading to a significant worsening of quality of life. “Intractable hiccups” are more frequent in men (91%), over 50 years of age. Women suffer from psychogenic hiccups more frequently than men. Anxiety or stress can trigger hiccups. Multiple neurotransmitters are involved.ObjectivesWe present a theoretical review on the topic.MethodsA bibliographic review on the topic.ResultsIn recent years, new trials and case series have been published, and regulatory agencies have issued new recommendations on the use of pharmacologic agents for this indication. The literature has described the efficacy of several pharmacologic agents in the empiric treatment of persistent and intractable hiccups. Most of these target dopaminergic and GABAergic receptors.Based on limited efficacy and safety data, Baclofen and Gabapentin can be considered as first-line treatment for intractable and persistent hiccups, as they suggest efficacy and are less likely to cause long-term side effects than standard neuroleptic agents. Dopamine blocking agents such as Metoclopramide, Chlorpromazine, and Haloperidol, could be used as second line. In one study, withdrawal of Benzodiazepines or addition of Pregabalin was found to help reduce hiccups.The patient we consulted came for persistent hiccups or singultus of 2 years of evolution. Organic pathology was ruled out. She related the onset of the symptoms to different stressors that had caused her anxiety. We administered Escitalopram and Gabapentin and indicated withdrawal of Bromazepam, which she started taking months ago. In follow-up appointments she reported a decrease in the intensity and frequency of the symptoms, with a notable improvement in her quality of life.ConclusionsConsidering all available evidence, a treatment algorithm with Baclofen is recommended as first-line therapy for persistent and intractable hiccups. Gabapentin may also be safe and effective in the long-term treatment of this condition, especially for patients with CNS disease. Metoclopramide is no longer recommended for long-term treatment of hiccups. Clinical experience also supports the use of Chlorpromazine and other neuroleptics for acute, but not long-term, treatment. Going forward, large multicenter studies will be needed to create an adequate evidence base for the treatment of persistent and intractable hiccups. Until then, guidelines will continue to be based on unreliable data and clinical experience.Disclosure of InterestNone Declared

Chlorpromazine-Induced Neurological Symptoms Mimicking Stroke in an Elderly Patient with Intractable Hiccups: A Case Report

Background: Chlorpromazine, a widely utilized antipsychotic medication, has been recognized for its efficacy in treating intractable hiccups through its antagonistic action on histamine H1, dopamine D2, and muscarinic M1 receptors. Despite its therapeutic benefits, there is a spectrum of potential side effects, including neurological symptoms such as drug-induced stuttering, which poses diagnostic challenges and may lead to unnecessary investigations. Objective: This case study aims to explore the paradoxical effect of chlorpromazine, which, while effectively treating an 80-year-old male patient's intractable hiccups, induced slurred speech and drowsiness, symptoms that resolved upon cessation of the drug. Methods: A comprehensive evaluation was conducted, involving the patient's clinical presentation, treatment regimen, and the temporal relationship between medication administration and symptom onset. Investigations included a complete blood count, C-reactive protein, liver function tests, COVID-19 antigen test, cardiac workup, and brain MRI. Treatment response and side effects were meticulously documented, with follow-up to assess the resolution of symptoms. Results: Following the administration of chlorpromazine (50mg orally), the patient's hiccups ceased, but he subsequently developed slurred speech and drowsiness. These symptoms were not present upon initial examination and resolved completely following the discontinuation of chlorpromazine. The brain MRI conducted to explore potential neurological causes was found to be insignificant, reinforcing the diagnosis of drug-induced neurological symptoms. Conclusion: While chlorpromazine remains a valuable treatment for intractable hiccups, healthcare providers must be vigilant about its potential to induce neurological symptoms. This case highlights the importance of recognizing drug-induced side effects to avoid unnecessary diagnostic procedures and emphasizes the need for ongoing research into the mechanisms underlying such adverse reactions.

