Download Severe hiccups associated with intra-articular

Cent. Eur. J. Med. • 7(1) • 2012 • 63-65
DOI: 10.2478/s11536-011-0105-2
Central European Journal of Medicine
Severe hiccups associated with intra-articular
corticosteroid injection – A case report
Case Report
Boris Solun1*, Yakov Ori2
Hasharon Hospital, Rabin Medical Center,
Petah Tikva, 49100, Israel
1
2
Sackler Faculty of Medicine, Tel-Aviv University,
Ramat Aviv, 69978, Israel
Received 11 August 2011; Accepted 13 September 2011
Abstract: A hiccup is a sudden contraction of the inspiratory and diaphragmatic muscles followed by an abrupt closure of the glottis; that produces
a characteristic noise resulting from vibrations of the vocal cords. Brief episodes of hiccups are common in humans at all stages of life
and are usually benign. Prolonged attacks that last for days or weeks are considered a more serious phenomenon and may indicate an
underlying disorder warranting a comprehensive medical evaluation. These attacks have been associated with significant burden and
morbidity. The most common triggers for acute hiccups are linked with gastro-intestinal causes, such as the gastric distension that
occurs after an abundant meal, or with gastroesophageal disease. Sudden changes in temperature, excessive alcohol consumption,
as well as excitement or emotional stress, may also set off acute hiccups. Certain drugs, including benzodiazepines, barbiturates, and
many others, have been reported to induce hiccups. Drug-induced hiccups are diagnosed by exclusion of other causes and represent
a very unusual side-effect of drugs like corticosteroids. We present a case of hiccups associated with intra-articular Diprospan
(Betamethasone Sodium Phosphate) administration.
Keywords: Corticosteroids • Drugs • Hiccups
© Versita Sp. z o.o.
1. Introduction
The term “hiccup” is defined as a sudden, involuntary
contraction of the diaphragm and inspiratory muscles with
abrupt closure of the glottis that produces the characteristic sound [1]. Brief episodes of acute hiccups are common
in humans during all stages of life, are generally self-limited, and are frequently linked with an abundant meal, alcohol intake, or emotional distress. Persistent or protracted
hiccups lasting longer than 48 hours usually have multiple
possible etiologies, and often pose a diagnostic dilemma;
they are associated not only with burden, but also with significant morbidity. Hiccups can occur at any age and are
equally prevalent in both sexes. However, persistent or
intractable hiccup attacks are more common in men [2].
Certain drugs, such as benzodiazepines, barbiturates,
corticosteroids, alpha methyldopa, and many others, may
cause hiccups [3].
We report a case of severe hiccups in a patient who
received intra-articular corticosteroid injection Diprospan (Betamethasone Sodium Phosphate) for intractable shoulder pain.
2. Materials and methods
A 42-year old man of Jewish descent with good performance status and with a personal history of heavy smoking and hyperlipidemia suffered long-term from pain in
the left brachio-clavicular region. The pain was resistant
to treatment with different NSAIDs (non-steroidal antiinflammatory drugs) and prolonged physiotherapy. An
orthopedic examination diagnosed left frozen shoulder.
His medical treatment at that time included rosuvastatin
20 mg once daily and etoricoxib 90 mg once daily. There
was no history of a known drug allergy. Laboratory data
were within the acceptable limits. There was no history
* E-mail: [email protected]
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Severe hiccups associated with intra-articular
corticosteroid injection – A case report
of alcohol consumption in the 24 h before the onset of
hiccups, and there was no clinical evidence of any gastrointestinal, central nervous system, cardiovascular, renal, or metabolic disorder.
He visited the outpatient clinic with severe hiccups
after receiving an intra-articular injection of 6 mg/2 ml
of Diprospan (Betamethasone Sodium Phosphate) for
the first time, through posterior approach using a 17G
needle. Physical examination after the procedure, including auscultation, revealed no any other problems.
Therefore, an X-ray examination was not done.
Hiccups developed within approximately 12 hours
after the Diprospan injection, and continued for about 1
day, producing a considerable distress. He sought medical assistance after home-remedy attempts had failed.
The hiccups stopped following a Valsalva maneuver
without an additional medical treatment.
3. Discussion
Hiccups are usually an idiopathic and nonspecific symptom. Occasional brief bouts of hiccups are very common
in humans. Many conditions are associated with hiccups, but the most frequent are gastrointestinal in origin.
Eating too fast or too much, especially fatty food, as well
as too much drinking, and alcohol intake—all may be
the causes of hiccups. In these instances, the stomach,
which sits just beneath and adjacent to the diaphragm,
is distended or stretched. Other possible causes include
pharyngitis, foreign bodies in the oropharynx and ear,
pneumonia, glaucoma, and others. Besides those possibilities, the patient’s emotional state, a sudden change
in room temperature or inside the stomach, and excessive smoking, are well-known benign causes of hiccups
and are usually self-limiting. The more serious, and also
common, causes such as gastroesophageal reflux disease (GERD), gastroenteritis, gastritis, and small bowel
obstruction, require medical or surgical therapy, and
should not be ignored [4,5].
