(P35) Hiccups as an Ominous Sign of Pulmonary Embolus

Chief Complaint : Shortness of breath and hiccups.

History of Present Illness : A 53-year-old male with a past medical history of stage IV metastatic pancreatic tail adenocarcinoma with liver metastasis presenting to the emergency department for shortness of breath and progressively worsening hiccups starting four days prior. The patient reports his symptoms have been constant He has tried home remedies to alleviate his hiccups without success. He denies fevers, lightheadedness, chest pain (pleuritic or exertional), palpitations, nausea, or a prior history of blood clots.

Pertinent Physical Exam: The patient is on 2 liters nasal cannula, jaundiced with scleral icterus, but otherwise well-appearing. He is is tachycardic to 133 beats per minute. Respiratory effort is non-labored, with equal and clear breath sounds bilaterally. The patient is able to speak full sentences only interrupted by hiccupping. Pulse oximetry was 97% on room air but he reports feeling more comfortable with nasal cannula oxygen.

Pertinent Laboratory Data: WBC 14.4, Hgb 9.5, Troponin negative, Total bilirubin 9.4
CT angiogram of the chest reveals bilateral pulmonary emboli, present in the right upper lobe anterior and posterior segmental pulmonary arteries, left lower lobe pulmonary artery, left lower lobe medial basal and anterobasal segment pulmonary arteries, and right lower lobe distal postero-basal segmental artery, without evidence of right heart strain.

Case Discussion: The patient presents with shortness of breath and hiccups in the setting of stage IV cancer that was refractory to Chlorpromazine. The patient is not hypoxic when arriving to the emergency department. A CTA chest shows bilateral pulmonary emboli. The patient is started on heparin and admitted to the hospital for two days, and subsequently discharged home on Eliquis. On follow up with the patient, he reports that his hiccups subsided one week following the initiation of heparin.

This patient likely had pulmonary emboli secondary to his cancer diagnosis as he had no other risk factors, however his presentation of hiccups is unique. Since symptoms of pulmonary emboli are highly variable among patient populations, a high index of suspicion is always necessary. Only a few cases of hiccups attributed to pulmonary emboli are documented in the literature. It is hypothesized in these reports that pulmonary emboli irritate the hiccup reflex arc resulting in presenting symptoms of our patient, however the exact mechanism is not well known.

References and Acknowledgements (Optional): Hassen, G. W., Singh, M. M., Kalantari, H., Yemane-Merriwether, S., Ferrante, S., & Shaw, R. (2012, December). Persistent hiccups as a rare presenting symptom of pulmonary embolism. The western journal of emergency medicine. Retrieved March 22, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555588/#:~:text=Pulmonary%20embolism%20may%20cause%20irritation,embolism%20presenting%20as%20persistent%20hiccups

Thind, M., & Cohen, D. A. (2017, September 8). Pulmonary embolism presenting as persistent hiccups. The American Journal of Medicine. Retrieved March 22, 2023, from https://www.amjmed.com/article/S0002-9343(17)30908-7/fulltext

Sansom, S., & Khorfan, O. (2015, October 27). Intractable hiccups: A benign nuisance or bad omen? - chest. Chest Journal. Retrieved March 22, 2023, from https://journal.chestnet.org/article/S0012-3692(16)36890-8/fulltext