Retracted: Observation of Clinical Efficacy of Anisodamine and Chlorpromazine in the Treatment of Intractable Hiccup after Stroke.

[This retracts the article DOI: 10.1155/2022/6563193.].

Lateral Medullary Syndrome Presenting as Section Persistent Singultus and Upper Motor Neuron Facial Palsy in a young Adult: A Rare Case

Lateral Medullary Syndrome (LMS) is a collection of different neurologic symptoms after cerebral haemorrhage/infarction. The areas most frequently afflicted are the cerebellum and the posterolateral portion of the brain stem’s medulla oblongata; the Posterior Inferior Cerebellar Artery (PICA) supplies blood. Dizziness, vertigo, nystagmus, nausea, ataxia, dysphagia, vomiting, hiccups, hoarseness, sensation impaired on half of the face, impaired thermal sensation and pain on the contralateral side of the limbs, trunk, ipsilateral face, along with Horner’s syndrome are amongst the typical symptoms of lateral medullary infarction. Hiccups are among the signs that are simple to ignore, although they can also result in oesophagitis, and respiratory depression, as Wallenberg’s syndrome is the most frequently reported. The authors discuss the case of a 30-year-old male who complained of recurrent, uncontrollable hiccups as an LMS-presenting symptom and was brought to our hospital. He arrived at our emergency room complaining of persistent, intractable hiccups and cerebellar symptoms on the left-side. In addition to being hypertensive, he had a long history of tobacco (chewing) and alcohol addictions dating back six years. He had 7, 9 and 10th cranial nerve involvement. The authors are reporting this case because the patient had Upper Motor Neuron (UMN)-type facial palsy, a rare presentation in LMS

The Etiology and Outcome of Area Postrema Syndrome in Childhood: Two Cases and a Literature Review

BackgroundArea postrema syndrome (APS), a rare childhood condition, manifests as intractable nausea and hiccups. APS has high diagnostic significance in neuromyelitis optica syndrome spectrum disorders (NMOSD) and can be the initial presentation of other critical diseases, including brainstem glioma. MethodsWe described two representative cases of unrelated Japanese patients with APS. An etiologic evaluation, including a detailed intracranial neuroradiological examination and autoantibodies assessment, was performed. We also reviewed the literature focusing on the prognosis of pediatric APS symptoms. ResultsA 14-year-old girl with aquaporin-4 antibody-positive NMOSD showed a good prognosis with immunotherapy, whereas another nine-year-old girl with irresectable medullary low-grade glioma had persistent symptoms for more than 10 years. All reported children aged >12 years were diagnosed with NMOSD, and patients aged <13 years showed heterogeneous etiologies. ConclusionsDistinctive time courses and neuroimaging features were key clinical findings for the diagnostic and therapeutic processes in these patients. This literature review highlights the wide spectrum and prognosis of pediatric-onset APS.

Abstract 107: Endovascular Therapy for Tandem Vertebral and Basilar Artery Occlusion in a Patient with Low NIHSS

