COVID-19 infection typically presents with various symptoms encompassing fever, cough, and shortness of breath, with occasional reports of less common manifestations such as dizziness and persistent hiccups. Herein, we present a distinctive case wherein refractory hiccups constituted the exclusive complaint, persisting despite standard therapeutic interventions and serving as a misleading sole presentation for COVID-19 infection that, unfortunately, was complicated by septic shock and patient demise. This case prompts contemplation regarding the potential impact of hiccups on the prognosis of COVID-19. It also underscores the imperative nature of recognizing and considering atypical and uncommon presentations, as these may carry significant and even more severe consequences.

OBJECTIVE: Cervical epidural steroid injections (ESIs) can provide effective pain management for patients suffering from chronic neck pain due to various pathological changes of the cervical spine. There are several rare adverse effects reported from interventional pain procedures, including persistent hiccups (\"singultus\"). Based on a limited number of cases, we propose a modified treatment algorithm for this adverse outcome (Fig. 3).
METHODS: Singultus has been documented as an adverse effect of interventional pain procedures, including epidural steroid, facet joint, and sacroiliac joint injections. We describe the case of a general contractor who presented to our clinic with chronic neck pain and central canal stenosis. The patient received an uncomplicated lumbar ESI in the past and was recommended for a cervical interlaminar ESI. After an uneventful C6-C7 interlaminar ESI with dexamethasone, 1% lidocaine, and normal saline the patient developed singultus. Baclofen was sent to his pharmacy, but this was unsuccessful at alleviating his hiccups. The patient was subsequently started on chlorpromazine and found relief from his symptomatology.
CONCLUSIONS: Persistent hiccups after ESI or interventional pain procedures can be treated with conservative measures and non-pharmacologic methods, with escalation to therapy with baclofen, gabapentin, pregabalin, metoclopramide, chlorpromazine, other antipsychotic or antidopaminergic agents, and possible dual or triple therapy if further indicated.

Steroids are commonly used for medical purposes. While hiccups are a recognized side effect of steroid therapy, we have not found any reports of hiccups interfering with the progress of radiotherapy. A case of dexamethasone (DEX)-induced hiccups (DIH) during CyberKnife radiotherapy (CKR) is presented. A 42-year-old man with neurofibromatosis type I had a history of malignant peripheral schwannomas originating in the right femur. We started to perform CKR with oral DEX at an increased dose of 4 mg/day for the recurrence of cranial metastasis and primary lesions. Severe hiccups developed four days after the increased DEX dose. DEX was stopped six days after CKR initiation, and the hiccups subsided over the next four days. However, the CKR procedure was not possible due to the patient\'s worsening swelling of the head and thigh lesions, which prevented the proper fit of the mesh face mask and body fixation device. Intravenous (IV) DEX 6.6 mg/day was initiated, which allowed the resumption of CKR due to reduced swelling of the lesions. The CKR was completed due to the absence of hiccups following the transition to IV DEX. DIH could occur even at a dosage of 4 mg/day when taken orally. Our case suggests the significance of recognizing DIH during radiotherapy. Switching the administration from oral to IV DEX may be an option for dealing with DIH.

Carbamazepine, a commonly prescribed antiepileptic drug, is known to induce hiccups in a subset of epileptic patients. Although relatively uncommon, can have significant clinical implications. This comprehensive review delves into the clinical and electroencephalographic correlates of carbamazepine-associated hiccups, aiming to enhance understanding and management of this neurological side effect. The authors\' review synthesizes qualitative epidemiological data, revealing that carbamazepine-induced hiccups occur in a subset of patients receiving the medication, with reported incidence rates ranging from 2.5 to 40%. Despite its relatively low prevalence, hiccups pose substantial challenges for patients and healthcare providers. Complications associated with carbamazepine-induced hiccups include disruption of sleep, impaired social functioning, and decreased quality of life, underscoring the clinical significance of this side effect. Effective management strategies can be implemented through a multidisciplinary approach, including collaboration among neurologists, pharmacists, and other healthcare professionals. These may include dose adjustments, medication discontinuation, and adjunctive therapies such as diaphragmatic breathing exercises or acupuncture. Additionally, close monitoring for adverse effects and timely intervention are essential to mitigate the impact of hiccups on patient well-being. Essentially, carbamazepine-induced hiccups represent a clinically relevant phenomenon that warrants attention in the management of epilepsy. By recognizing the clinical manifestations, understanding the underlying pathophysiology, and implementing evidence-based management strategies, healthcare providers can optimize patient care and improve outcomes in this patient population.

