BACKGROUND: Hiccups are among the rare complications of COVID-19 infections. There are several published reports of persistent hiccups presenting during the acute COVID-19 period. However, there are very few published reports of persistent hiccups occurring in the post-acute COVID-19 period. Consequently, most clinicians may not be aware of this rare presentation. This case highlights an atypical presentation of persistent hiccups that manifested during the post-acute COVID -19 period that clinicians need to be aware of. The caseadds to the ever increasing body of knowledge about symptoms and signs associated with Severe Acute Respiratory Syndrome Corona Virus type 2 (SARS CoV-2) infection.
METHODS: A 27 year old male black Zambian patient presented to the emergency department of our hospital with persistent hiccup, 35 days after the initial acute episode of COVID-19. This was associated with breathlessness. There were no other symptoms. He had no history of pulmonary, gastrointestinal, neurological disease or malignancy. He did not take any alcohol or smoke. He had never used any recreational drugs. He was employed as a monitoring and evaluation officer at one of the main COVID centres in the capital. On examination, the patient was anxious. Blood pressure was 141/82, pulse rate was 95 beats per minute, respiratory rate was 26 breaths per minute, temperature was 36.8C and oxygen saturation was 97% on room air. Systemic examination was normal. Chest X-ray and abdominal ultrasonography were normal. A rapid COVID-19 antigen test, and COVID-19 Polymerase Chain Reaction (PCR) test that were done the following day were negative. All other haematological and biochemical tests, including D-dimer and C-reactive protein (CRP), were also normal. A diagnosis of post-acute COVID-19 associated hiccups was made. The patient responded well to treatment with chlorpromazine 25 mg 8 hourly. The hiccups disappeared completely after the fourth dose of chlorpromazine.
CONCLUSIONS: This is one of the few published cases of COVID-19 associated persistent hiccups, occurring more than a month after the initial presentation. Most of the published cases report hiccups occurring in the acute COVID-19 period. Consequently, hiccups occurring in the post-acute COVID-19 period may not be attributable to COVID-19. This case has highlighted the need to consider post-acute COVID-19 in the differential diagnosis of persistent hiccup.

UNASSIGNED: Chlorpromazine, one of the oldest antipsychotic medications, remains widely available and is still taken in overdose. We aimed to investigate the clinical effects of chlorpromazine overdose and determine if there is a relationship between the reported dose ingested and intensive care unit admission or endotracheal intubation.
UNASSIGNED: We performed a retrospective analysis of patients admitted to our toxicology tertiary referral hospital with chlorpromazine overdose (reported dose ingested greater than 300 mg) between 1987 and 2023. We extracted demographic information, details of ingestion, clinical effects and complications (Glasgow Coma Scale, hypotension [systolic blood pressure less than 90 mmHg], delirium, dysrhythmias), length of stay, intensive care unit admission, and endotracheal intubation.
UNASSIGNED: There were 218 chlorpromazine overdose cases, with presentations decreasing in frequency over the 36 years. The median age at presentation was 32 years (interquartile range: 25-40 years) and 143 (61 per cent) were female. The median reported dose ingested was 1,250 mg (interquartile range; 700-2,500 mg). The majority of presentations (135; 62 per cent) involved reported co-ingestion of other medications, typically benzodiazepines, paracetamol or antipsychotics. There were 76 (35 per cent) chlorpromazine alone ingestions in which there was a slightly higher median reported dose ingested of 1,650 mg (interquartile range: 763-3,000 mg) compared to the reported co-ingestion group, median reported dose ingested of 1,200 mg (interquartile range: 700-2,100 mg). Of all presentations, 36 (27 per cent) had a Glasgow Coma Scale less than 9, 50 (23 per cent) were admitted to the intensive care unit, and 32 (15 per cent) were endotracheally intubated. There was a significant difference in the median reported dose ingested between patients intubated (2,000 mg; interquartile range: 1,388-3,375 mg) and those not intubated (1,200 mg; interquartile range: 644-2,050mg; P < 0.001), and between those admitted to the intensive care unit and not admitted to the intensive care unit (P < 0.0001). The median reported dose ingested in seven chlorpromazine alone presentations who were intubated was 2,500 mg (interquartile range: 2,000-8,000 mg, range: 1,800-20,000 mg). Eighteen (8 per cent) patients developed delirium, eight (4 per cent) had hypotension, three had seizures, and there was one death.
UNASSIGNED: Almost one quarter of cases were admitted to the intensive care unit and over half of these were intubated. Whist the decision to admit to an intensive care unit or intubate a patient is based on clinical need, there was a significant association between reported dose ingested and requirement for endotracheal intubation. Both the frequency of presentation and reported dose ingested declined after 2013. The major limitations of the study were a retrospective design and no analytical confirmation of ingestion.
UNASSIGNED: We found that the most common effect of chlorpromazine overdose was central nervous system depression and that endotracheal intubation was associated with larger reported doses ingested, particularly in single chlorpromazine ingestions.

