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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. References 1. WALKER P,WATANABE S, BRUERA E. Baclofen ^ a treatment for chronic hiccups. J Pain Symptom Manage 1998: 2: 125^132. 2. GILSON I, BUSALACCHI M. Marijuana for intractable hiccups. Lancet 1998: 9098: 267. 3. P ETROIANU G, H EIN G, P ETROIANU P, 00 BERGLER W, RU FER R. Idiopathic chronic hiccups ^ combination therapy with cisapride, omeprazole and baclofen. ClinTher 1997: 5: 1031^1038. 4. H ERNAŁ NDEZ JL, FERNAŁ NDEZ-M IERA MF, SAMPEDRO I, SANROMA P. Nimodipine treatment for intractable hiccups. Am J Med 1999: 5: 600. 5. LAUNOIS S, BIZEC JL,W HITELAW WA, CABANE J, DERENNE PJ. Hiccup in adults: an overview. Eur Respir J 1993: 6: 563^575. 6. G OLD M, SPRUIT O,TONER GC. Chronic hiccups following chemotherapy. J Pain Sympt Manage 1999: 6: 387^388. 88 7. S OLEZ K, A XELSEN RA, BENEDIKTSSON H, et al. International standardization of criteria for the histologic diagnosis of renal allograft rejection: the Ban¡ working classi¢cation of kidney transplant pathology. Kidney Int 1993: 44: 411^422. 8. C EROSIMO RJ, BROPHY MP. Hiccups with high dose dexamethasone administration. Cancer 1998: 2: 412^414. 9. A LDRETE JA, DANIEL W, O’H IGGINS JW, H OMATAS J, STARZL TE. Analysis of anesthetic-related morbidity in human recipients of renal homografts. Anesth Analg 1971: 50: 321^329. 10. W ILCOX CM. Esophagitis in the immunocompromised host. In: CASTELL DO, R ICHTER JE, eds. The Esophagus (3rd edn). Philadelphia: Lippincott Williams & Wilkins, 1999: 539^555. 11. CAIN JS, A MEND W. Herpetic esophagitis causing intractable hiccups. Ann Intern Med 1993: 119: 249. Transplant Infectious Disease 2005: 7: 86^88 12. P OLLACK MJ. Intractable hiccups: a serious sign of underlying systemic disease. J Clin Gastroenterol 2003: 37: 272^273. 13. BURDETTE SD, M ARINELLA MA. Pneumonia presenting as singultus. South Med J 2004: 97: 915. 14. C HAND EM, NASIR A, PASCAL RR. Pathologic quiz case. Refractory hiccups in a man after liver transplantation for hepatitis C. Arch Pathol Lab Med 2003: 127: 248^250. 15. NGUYEN JD, D UNLEAVY K, CARRASQUILLO JA, C HEN CC. F-18 £uorodeoxyglucose positron emission tomographic imaging in a patient with persistent hiccups. Clin Nucl Med 2004: 29: 35^36. 16. FRIEDLAND JS. Hiccups, toxoplasmosis, and AIDS. Clin Infect Dis 1994: 18: 835. 17. JANSEN PH, JOOSTEN EM,V INGERHOETS HM. Persistent periodic hiccups following brain abscess: a case report. J Neurol Neurosurg Psychiatry 1990: 53: 83^84.