Belching is the act of expelling air from the stomach or esophagus into the pharynx. Although the process is regarded as physiological, excessive belching might be associated with a significant burden for affected patients in the sense of a belching disorder. Diagnosis of a belching disorder is often challenging, and its differentiation from other conditions such as rumination syndrome, singultus, or aerophagia can be difficult. Treatment of these disorders also represents a challenge for otorhinolaryngologists. Hence, the aim of this review is to provide an interdisciplinary overview of these clinical syndromes and provide practical guidance for their diagnosis and treatment.
UNASSIGNED: Das als „belching“ bezeichnete Aufstoßen von Luft aus dem Ösophagus oder Magen in den Mund- und Rachenbereich gilt als physiologischer Prozess. Es kann jedoch in einem vermehrten Maße auftreten und im Sinne einer „belching disorder“ für die betroffenen Patienten mit einem erheblichen Leidensdruck verbunden sein. Die Diagnosestellung gestaltet sich zum Teil schwierig, insbesondere in Hinblick auf die Abgrenzung zu verwandten Krankheitsbildern wie der Aerophagie, dem Ruminationssyndrom oder dem Singultus. Neben der Diagnosestellung stellt auch die Therapie dieser Störungsbilder für den Hals-Nasen-Ohren-Arzt eine Herausforderung dar. Ziel dieser Arbeit ist es, eine interdisziplinäre Übersicht zu diesen Krankheitsbildern zu schaffen und klinisch-praktische Gesichtspunkte zur Diagnosestellung und Therapie aufzuarbeiten.

UNASSIGNED: Intractable hiccups, persisting beyond 48 h, pose a clinical challenge, particularly in demyelinating diseases like Neuromyelitis Optica (NMO) and Multiple Sclerosis (MS). Understanding the complex neural pathways of the hiccup reflex and the impact of high-dose steroid therapy is crucial for managing this rare but distressing symptom. The hiccup reflex involves afferents from the vagus, phrenic, and sympathetic nerves, with the reflex center in the anterior horns at the C3 to 5 level and the medulla oblongata. The potential interplay between demyelination and corticosteroid therapy in triggering persistent hiccups requires exploration.
UNASSIGNED: This case report details a 21-year-old male with undiagnosed demyelinating disorder, presenting persistent hiccups following high-dose steroid therapy for an acute disease flare. The patient\'s history included vertigo and progressive neurological symptoms, leading to an MS diagnosis with significant brain and spinal lesions. Persistent hiccups, initiated by steroid administration, were recurrent but responsive to metoclopramide after other measures failed.
UNASSIGNED: The discussion centers on investigating the cause of hiccups in a patient with demyelination following steroid administration. Steroids\' impact on neurological systems, including neurotransmitter function, and the potential disruption of neurological pathways due to demyelination may contribute to hiccups. Successful hiccup resolution with metoclopramide suggests a potential pharmacological approach for corticosteroid-induced hiccups in demyelinating diseases. This case emphasizes the need for further research into the intricate relationship between demyelination, steroid therapy, and hiccups to enhance management strategies for this uncommon yet impactful symptom.

BACKGROUND: Previous reports have described hiccups during general anesthesia that were possibly induced by drugs, including benzodiazepines. However, there are few reports of hiccups caused by remimazolam. Case presentation A 75-year-old woman underwent corneal transplantation under general anesthesia with remimazolam. She presented with hiccups once the effects of muscle relaxants used during induction wore off, which persisted even after various treatments, such as the administration of antipsychotic drugs. However, when remimazolam administration was terminated after surgery to awaken the patient, the hiccups stopped and did not recur after extubation. Evaluation of predicted blood levels of remimazolam suggests that higher levels of remimazolam might cause hiccups.
CONCLUSIONS: Remimazolam might induce hiccups during general anesthesia. Anesthesiologists should consider administering muscle relaxants or changing the anesthetic in cases of refractory hiccups under general anesthesia.

