Download A renal transplant patient with intractable hiccups and review of the

Case report
J. Rosenberger
E.Veseliny
L. Bena
R. Roland
Key words:
hiccups; transplantation; adverse e¡ects;
corticosteroids; esophagitis; pulmonary abscess
A renal transplant patient with
intractable hiccups and review of the
literature
Abstract: Intractable hiccups in transplanted patients may be caused by various
medical conditions including infections.We report a case of a 44 -year-old man who
su¡ered from intractable hiccups after cadaveric kidney transplantation.We
identi¢ed 3 di¡erent hiccup periods with di¡erent causes: 1) steroid and
anesthetics use, 2) severe ulcerose herpetic and mycotic esophagitis, and 3)
pleuropneumonia caused by nosocomial methicillin-resistant Staphylococcus
epidermidis and pulmonary abscess requiring thoracic surgery.
Hiccups, or singultus, are involuntary spasms of the diaphragm and in-
Authors’ a⁄liations:
J. Rosenberger1,
E.Veseliny2,
L. Bena1,
R. Roland1
1
Transplantation
Department, Faculty Hospital
of L. Pasteur, Kos›ice,
Slovak Republic
2
Internal Clinic, Medical
Faculty, University of PJ
Safa¤rik, Kos›ice,
Slovak Republic
tercostal muscles causing sudden inspiration and a characteristic sound.
They are usually benign and self-resolving. However, in some cases
chronic or recurrent hiccups are troublesome for the patient as well as
for the clinician (1). Persisting or recurrent hiccups that do not respond
to di¡erent therapeutic approaches are often a symptom of severe disorder (1^5). Table 1 shows the most important and most common clinical
conditions leading to persistent or repeated hiccups (1, 2, 4^6).
Case report
A cadaveric kidney was transplanted into a 44 -year-old man. His immunosuppressive regimen included a standardized protocol with steroids,
cyclosporine, and mycophenolate mofetil. The postoperative course was
characterized by primary graft function without any complications except for recurring hiccup episodes that began immediately after the patient woke up from anesthesia. These hiccups responded to treatment
with p.o. metoclopramide, and they were not severe. Presentation and
course suggested a medication-induced etiology related to steroid induction and/or anesthesia.
Received 2 March 2005, revised 14 June and 8 July 2005,
accepted for publication 8 July 2005
Copyright & Blackwell Munksgaard 2005
Transplant Infectious Disease . ISSN 1398 -2273
Transpl Infect Dis 2005: 7: 86^88
Printed in Denmark. All rights reserved
86
The patient was discharged from the hospital on the 10th day, but 1 day
later he was re-admitted because of dyspnea associated with very severe
attacks of hiccuping. A chest and abdominal x-ray scan was negative, as
was abdominal ultrasonography, despite the dramatic course. When the
Correspondence to:
Jaroslav Rosenberger
Transplantation Department
Faculty Hospital of L. Pasteur
Tr. SNP 1, 040 11 Kos›ice
Slovak Republic
Tel: 1421 903 193089
Fax: 1421 55 6444664
e-mail: rosenberger_ jaro@
hotmail.com
Rosenberger et al: Renal transplant patient with hiccups
Causes of persistent or recurrent hiccups
Non-infectious etiology (references)
Mediastinal or pulmonary tumors (5)
Diaphragmatic herniation, liver tumor (4, 5)
Esophageal tumor or re£ux; gastric distention, ulcer, tumor, or bleeding
(2, 5)
infrequent hiccups and good therapeutic response to metoclopramide.
The start of hiccups immediately after transplantation leads us to suspect the anesthetic and/or methylprednisolone as the causative agents (1,
8, 9). The latter drug was given during the 4 days following transplant,
and then it was replaced with prednisone.We failed to identify any other
possible causes.
Neurological disorders a¡ecting brain or phrenic nerves (tumors, injury)
(4, 5)
Electrolyte and metabolic disturbances
( # Na 1 , # Mg2 1 , # Ca2 1 , # CO2,, uremia) (5)
Symptoms associated with singultus depending on etiology, and recommended diagnostic approach
Pharmacological agents (corticosteroids, anesthetics, ethanol,
barbiturates, midazolam, methyldopa, morphine) (1, 5)
Symptoms
Etiology
Diagnosis
References
Infectious etiology
Dyspnea
Pneumonia,
pulmonary
abscess
Chest x-ray
and CT scan
(13)
Esophagitis
Endoscopy
(2, 5, 10^12)
Nonspeci¢c
Adverse e¡ects
of medication
Careful
medication
analysis
(6, 8, 9)
Nausea
Liver tumor
Abdominal
ultrasound
and CT scan
(4, 14)
Brain abscess,
encephalitis
Head CT or
MRI scan
(16, 17)
Brain tumor
Head CT or
MRI scan
(5)
Mediastinal abscess (5)
Pleural and pulmonary infections (abscess, tuberculosis, pneumonia,
pleuritis) (5)
Liver abscess (4, 5)
Fever
Cough
Esophagitis (Candida sp., Herpes simplex) (2, 5)
Elevated markers
of in£ammation
Encephalitis, brain abscess (HIV, toxoplasmosis) (4, 5)
Odynophagia
Table 1
Retrosternal pain
Pyrosis
patient reported retrosternal pain and odynophagia that were previously
not present, he underwent esophagogastroscopy, which revealed severe
ulcerative herpetic and candidal esophagitis. After treatment with acyclovir, £uconazole, and omeprazole, the hiccups faded away during the
next few days.
