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Author: Jaclyn H. Jansen, MD MS
Emergency Medicine Resident
Department of Emergency Medicine, Indiana University School of Medicine
Indianapolis, Indiana
ABSTRACT
BACKGROUND:
While patients with COVID-19 infection most frequently present with fever, dry cough, and dyspnea, other symptoms have been associated with viral infection. This case report describes a patient presenting without respiratory complaints, initially screened as low-risk for COVID-19. With known communal spread, it is paramount to recognize unusual presentations of COVID-19 infection including hiccups and gastrointestinal complaints. Early recognition and isolation of patients with possible infection while in the emergency department improves provider safety and patient care.
The patient was a 76-year-old male with no reported chronic medical comorbidities who presented for intractable hiccups lasting five days. The patient reported he had been feeling generally unwell and with review of systems reported fever of 101°F for five days prior to hiccups. He also reported decrease appetite and oral intake. He denied associated cough or shortness or breath, any known sick or COVID-19 exposed contacts, or any recent travel.
CONCLUSION:
COVID-19 is a novel virus that has quickly infected tens of thousands of individuals globally. While typical presentation includes fever, dry cough, and shortness of breath, multiple complaints have been associated with infection. It is necessary to recognize infected individuals early, as there is a known asymptomatic period of viral shedding as well as prolonged period of infectivity with symptoms. COVID-19 is highly infectious and infection has demonstrated high mortality in the elderly and patients with multiple medical comorbidities. Practitioners must recognize and recommend isolation in order to control its spread.
BACKGROUND:
COVID-19 is a novel coronavirus first diagnosed in Wuhan, China in December 2019. By mid-January 2020 the first case was diagnosed in the United States and by January 30, 2020 COVID-19 had spread to more than twenty countries.1
In the absence of targeted antivirals or a vaccine, early recognition and public health measures such as social distancing, isolation, and quarantine are necessary to control spread in the context of extreme virulence. Reporting unusual or infrequent presentations of COVID-19, such as intractable hiccups, will increase early recognition and self-quarantine measures in stable patients with possible infection.
Hiccups may represent a number of pathologies ranging from benign to life threatening. A hiccup occurs secondary to an involuntary, spasmic contraction of the diaphragm and intercostal muscles.2 Most patients will experience hiccup bouts lasting less than 48 hours at some point in their lifetime. However, patients with prolonged or intractable hiccups lasting more than 48 hours are more likely to experience serious causes often including structural, infectious, or inflammatory disorders affecting the phrenic nerve.2 Pneumonia is one infectious cause of hiccups as seen in this case report. Others infectious causes include empyema, bronchitis, pleuritis, and mediastinitis.2 A differential for intractable hiccups should further include gastroesophageal irritation, such as reflux, gastritis, peptic ulcer disease, or gastric cancer, phrenic nerve irritation secondary to prolonged intubation and some general anesthetics in the post-operative setting, cancerous masses centrally located between the neck and diaphragm, medications, such as dexamethasone, and even toxic metabolites and electrolyte abnormalities. The differential for intractable hiccups is vast and warrants investigation in the emergency department setting.
CASE PRESENTATION:
A 76-year-old African American male who denied any chronic medical comorbidities presented to the emergency department with a chief concern for five days of intractable hiccups. He also reported decreased appetite and decreased oral intake secondary to the hiccups. He noted no improvement in hiccups with home remedies. Additionally, he reported a fever of 101° F for five days prior to onset of hiccups, which had since resolved. He denied dyspnea, dry cough, and diarrhea. The patient’s exam was non-focal with mild abdominal tenderness. He exhibited normal work of breathing that was free of cough and retractions. His vital signs were within normal limits and oxygen saturation was 96% on room air.
A 76-year-old African American male who denied any chronic medical comorbidities presented to the emergency department with a chief concern for five days of intractable hiccups. He also reported decreased appetite and decreased oral intake secondary to the hiccups. He noted no improvement in hiccups with home remedies. Additionally, he reported a fever of 101° F for five days prior to onset of hiccups, which had since resolved. He denied dyspnea, dry cough, and diarrhea. The patient’s exam was non-focal with mild abdominal tenderness. He exhibited normal work of breathing that was free of cough and retractions. His vital signs were within normal limits and oxygen saturation was 96% on room air.
The patient’s urine appeared significantly concentrated and he had no previous records of emergency department visits. We obtained computed tomography (CT) imaging of the abdomen and pelvis with intravenous (IV) contrast given the patient’s inability to tolerate oral contrast. He was treated with 10mg IV of metoclopramide and his hiccups resolved. CT imaging demonstrated bibasilar ground-glass opacities in lower lung fields. We obtained COVID-19 testing via nasopharyngeal swab and discharged the patient with strict instructions for self-quarantine for fourteen days with return precautions. Testing returned positive after discharge and patient was notified of results.
DISCUSSION:
While most patients with COVID-19 present with dyspnea, dry cough, and fever, a number of alternate presentations have been reported. Symptoms often resolve spontaneously in many patients. However, elderly patients and patients with medical comorbidities such as cardiovascular and pulmonary disease frequently experience severe disease with complications including organ failure, septic shock, pulmonary edema, severe pneumonia, and acute respiratory distress syndrome. 3 Recognizing signs of infection early is key to protecting health care workers as well as reducing the spread to other patients in emergency departments. Great uncertainty remains regarding the spread of COVID-19. Respiratory virus infections typically occur while a patient is symptomatic, however, there growing evidence indicates that COVID-19 sheds during an asymptomatic period between two and ten days after infection.3
While most patients with COVID-19 present with dyspnea, dry cough, and fever, a number of alternate presentations have been reported. Symptoms often resolve spontaneously in many patients. However, elderly patients and patients with medical comorbidities such as cardiovascular and pulmonary disease frequently experience severe disease with complications including organ failure, septic shock, pulmonary edema, severe pneumonia, and acute respiratory distress syndrome. 3 Recognizing signs of infection early is key to protecting health care workers as well as reducing the spread to other patients in emergency departments. Great uncertainty remains regarding the spread of COVID-19. Respiratory virus infections typically occur while a patient is symptomatic, however, there growing evidence indicates that COVID-19 sheds during an asymptomatic period between two and ten days after infection.3
As of February 11, 2019 the Chinese Center for Disease Control and Prevention reported 72, 314 cases of COVID-19 since its initial discovery in December.4 In fewer than 30 days, COVID-19 spread from a single city across China, quickly overwhelming the healthcare system. Because no antiviral drugs or vaccines are available, countries have been forced to utilize traditional methods of pandemic containment—social distancing, quarantine, and isolation to limit community spread.4 Social distancing is particularly effective in settings with community transmission when case linkage is unclear.1 Intractable hiccups with decreased oral intake is an uncommon presentation of COVID-19. Furthermore, this patient was screened as low risk because of his absence of respiratory symptoms. Practitioners must appreciate that COVID-19 may present with predominantly gastroenterological symptoms as well as familiarize themselves with less frequent presentations, such as hiccups secondary to pneumonia. Recognition of these symptoms allows appropriate proper donning and doffing of personal protective equipment for all health care workers as well as isolation from other patients. Additionally, recognition of early or mild infection with atypical symptoms will lead to increased isolation and self-quarantine and in turn decreased communal transmission.
References
1. Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med. 2020;27(2).
2. Lembo, AJ, (2020). Hiccups. UpToDate. Retrieved April 15, 2020, from https://www-uptodate.com/contents/hiccups
3. Sohrabi C, Alsafi Z, O’Neill N, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg. 2020;76:71-76.
4. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020.