Drug-induced hiccups may be diagnosed after
excluding other causes and are very unusual side effects of drugs like high dose corticosteroids, benzodiazepines, general anesthetics, NSAID’s, methyldopa,
antibiotics, and many others [6]. The exact incidence of
corticoid-associated hiccups is unknown. Despite their
wide use in general practice, the medical literature comprises only a short list of letters or brief reports indicating
that the true hiccups incidence is either quite low or underreported and unrecognized because the attacks are
so mild and self-limiting [7].
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The physiologic mechanism of hiccups originally
proposed by Bailey in 1943 proposed that hiccups result from stimulation of one or more components of the
hiccups reflex arc: the afferent, central, and efferent
limbs [8]. The afferent limb contains the phrenic and
vagus nerves and the sympathetic chain arising from
the thoracic segments T6-12. The central connection
between the afferent and efferent limbs is not ascribed
to a specific anatomic location in the spinal cord; it
probably lies between C3 to C5, and involves interactions within the brainstem and the midbrain areas as
well. The efferent portion of the arc primarily consists
of the phrenic nerve, the glottis, accessory respiratory
muscles, and multiple interactions between the brainstem and midbrain areas that involve the respiratory
center, phrenic nerve nuclei, medullary reticular formation, and hypothalamus [9].
The mechanism of corticosteroid-induced hiccups
is unknown, but the etiology is complex. It has been
suggested in animal studies that corticosteroids may
stimulate the hiccup reflex arc and reduce the synaptic
transmission threshold in the midbrain, thus affecting
the metabolism of brain neurotransmitters. Moreover,
stimulation of numerous steroid receptors within the efferent limb, including the medullary reticular formation,
respiratory center, and hypothalamus in the hiccup reflex arc, lead to hiccups [9]. Standard doses of corticosteroids penetrate the brain only to a limited degree,
but an exceedingly high dose can activate receptors in
the hippocampus and hypothalamus as well as within
the efferent limb of the hiccup reflex arc, thus leading
to hiccups [10].
Nonpharmacologic techniques for stimulation of the
nasopharynx and the vagus nerve, which runs from the
brain to the stomach, can decrease hiccupping. Carotid massage, hyperventilation, breath holding, and the
Valsalva maneuver have all been employed to control
hiccups. Although these remedies may be effective at
times, and are generally sufficient to resolve the simple
acute bouts, they may not be effective in patients with
persistent drug-induced hiccups. In these cases, pharmacologic intervention is required. The first-line medication prescribed for hiccups is usually chlorpromazine. Other medications used to treat hiccups include
haloperidol and metoclopramide. For more serious
cases muscle relaxants, sedatives, analgesics, and
even stimulants have also been used to alleviate hiccup symptoms. Phrenic nerve surgery is a last-choice
treatment. It is a rarely performed procedure, and used
only after other treatments have failed [11].
B. Solun et al.
References
[1] Bizec JL., Launois S., Bolgert F., Lamas G., Chollet
R., Derenne JP., Hiccups in adults, Rev. Mal Respir.,
1995,12, 219-29
[2] Liaw CC., Wang CH., Chang HK., Wang HM., Huang
JS., Lin YC., et al., Cisplatin-related hiccups: male
predominance, induction by dexamethasone, and
protection against nausea and vomiting, J. Pain
Symptom Manage, 2005, 30,359-66
[3] Bagheri H., Cismondo S., Montastruc JL., Druginduced hiccup: a review of the France pharmacologic
vigilance database, Therapie, 1999, 54, 35-9
[4] Federspil PA, Zenk J. Hiccup. HNO, 1999, 47,86775
[5] Javot L., Scala-Bertola J., Petitpain N., Trechot P.,
Pere P., Gillet P., Methotrexate-induced hiccups,
Rheumatology (Oxford), 2011, 50,989-90
[6] Surendiran A., Krishna Kumar D., Adithan C.,
Azithromycin-induced hiccups, J. Postgrad. Med,
2008, 54,330-1
[7] Ross J., Eledrisi M., Casner P., Persistent hiccups
induced by dexamethasone, West J. Med., 1999,
170,51-2
[8] Kolodzik PW., Eilers MA., Hiccups (singultus):
review and approach to management, Ann. Emerg.
Med., 1991, 20,565-73
[9] Chuang-Chi Liaw, Cheng-Hsu Wang, Hsien-Kun
Chang, Hung-Ming Wang,
Jen-Sheng Huang,
Yung-Chang Lin, et al., Cisplatin-Related Hiccups:
Male Predominance, Induction by Dexamethasone,
and Protection Against Nausea and Vomiting, J.Pain
and symptom management, 2005, 30,359-66
[10] Cersosimo RJ., Brophy MT., Hiccups with high
dose dexamethasone administration, Cancer,
1998, 82, 412–414
[11] Lewis JH., Hiccups: causes and cures, J. Clin.
Gastroenterol., 1985, 7,539-52
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