UNASSIGNED: Both myelin oligodendrocyte glycoprotein-IgG associated disorders (MOGAD) and neuromyelitis optica spectrum disorder (NMOSD) are demyelinating diseases of the central nervous system. They present similar clinical manifestations such as optica neuritis, myelitis and area postrema syndrome (APS). The distinctions of optica neuritis (ON) and myelitis between them have been elaborated to great length while their differences in APS remain to be elucidated. We aim to report the frequency of APS in patients with MOGAD as well as NNOSD patients, and to compare the characteristics of APS between patients with MOGAD and those with NMOSD.
UNASSIGNED: Seven MOG-IgG positive APS patients were retrospectively identified between 2017 and 2022. APS phenotypes have been previously described. The similarities and differences between MOGAD and NMOSD patients with APS was compared, including the frequency and duration of APS between the two diseases, and their incidences of accompanied subtentorial lesions have also been described and compared.
UNASSIGNED: We reviewed a cohort of 218 MOG-IgG-positive patients, and 396 patients with NMOSD. 200 MOGAD patients and 332 NMOSD patients were included in this study. In the cohort, seven patients with MOG-IgG-positive antibody presented with APS were analyzed, four of whom had disease onset with APS. Of the 332 patients with NMOSD, 47 had APS attacks while 31 had APS at disease onset. In patients with MOGAD, 2 had nausea, 3 had vomiting, 5 had hiccups, and 1 patient presented with all three symptoms above. In patients with NMOSD, 70.2 % had nausea, vomiting and hiccups at the same time during APS attacks. Apart from the medulla oblongata, other subtentorial regions were also affected in 6/7 MOGAD patients while 14/47 NMOSD patients had other subtentorial regions involved. During an APS attack, the incidence of concomitant lesions in the brainstem and other regions was significantly greater in MOGAD than in the NMOSD cohort (P = 0.008*).
UNASSIGNED: APS is a rare, but not isolated clinical manifestation of MOGAD. APS happened more frequently with other supratentorial and subtentorial lesions in MOGAD. The symptoms of NVH (nausea, vomiting, hiccups) tended to happen respectively in MOGAD compared with NMOSD. The phenotype or mechanism of APS in MOGAD may differ from that in NMOSD.

Although hiccups are regularly self-limited and rarely life-threatening, prolonged hiccups are bothersome, which can significantly decrease the quality of life. Here, we report a case of persistent hiccups coexisting with an enlarging liver cyst situated just below the diaphragm in a patient with autosomal dominant polycystic kidney disease (ADPKD). No other underlying etiologies related to the symptoms were suspected. The cyst was difficult to drain surgically and the patient continued with symptomatic treatment. Although rare, hepatic cysts should be considered a potential cause of prolonged hiccups in patients with ADPKD. We emphasize the significance of systematically excluding potential etiologies that cause prolonged hiccups and considering appropriate therapeutic interventions.

BACKGROUND: Even in patients who survive resuscitation through multidisciplinary treatment, minor persistent symptoms can make hospital discharge difficult. Herein, we report a case of myocardial infarction with intractable symptoms following resuscitation, which were successfully treated using Kampo medicine.
METHODS: A 71-year-old man experienced intractable cough and hiccups following resuscitation for acute myocardial infarction. Despite successful invasive treatment for his cardiac condition, the patient\'s persistent symptoms hindered his recovery and discharge from hospital. The patient was diagnosed with qi and blood deficiency, qi stagnation, and fluid retention, before being prescribed the Kampo medicine \"bukuryoingohangekobokuto (BRIHK)\". Within days of treatment initiation, his symptoms notably improved, allowing him to be discharged.
CONCLUSIONS: This case highlights the potential of Kampo medicine for addressing post-resuscitation symptoms that are refractory to conventional treatments, and emphasizes the importance of integrating Kampo medicine with Western medical practices to enhance patient care and quality of life.