Chronic, intractable hiccups can be a frustrating and debilitating condition. While often benign and self-limiting, persistent hiccups can sometimes signal an underlying medical issue. A recent case report published in the Journal of Medical Case Reports details the unusual case of a 93-year-old man whose two-year battle with hiccups was ultimately linked to eosinophilic esophagitis (EoE), a relatively rare allergic condition.
Understanding the Connection: Hiccups and Eosinophilic Esophagitis
Hiccups are involuntary contractions of the diaphragm, the muscle that plays a crucial role in breathing. These contractions cause a characteristic sound as the vocal cords briefly close. Typically, hiccups are triggered by common factors like eating too quickly, consuming carbonated beverages, or experiencing excitement. However, when hiccups persist for more than 48 hours, they are considered chronic and warrant medical investigation.
Eosinophilic esophagitis is a chronic inflammatory disease of the esophagus, characterized by a high number of eosinophils – a type of white blood cell – infiltrating the esophageal lining. While the exact cause of EoE is not fully understood, it is believed to be triggered by an allergic reaction to food or environmental allergens. Common symptoms include difficulty swallowing (dysphagia), food impaction, and heartburn. However, as this case illustrates, EoE can sometimes present with atypical symptoms, such as persistent hiccups.
A Two-Year Struggle and an Unexpected Diagnosis
The patient in this case report had been experiencing intermittent hiccups for over two years. He had tried several conventional treatments, including baclofen (a muscle relaxant), chlorpromazine (an antipsychotic sometimes used for chronic hiccups), and proton pump inhibitors (to address potential acid reflux), but none provided lasting relief. His condition worsened, culminating in two weeks of continuous hiccups accompanied by significant fatigue, prompting hospitalization.
Initial investigations, including a computed tomography (CT) scan of the chest and abdomen, were unremarkable. An upper endoscopy, a procedure to visualize the esophagus, also did not reveal any obvious abnormalities. However, a blood test revealed an elevated eosinophil count – 18%, significantly higher than the normal range of 1 to 4%. This finding prompted further investigation, leading doctors to take biopsies from the mid and distal esophagus.
The biopsies revealed eosinophilic infiltration, with 15 eosinophils per high-power field, confirming a diagnosis of eosinophilic esophagitis. This meant that the patient’s esophagus was inflamed due to an accumulation of eosinophils. The doctors theorize that the inflammation and esophageal dysfunction triggered abnormal nerve impulses that stimulated the phrenic and vagus nerves, leading to the persistent hiccups.
Treatment and Resolution
Following the diagnosis of EoE, the patient was treated with a combination of a proton pump inhibitor and baclofen, which provided some initial relief. However, the hiccups ultimately resolved only after the addition of a topical corticosteroid, a medication used to reduce inflammation in the esophagus. The corticosteroid effectively reduced the eosinophil count and inflammation, restoring normal esophageal function and eliminating the hiccups.
Why This Case Matters
This case report adds to a growing body of evidence suggesting a link between eosinophilic esophagitis and chronic hiccups. While only a few cases of this association have been documented – only two prior cases were previously reported – it highlights the importance of considering EoE in the differential diagnosis of patients presenting with persistent, unexplained hiccups.
As the authors of the case report emphasize, “Eosinophilic esophagitis should be considered in the differential diagnosis in patients with chronic refractory hiccups, even in the absence of typical symptoms.” This is particularly important because early diagnosis and treatment of EoE can significantly improve a patient’s quality of life and prevent potential complications, such as esophageal strictures (narrowing of the esophagus).
The atypical presentation of EoE in this case underscores the need for clinicians to maintain a broad differential diagnosis when evaluating patients with chronic hiccups. A thorough evaluation, including blood tests to assess eosinophil levels and esophageal biopsies, may be necessary to identify the underlying cause and initiate appropriate treatment. While hiccups are often harmless, persistent cases can be a sign of a more serious condition that requires medical attention.