During the second hospitalization, the patient was a¡ected by severe
acute antibody-mediated rejection Grade IIA of the Ban¡ 97 working
classi¢cation of kidney transplant pathology (7 ). Because of corticosteroid resistance, we decided to treat the patient with a course of high-volume plasmapheresis and the replacement of cyclosporine with tacrolimus. During the period of the anti-rejection treatment, the patient ac-
Vomiting
Cachexia
Elevated markers of
liver damage
Focal neurologic
symptoms
quired nosocomial pleuropneumonia with no other agent identi¢ed
Seizures
but coagulase-negative methicillin-resistant Staphylococcus epidermidis
Coma
(MRSE). Despite combined antibiotic treatment (initially merope-
Headaches
nem 1 clindamycin, but after ¢nding MRSE in the bronchoalveolar
Positive meningeal
sign
lavage £uid, then vancomycin 500 mg/48 h), the patient’s status deteriorated. A computed tomography scan revealed an abscess in the right
Elevated markers
of in£ammation
lower pulmonary lobe. At this time, the patient again reported new epi-
Fever
sodes of hiccups that became more and more severe. The abscess was
successfully removed by a thoracotomy, after which the patient’s status
Focal neurologic
symptoms
improved rapidly and the hiccups ¢nally disappeared.
Seizures
Coma
Discussion
Our patient su¡ered from recurring episodes of hiccups, which could
be divided into 3 di¡erent periods. The ¢rst period was represented by
Headaches
Cachexia
CT, computed tomography; MRI, magnetic resonance imaging.
Table 2
Transplant Infectious Disease 2005: 7: 86^88
87
Rosenberger et al: Renal transplant patient with hiccups
The second time hiccups appeared was during a bout of esophagitis.
infections and tumors (gastrointestinal lymphomas) are the most likely
The immunocompromised patient is predisposed to infectious
causes. Neurological causes known from oncology are unlikely to be re-
esophagitis involving herpes simplex and Candida sp., which is often
sponsible for hiccups in transplanted patients, as are metabolic and elec-
accompanied by odynophagia, retrosternal pain, hiccups, and pyrosis
trolyte disturbances, because patients become accustomed to them.
(2, 10^12). After treatment of the cause, the endoscopic changes disap-
However, brain abscesses as encountered in immunocompromised hu-
peared and all symptoms (including hiccups) ceased as well.
man immunode¢ciency virus-infected patients with AIDS can be a rare
After a hiccup-free period, singultus appeared again and its inten-
cause of intractable hiccups (16, 17 ). Table 2 refers to the most common
sity increased with the severity of pulmonary changes. In this
clinical symptoms associated with the causes of hiccups and suggests a
period, the hiccups were de¢nitely of pulmonary origin (1, 13), and
diagnostic approach.
their response to di¡erent drugs (metoclopramide, chlorpromazine,
haloperidol, lidocaine, nifedipine, omeprazole) was weak and short
termed. After discovery and removal of a supradiaphragmatic abscess,
the hiccups immediately discontinued and they did not appear again.
Few studies have been published about hiccups in transplant patients.
Conclusions
We were able to identify 8 articles using a systematic review with the key
words ‘hiccups’ and ‘transplantation.’ F|ve of these articles included pa-
Usually benign and self-resolving, hiccups can sometimes indicate se-
tients with chronic renal failure in the dialysis program, but no patients
vere underlying problems, and should be taken into consideration in
after transplantation. The 3 remaining articles are case reports (11, 14,
the clinician’s di¡erential diagnosis and therapeutic approach. Espe-
15). This lack of evidence-based information makes it impossible to fol-
cially in transplant patients, who receive multiple drugs and tend to be
low any guidelines and allows only approximations based on experience
very susceptible to various pulmonary, abdominal, and esophageal
from other ¢elds of medicine, especially oncology. Based on all known
infections, the presence of hiccups needs careful examination. The
data, we may conclude that infections (esophagitis, pleuropneumonia,
recommended diagnostic algorithm should include careful analysis
pulmonary, and liver abscess) and adverse e¡ects of various drugs (ster-
of medication and other symptoms, physical examination, abdominal
oids, anesthetics) are the most probable causes of hiccups in trans-
ultrasound, chest x-ray scan, and esophago-gastro-duodenoscopic
planted patients in the early post-transplant period. In later periods,
examination.
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