Introduction Basilar artery occlusion (BAO) is a devastating minority stroke subtype with variable clinical presentations and high mortality.1,2 The National Institute of Health Stroke Scale (NIHSS) cutoff for poor outcomes is lower in BAO compared to anterior circulation large vessel occlusions (LVO) due to the scale’s weighted scoring towards cortical signs.3,4 To bridge this gap, Alemseged et.al created the underutilized posterior circulation (PC) NIHSS as an improved stroke assessment tool in PC LVO to better identify endovascular therapy (EVT) candidates. 5 Current randomized trials point to mixed evidence regarding EVT for BAO; although recent studies such as Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION)6 and Basilar Artery Occlusion Chinese Endovascular Trial (BAOCHE)7 suggest positive results of EVT within 24hrs. Smaller retrospective subgroup analyses demonstrated EVT for BAO with low NIHSS has good clinical outcome of modified Rankin Scale (mRS) 0‐2 at 3 months in 60‐70% of patients4,8. We present a case of tandem vertebrobasilar artery occlusion in a patient with subacute symptoms and low NIHSS treated with mechanical thrombectomy. Methods '‐ Results 41‐year‐old male with past medical history of hypertension, insulin dependent diabetes and active smoking presented with worsening vertigo, nausea and vomiting for 3 weeks with progression to right sided headache and syncope. EMS noted right facial weakness prompting transport to nearest primary stroke center where CT head non‐contrast showed right cerebellar infarct and CT angiogram (CTA) head and neck showed right vertebral artery occlusion with basilar extension. Intravenous thrombolytic (IVT) was deferred due to unclear last known well. He was treated with aspirin 324mg and transferred to our tertiary stroke center. Arrival NIHSS was 1 for right upper extremity ataxia. Premorbid mRS was 0. Repeat CTA redemonstrated right vertebrobasilar artery tandem occlusion. CT perfusion was without mismatch. Patient underwent emergent mechanical thrombectomy with ADAPT to TICI3 revascularization with future plan for possible angioplasty and stenting of R vertebral stenosis. Subsequently admitted to neurocritical care unit and treated with dual antiplatelet therapy. Initially maintained on aspirin and Cangrelor infusion, then transitioned to aspirin and Plavix without hemorrhagic conversion. Diffusion weighted MRI brain showed right cerebellar and right pontine infarcts. Hospital course was complicated by severe intractable hiccups due to area postrema syndrome; ultimately resolved with baclofen and gabapentin after extensive unsuccessful medication trails. NIHSS remained 1 for ataxia throughout admission, although exam also revealed mild unsteady gait requiring home physical therapy and a walker on discharge. Post‐stroke mRS was 1 on discharge; 3‐month mRS is pending. Conclusion Evidence regarding EVT for low NIHSS BAO remains varied with some studies showing superior benefit with IVT alone9 while others suggest improved outcomes with EVT in mild to moderate deficits.4,8 One prospective study particularly revealed better outcomes in EVT for BAO due to tandem occlusions similar to this case.10 Given the potential devastating sequalae of BAO and limited overall treatment options, EVT should remain a strong contender for treatment of PC LVO, especially in patients with milder neurologic deficits or tandem occlusions. Additionally, heightened use of PC‐NIHSS may better prognosticate candidates for EVT.

A Case Report of Korean Medicine Treatment for an Intractable Hiccup Patient with Unknown Cause after a Traffic Accident

Objectives: The purpose of this study was to report a case of a woman with intractable hiccups after a traffic accident through Korean medicine treatment.Methods: A combination of treatments, including herbal medicine (&lt;i&gt;Soshiho-tang&lt;/i&gt;), pharmacopuncture, acupuncture, Chuna, cupping, and moxibustion, was administered to the patient for 21 days. The frequency and duration of hiccups, the degree of body shaking, and total sleep time were measured daily. The accompanying symptoms were measured daily using the Visual Analogue Scale.Results: After Korean medicine treatment, Hiccup symptoms disappeared. Further, the degree of clinical symptoms and QOL improved significantly after Korean medicine treatment. No adverse events were observed.Conclusions: This study suggests that Korean medicine treatment can be an effective treatment for intractable hiccups after traffic accidents.