A patient with schizophrenia who was treated with chlorpromazine developed lupus anticoagulant (LA) and antiphospholipid syndrome (APS). On protein electrophoresis, a monoclonal immunoglobulin A peak was seen in this patient, defining a condition of monoclonal gammopathy of undetermined significance. Additionally, β-thalassemia was diagnosed with the CD41-42 genotype. This condition is extremely rare, particularly in patients with schizophrenia and APS. We present a case of a patient with schizophrenia and secondary APS who had a positive LA, a significantly prolonged activated partial thromboplastin time, endogenous coagulation factor deficiency and inhibitor, no bleeding, and an unexpected finding of β-thalassemia and monoclonal IgA. Following that, a literature review on the disorders was presented.

METHODS: A 52-year-old man developed a cerebral infarction from the right middle cerebral artery occlusion, and the infarction extensively damaged the right insula. Three months after the onset of the cerebral infarction, persistent hiccups appeared, occurring during sleep. The thoracic and abdominal cavities showed no lesions; hence, the hiccups were considered to be caused by central nervous system dysfunction. Administration of metoclopramide, chlorpromazine, and diazepam were ineffective, while levetiracetam had a partial effect. Combining perampanel with baclofen finally suppressed the symptoms.
CONCLUSIONS: Lesions at the right insula impair respiratory reflex and may present with hiccups as a symptom of respiratory reflex disinhibition. Here, we review similar cases of treatment-resistant hiccups, as well as perampanel and baclofen efficacy in myoclonus cases.
CONCLUSIONS: Our patient\'s case suggested that perampanel with baclofen may be effective for myoclonus due to respiratory reflex disinhibition and can be used to treat hiccups derived from cerebral infarctions.

Hiccups are common reflexes and many treatment methods have been reported. Chlorpromazine is a known treatment option for hiccups, but its efficacy under general anesthesia remains unclear. We report the case of a patient with vagal schwannoma who developed hiccups while under general anesthesia. Muscle relaxants were not used because the patient was under neuromonitoring. The depth of anesthesia was deepened; however, the hiccups did not disappear. The hiccups were relieved by intravenous chlorpromazine administration (total; 5 mg), which allowed for surgery under neuromonitoring. This case indicates that chlorpromazine may be effective to treat hiccups under general anesthesia.

BACKGROUND: Drug reaction with eosinophilia and systemic symptoms reaction (DRESS) syndrome is a serious, potentially life-threatening drug side effect associated with more and more drugs. However, antipsychotics have rarely been involved in such condition.
METHODS: We report here a suspected case of chlorpromazine induced DRESS syndrome in a 33-year-old woman with a history of allergic rhinitis and bipolar disorder who has reported an unexplored generalized skin eruption after taking chlorpromazine 10 years before. Only 24 hours after starting the therapy, the patient developed erythematous skin eruption on her limbs and her trunk with biological abnormalities, including liver enzyme elevation and eosinophilia. Skin eruption disappeared spontaneously within 3 days after therapy discontinuation and subsequently, biological abnormalities regressed. Patch tests were performed and were positive for chlorpromazine. At same time, we performed a literature review of the DRESS syndrome induced by antipsychotics. No patch tests were performed for those cases.
CONCLUSIONS: Clinicians should be aware of such clinical features after starting patients on antipsychotics to withdraw the culprit drug as early as possible and avoid further complications.

