Persistent
hiccups (lasting more than 48 hours) can cause physical and emotional distress. They can result in
dehydration, exhaustion,
malnutrition,
insomnia,
wound dehiscence, ventilatory desynchronization, and hemodynamic changes.
Hiccups are thought to be due to a complex reflex
arc involving peripheral nerves and central structures such as the brainstem, temporal lobe, basal ganglia, hypothalamus, and spinal cord levels C3-5. Medullary
strokes, for instance, have been reported to cause
hiccups. We report a patient with a thalamic bleed who developed persistent
hiccups. A 56-year-old man was brought to the hospital in an unresponsive state. He was intubated for airway protection. CT brain showed a left thalamic
hemorrhage with
edema and mass effect on the 3rd ventricle, intraventricular extension of
hemorrhage, and
hydrocephalus. An external ventricular drain was placed successfully with adequate drainage. One week after admission, the patient developed persistent abdominal jerks. These jerks were occurring every 3-4 seconds and would last for hours with brief periods of remission. He was started on
levetiracetam 1000 mg IV bid and then increased to 1500 mg IV BID without any improvement of symptoms. The patient was also placed on EEG which did not reveal any epileptiform abnormality but did show an EMG artifact. His
electrolytes including
sodium, and
potassium, and corrected
calcium levels were normal. He did not have any evidence of
pneumonia or other
infections. It was determined that these jerks were likely
hiccups.
Metoclopramide 10 mg IV was tried without any benefit. He was then started on
Baclofen 10 mg PO TID which resulted in a significant improvement in
hiccups. Our case suggests that thalamic lesions might also lead to persistent
hiccups.