B-101 Aquaporin 4 and Neuromyelitis Optica Spectrum Disorders

Abstract Background Neuromyelitis óptica (NMO) is a rare demyelinating inflammatory disease of the central nervous system, characterized by acute optic neuritis (ON) and transverse myelitis (TM). Previously, it was considered as a variant of multiple sclerosis (MS), however, there are now several clinical, laboratory, neuroimaging and pathological anatomical features that distinguish it from MS as the presence of a specific autoantibody in blood called IgG-NMO or anti-AQP4 that binds to water channels named aquaporin-4 (AQP4) expressed on astrocytes and plays a key role in the pathogenesis of this disease. Some patients remain seronegative for AQP4-IgG despite a definite diagnosis of NMO and the use of the finest methods for antibody detection. In anti-AQP4 seronegative forms, antibodies against myelin oligodendrocyte glycoprotein (MOG) may be identified. We have carried out a review of those patients with anti-AQP4-IgG detected in the autoimmunity laboratory during the last 3 years. Methods Each year we receive an average of 260 samples from patients with suspected demyelinating pathology with or without visual impairment. For the detection of antibodies against AQP-4 specifically HEK293 cells transfected were used as the standard substrate. Anti-MOG antibody can be detected in the same test. Measurement range: The dilution starting point for this measurement system is 1:10 (serum/plasma) and 1:1 (CSF, undiluted). Results A total of 5 patients were positive for anti AQP-4 antibody in serum samples, all women aged between 23 and 78 years. All patients except the youngest, who presented to the neurology department for loss of visual acuity, had other autoimmune diseases: systemic lupus erythematosus (SLE) in conjunction with rheumatoid arthritis, SLE in conjunction with Graves’ disease and hypothyroidism, the two oldest (59 and 78 years), respectively. The oldest patient was admitted to the internal medicine department for persistent nausea, vomiting and hiccups and was diagnosed as NMO spectrum disorder. In all cases, the oligoclonal immunoglobulin G bands study in CSF was negative. None of the CSF samples tested were positive for anti AQP-4 antibody. All patients were treated with methylprednisolone, but treatment with azathioprine or rituximab was necessary in 3 patients. Conclusion Titers of antibodies against AQP-4 are significantly higher in serum than in CSF, with serum being the most sensitive simple. NMO is more prevalent in women than men, with a female predominance usually higher than observed in MS. The median age of onset is also higher than MS, with a median of 35–45 years. Since the discovery of AQ-4 antibodies, there has been an increase in the number of clinical and radiological manifestations of NMO beyond involvement of the optic nerve and the spinal cord, including manifestations in the brain. It is important to recognise them in order to make an early diagnosis, to avoid unnecessary complementary tests and to establish the most suitable treatment. Persistent and intractable hiccups and nausea may occur in 17%–43% as in our oldest patient’s case. Associations with organ-specific autoimmune diseases such as autoimmune thyroiditis, and non-organ-specific diseases such as SLE and Sjögren’s syndrome have been described.

Clinical features of MOGAD with brainstem involvement in the initial attack versus NMOSD and MS.

To assess the characteristics of Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disorder (MOGAD) with brainstem involvement in the first event (BSIFE) and make comparisons with aquaporin-4-IgG seropositive neuromyelitis optica spectrum disorder (AQP4-IgG-NMOSD) and multiple sclerosis (MS). From 2017 to 2022, this study identified MOG-IgG-positive patients with brainstem or both brainstem and cerebellum lesions in the first episode. As a comparison group, AQP4-IgG-NMOSD (n=30) and MS (n=30) patients with BSIFE were enroled. Thirty-five patients (35/146, 24.0%) were the BSIFE of MOGAD. Isolated brainstem episodes occurred in 9 of the 35 (25.7%) MOGAD patients, which was similar to MS (7/30, 23.3%) but was lower than AQP4-IgG-NMOSD (17/30, 56.7%, P=0.011). Pons (21/35, 60.0%), medulla oblongata (20/35, 57.1%) and middle cerebellar peduncle (MCP, 19/35, 54.3%) were the most frequently affected areas. Intractable nausea (n=7), vomiting (n=8) and hiccups (n=2) happened in MOGAD patients, but EDSS of MOGAD was lower than AQP4-IgG-NMOSD (P=0.001) at the last follow-up. MOGAD patients with or without BSIFE did not significantly differ in terms of the ARR (P=0.102), mRS (P=0.823), or EDSS (P=0.598) at the most recent follow-up. Specific oligoclonal bands appeared in MOGAD (13/33, 39.4%) and AQP4-IgG-NMOSD (7/24, 29.2%) in addition to MS (20/30, 66.7%). Fourteen MOGAD patients (40.0%) experienced relapse in this study. When the brainstem was involved in the first attack, there was an increased likelihood of a second attack occurring at the same location (OR=12.22, 95%CI 2.79 to 53.59, P=0.001). If the first and second events were both in the brainstem, the third event was likely to occur at the same location (OR=66.00, 95%CI 3.47 to 1254.57, P=0.005). Four patients experienced relapses after the MOG-IgG turned negative. BSIFE occurred in 24.0% of MOGAD. Pons, medulla oblongata and MCP were the most frequently involved regions. Intractable nausea, vomiting and hiccups occurred in MOGAD and AQP4-IgG-NMOSD, but not MS. The prognosis of MOGAD was better than AQP4-IgG-NMOSD. In contrast to MS, BSIFE may not indicate a worse prognosis for MOGAD. When patients with BSIFE, MOGAD tent to reoccur in the brainstem. Four of the 14 recurring MOGAD patients relapsed after the MOG-IgG test turned negative.

