SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary embolism (PE) is a serious, possibly life-threatening, condition that can present asymptomatically or with a wide range of symptoms. Therefore, it is essential to identify PE and initiate prompt treatment. The most common presenting symptom is dyspnea followed by pleuritic pain and cough. Here we present an unusual case of PE that presents with chief complaint of intractable hiccups.
CASE PRESENTATION: A 61-year-old male with a past medical history of recent left total knee arthroplasty at an outside hospital presented on post-operative day 6 with complaint of intractable hiccups for 4 days. He was discharged from the outside hospital on 40 mg subcutaneous enoxaparin daily with a bridge to warfarin 5 mg daily for deep venous thrombosis (DVT) prophylaxis. On admission temperature was 37.4°C, HR 102 beats/minute, BP 146/84, RR 18 breaths/minute and oxygen saturation of 99% on room air. Physical exam revealed a well-appearing male in no apparent distress other than persistent hiccups. Exam was positive for healing left knee arthroplasty incision with staples intact with mild surrounding erythema and tenderness, and scattered ecchymoses over the entirety of the left leg. CMP was within normal limits. Troponin was negative. CBC showed hemoglobin of 10.4 gm/dL. INR was therapeutic at 2.4. EKG revealed normal sinus rhythm. ABG revealed hypoxia with PaO2 of 64mmHg and an A-a gradient of 38. CT with PE protocol revealed bilateral PE, worse on the right side. Lower extremity doppler was negative for DVT. He was initiated on therapeutic subcutaneous enoxaparin then switched to rivaroxaban prior to discharge. The hiccups resolved on chlorpromazine, prochlorperazine, and therapeutic enoxaparin within 24 hours of admission. He was discharged to sub-acute rehabilitation for knee rehabilitation.
DISCUSSION: A literature review reveals only two prior case reports of intractable hiccups as a presentation of pulmonary embolism (1,2). Hassen et al presented a small case series in which they described 3 patients with pulmonary embolism who presented with intractable hiccups. Zylicz presented a case of intractable hiccups that was likely due to PE, as was suggested by inferior vena cava thrombus, but no direct proof of PE was presented.
CONCLUSIONS: Here we present an additional case of PE presenting with intractable hiccups.
Reference #1: Hassen, G. et al. Persistent Hiccups as a Rare Presenting Symptom of Pulmonary Embolism. Western Journal of Emergency Medicine 2012;XIII:479-483
Reference #2: Zylicz, Z. Intractable hiccups caused by pulmonary embolism. A case report. Advances in Palliative medicine 2010;9:149-151
DISCLOSURE: The following authors have nothing to disclose: Sarah Sansom, Omar Khorfan
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