Intractable hiccups as an unusual presentation of diabetes mellitus A Case Report

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Background

We present a case of intractable hiccups, which was a presenting manifestation of hyperglycemia due to the new onset of diabetes mellitus.

Case Report

A 38 year-old African-American male was admitted with a chief complaint of hiccups lasting over one month.  The hiccups persisted throughout the day and caused difficulty with breathing.  He denied any other complications.

He was diagnosed with HIV three years previously.  His recent CD4 lymphocyte count was 596 cells/mm3 and his HIV viral load was undetectable.  He had Hodgkin’s lymphoma, treated with splenectomy and chemotherapy 11 months prior to admission.  A CT of chest five months prior to admission showed no recurrence of lymphoma. His parents had diabetes mellitus type II.  His medications included atazanavir, ritonavir, emtricitabine-tenofovir, and morphine sulphate controlled-release (for chronic knee pain). Six weeks prior to admission, he did not have hiccups and laboratory testing showed a serum glucose of 66 mg/dl and a glycated hemoglobin (HbA1c) of 5.1%.

On physical examination, he was a well-nourished male in no acute distress.  The vital signs were stable and other tests were normal.  The serum glucose was 601 mg/dl and the HbA1c was 10.4%.  His capillary glucose normalized and his hiccups resolved after starting subcutaneous regular insulin and intravenous fluids.  He was discharged home to take metformin.

However, the patient stopped taking metformin due to nausea.  Soon thereafter, the patient began having intractable hiccups again.  He was switched to pioglitazone and glyburide and reported that his capillary glucose averaged around 100 mg/dl.  He had complete resolution of his hiccups.  Four months after discharge, his HbA1c level was 5% and had no recurrence of hiccups.

Discussion

Hiccups are normally transient and clinically insignificant. However, hiccups may become persistent and debilitating. Organic causes of intractable hiccups include vagus or phrenic nerve irritation, meningitis, gastroesophageal reflux, peptic ulcer disease, hiatal hernia, central nervous system mass, multiple sclerosis, uremia, hyponatremia, hypokalemia, hypocalcemia, and hypocarbia. 1   Intravenous and intra-articular corticosteroids 2 3 4  have been associated with precipitating hiccups. Interestingly case reports involving corticosteroids were not associated with concurrent hyperglycemia.

In our case, the patient developed intractable hiccups as a presenting symptom of diabetes mellitus.  He likely developed diabetes mellitus type II as result of protease inhibitor use and genetic predisposition.  To our knowledge, there has been one case in the medical literature of diabetes mellitus associated with intractable hiccups in a retrospective case review. 5    The details of that case were not reported in that study.  However, hyperglycemia and subsequent normalization were clearly involved in this patient’s intractable hiccups and resolution, respectively.  Clinicians should be aware that hyperglycemia may be an easily detected and treatable etiology for intractable hiccups.

References

  1. Hung YM, Miller MA, Patel MM. Persistent Hiccups Associated With Intravenous Corticosteroid Therapy. J Clin Rheumatol. 2003; 9:306-9,

  2. Iijima M, Uchigata M, Ohashi T, Kato H. Intractable hiccups induced by high-dose intravenous methylprednisolone in a patient with multiple sclerosis. Eur jou of Neurol2006; 13:201-2.

  3. Lewis JH. Hiccups: causes and cures. J Clin Gastroenterol. 1985; 7:539-52.

  4. MacGregor EG, Villalobos R, Perini L. Hiccups with betamethasone dipropionate. J Rheumatol. 2000; 27:819-20.

  5. Souadjian JV, Cain JC. Intractable hiccup. Etiologic factors in 220 cases. Postgrad Med 1968; 43:72-77.