Amantadine for the intractable hiccup when weaning a patient with a brainstem lesion-a case study.

Amantadine for the intractable hiccup when weaning a patient with a brainstem lesion-a case study.

Intractable hiccups after VNS implantation: a case report

BackgroundHiccups (medically termed, “singultus”), when intractable, can cause significant medical consequences such as aspiration, malnutrition, and depression, leading to poor quality of life. Several case reports have shown that vagus nerve stimulator (VNS) implantation can help treat central idiopathic intractable hiccups. However, we present a contrary case of a patient who developed intractable singultus following VNS placement for medically refractory epilepsy.Case presentationWe report a 71-year-old male patient with drug-resistant epilepsy who underwent VNS implantation and developed intractable hiccups shortly thereafter. The hiccups were severe and persistent, such that the patient developed a Mallory-Weiss tear, which required intensive care, invasive intubation and mechanical ventilation, and a prolonged rehabilitation course. Despite multiple therapies including phrenic nerve block and Nissen fundoplication, the patient’s hiccups persisted and only stopped once the VNS was permanently deactivated.ConclusionsLittle is known about the incidence of hiccups after VNS implantation. We present one case of hiccups as a direct consequence of VNS implantation. The clinical impact of this report is significant given the relative unfamiliarity of hiccups as an adverse effect of VNS implantation. Neurologists and epileptologists, who present VNS implantation as a surgical option for seizure control to their patients, should be aware of the possibility of singultus development and its significant physical and emotional ramifications.

Intractable Hiccups and Belching: Approach, Evaluation, and Treatment

Intractable Hiccups and Belching: Approach, Evaluation, and Treatment

Analysis of the clinical characteristics and misdiagnosis of area postrema syndrome manifesting as intractable nausea, vomiting, and hiccups in neuromyelitis optica spectrum disorders

Objective: To investigate the misdiagnosis of area postrema syndrome (APS) manifesting as intractable nausea, vomiting and hiccups in neuromyelitis optic spectrum disease (NMOSD) and reduce the risk of misdiagnosis. Methods: We retrospectively analyzed data from NMOSD patients attending the Department of Neurology at the First Medical Center of PLA General Hospital between January 2019 and July 2021. SPSS25.0 was then used to analyze the manifestations, misdiagnosis, and mistreatment of APS. Results: A total of 207 patients with NMOSD were included, including 21 males and 186 females. The mean age of onset was 39±15 years (range: 5-72 years). The proportion of patients who were positive for serum aquaporin 4 antibody was 82.6% (171/207). In total, 35.7% (74/207) of the NMOSD patients experienced APS during the disease course; of these patients, 70.3% (52/74) had APS as the first symptom and 29.7% (22/74) had APS as a secondary symptom. The misdiagnosis rates for these conditions were 90.4% (47/52) and 50.0% (11/22), respectively. As the first symptom, 19.2% (10/52) of patients during APS presented only with intractable nausea, vomiting and hiccups; 80.8% (42/52) of patients experienced other neurological symptoms. The Departments of Gastroenterology and General Medicine were the departments that most frequently made the first diagnosis of APS, accounting for 54.1% and 17.6% of patients, respectively. The most common misdiagnoses related to diseases of the digestive system and the median duration of misdiagnosis was 37 days. Conclusions: APS is a common symptom of NMOSD and is associated with a high rate of misdiagnosis. Other concomitant symptoms often occur with APS. Gaining an increased awareness of this disease/syndrome, obtaining a detailed patient history, and performing physical examinations are essential if we are to reduce and avoid misdiagnosis.