Stuttering, a disturbance in the normal fluency and time patterning of speech is usually developmental. In some cases, it is acquired, and causes include stroke, brain tumor, and trauma. Implicated in the causation of stuttering are overactive presynaptic dopamine systems in the region of the brain that modulate verbalization. It is a rare side effect of antipsychotic medications and has been reported with phenothiazines, clozapine, and risperidone. This is a report of a patient who developed stuttering when treated first with chlorpromazine and later with risperidone. Patient had a diagnosis of schizoaffective disorder and had been treated with antipsychotic medications including haloperidol, olanzapine, and paliperidone. He developed stuttering for the first time upon receiving intramuscular injections of chlorpromazine for treatment of agitation. The stutter improved and eventually resolved. He subsequently presented with a severe stutter when he was treated with risperidone. The stutter improved after risperidone was discontinued. It is speculated that drug-induced stuttering may be a manifestation of akathisia leading to noradrenergic and serotonergic mechanisms being implicated. It could be that either the cholinergic, dopaminergic or serotonergic systems are involved or that there is an imbalance of these systems that may be relevant.

Pheochromocytoma multisystem crisis (PMC) is a potentially lethal emergency due to catecholamine secretion. The condition manifests as severe hypertension to intractable cardiogenic shock and has a high mortality rate. This study explored the efficacy and safety of applying chlorpromazine on PMC patients. The study included seven patients (median age, 42 years; range, 14-57 years) diagnosed with pheochromocytoma. Four consecutive PMC patients were admitted to our critical care unit between 2016 and 2020 due to abdominal or waist pain, nausea, and vomiting. Their blood pressure (BP) fluctuated between 200-330/120-200 and 40-70/30-50 mmHg. Chlorpromazine (25 or 50 mg) was injected intramuscularly, followed by continuous intravenous infusion (2-8 mg/h). The patients\' BP decreased to 100-150/60-100 mmHg within 1-3 h and stabilized within 3-5 days. Two weeks later, surgical tumor resection was successfully performed in all four patients. Similar clinical outcomes were also obtained in three patients with sporadic PMC reported in the literature who received chlorpromazine treatment, which reduced their BP readings from >200/100 mmHg to 120/70 mmHg. Our observations, combined with sporadic reports, showed that chlorpromazine efficiently controlled PMC. Thus, future studies on the use of chlorpromazine are warranted.

Two cases are presented with coronavirus disease 19 (COVID-19)-related hiccups: one during initial presentation and one 10 days after COVID-19 diagnosis. Hiccups in both patients were resistant to treatment and responded only to chlorpromazine. COVID-19 patients may present with hiccups and also may have hiccups after treatment. Resistant hiccups without any underlying disease other than COVID-19 should be considered in association with COVID-19 and may respond well to chlorpromazine.

The use of IV methylprednisolone has been shown to be associated with some adverse effects. The most feared side effect is acute gastrointestinal perforation and accelerated hypertension particularly during pulse therapy. Hiccups occur less frequently but can cause high levels of discomfort to the patient. In intractable cases, respiratory arrest and death can occur. This article reports the occurrence of hiccups in a patient managed for pseudo Foster-Kennedy syndrome. The hiccups were observed shortly after IV methylprednisolone was administered to the patient and abetted over a period of one week after it was discontinued. Hiccups occur through the neuronal pathway of the hiccup reflex arc, comprising the vagus nerve, phrenic nerve, parts of the sympathetic nervous system (T6-T12), and efferent fibers from the phrenic nerve that supply the glottis and the accessory muscles of respiration. The hiccups resolved with the use of gabapentin. This case report aims to add to the existing body of knowledge of the efficacy of gabapentin in the management of hiccups.