What’s the Cure for These Hiccups?: A Case of Area Postrema Syndrome due to Ventriculitis (P8-10.006)

<h3>Objective:</h3> N/a <h3>Background:</h3> 59-year-old man with history of diabetes and hypertension who presented for confusion, generalized weakness, and intractable nausea and vomiting. <h3>Design/Methods:</h3> N/a <h3>Results:</h3> Initial evaluation revealed diabetic ketoacidosis with blood pH of 7.16 and serum glucose &gt;500. CT Head W/O contrast was unremarkable. CT Chest/Abd/Pelvis showed multiple liver abscesses and bilateral pulmonary emboli. Patient was admitted to surgical ICU for acute management and hepatic drains. His urine, liver and blood cultures grew Klebsiella pneumoniae. On hospital day 5, MR brain W/+ W/O was obtained for worsening encephalopathy. This showed multifocal punctate infarcts and diffusion-restricting-fluid layering within the lateral ventricles and fourth ventricle. Transthoracic echocardiogram revealed a hypermobile mass attached to the aortic valve. General exam was notable for intractable hiccups; mental status and neurologic exam was unremarkable. <h3>Conclusions:</h3> Bacterial ventriculitis is a severe complication of CNS infections with a mortality rate of 42%. Common presenting symptoms are fever, headache, photophobia, phonophobia and nausea. To this date, area postrema syndrome (APS) has not been documented as one of its sequelae. APS is usually associated with NMO-SD and characterized by intractable nausea, vomiting, and hiccups secondary to anti-AQP4 mediated damage to the circumventricular organ of the 4^th ventricle, the <i>area postrema.</i> The area postrema is located within the dorsal medulla and made up of fenestrated capillaries and sensory neurons that together form the chemoreceptor trigger zone responsible for, amongst other functions, detecting toxins in the blood to induce emesis. It may be susceptible to any chemical stimuli within the ventricular system, including the purulent exudates of an active infection. The diffusion restriction within the caudal 4^th ventricle and dorsal medulla of this patient’s MRI suggests a plausible substrate for area postrema syndrome and establishes bacterial ventriculitis as one of its possible etiologies. <b>Disclosure:</b> Dr. Wadood has nothing to disclose. Dr. Etter has nothing to disclose. Dr. Falero Pomales has nothing to disclose.

Area postrema syndrome: Intractable hiccups and vomiting as a result of neuromyelitis Optica Spectrum disorder

A 31 year old woman was referred to the medical team for further investigation of intractable hiccups and vomiting. Initial investigations including blood tests, endoscopy and CT imaging did not identify any cause of symptoms. Following multidisciplinary team review, serial MRI Head imaging was arranged, which revealed progressive posterior fossa signal abnormality with involvement of the area postrema. In combination with a positive serum Aquaporin-4 antibody result, this helped establish a diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD). Treatment included high dose steroids, plasma exchange and immunomodulatory therapy, and led to a marked improvement in symptoms. This case highlights the importance of utilising specialty team input and broadening lines of investigation, when managing patients with intractable hiccups and vomiting in whom an initial workup has not established a clear diagnosis. While NMOSD is rare, early identification can inform treatment strategies that may lead to a significant improvement in clinical outcome.