The Challenge: Can you solve a medical mystery involving a middle-aged man with unrelenting hiccups?
The Diagnosis column of The New York Times Magazine regularly asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you’ll find a summary of a quirky new case as well as links to lab reports and images that will provide you with the same information as those who originally solved this medical mystery. My usual hero is a doctor, but in this case, the diagnosis was made by a physician assistant.
This month’s puzzle not only gives everyone a chance to play “House” (as in the T.V. doctor), but it also gives readers a unique insight into the challenges emergency room doctors face when presented with an unusual problem and a patient who isn’t under the care of a personal physician.
The first reader to solve the case gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction that you could hold your own on morning rounds. Let’s get started.
The Presenting Problem:
A 46-year-old man comes to the emergency room with a two-day history of hiccups.
The Patient’s Story:
The 46 year-old-man lay still in the bed, trying not to wake his wife, waiting. The next spasm came right on time: his chest jumped. The bed shifted. She didn’t move. He couldn’t believe she was sleeping through this storm of hiccups, but she was. As he waited for the next spasm, the man relaxed his throat so that the spasm of inhaled air passed with barely a sound. He had been hiccupping two to three times a minute for nearly 24 hours.
The problem started the morning before. He awoke at his usual time and ate breakfast with his wife and four children. Then he opened his tiny luggage storefront downstairs from his home in a small New York City neighborhood. And at some point that morning, he started hiccupping. Getting the hiccups wasn’t such a remarkable event — until they didn’t go away.
He tried all the usual treatments. He held his breath. He drank a glass after glass of cold water. He thought scary thoughts. But no matter what he did, every 20 to 30 seconds his chest would jump, and his throat would close, cutting short the involuntary inward gasp of air.
It was really just a minor inconvenience; and a source of humor for his customers as he hiccupped his way through his pitch on each of the bags he sold. He made it through the day, through dinner and went to bed at his usual hour. But the hiccups were still going strong, in the middle of the night. The man rolled over and tried again to get to sleep.
When he woke the next morning they were still there. Now he was starting to worry. In the afternoon, he called the emergency room. Was it normal to have hiccups for two whole days? A triage nurse urged him to come to the hospital.
The Doctor’s Exam:
The patient arrived at Metropolitan Hospital, on Manhattan’s Upper East Side, around 3 p.m. The emergency room was boiling with activity, but finally a young man with dark hair and a dimple in his chin came up to the stretcher in the hallway where the patient lay. He introduced himself as Steve Ferrante, the physician’s assistant assigned to see him.
Just looking at the patient, it was clear to Mr. Ferrante that he appeared to be pretty healthy. He radiated a kind of vigor and health not common in many of the patients who came to the E.R. Mr. Ferrante suspected this man had no doctor because he hadn’t needed one. Until now.
The patient didn’t smoke, didn’t drink, took no medication. He had undergone two hernia operations – one three years earlier and one earlier that week.
Mr. Ferrante questioned the man closely. Did he have any other symptoms besides the hiccups? No — no chest pain, no shortness of breath, no fever, no chills, no coughing, nausea, vomiting. Nothing. Other than these crazy hiccups, he felt fine. Every sentence was broken up by the quick gasps of the hiccups. Otherwise, the physical exam was completely unremarkable.
The Treatment:
Hiccups, more officially referred to as singultus, (from Latin – to catch your breath while sobbing) are repeated, spasmodic contractions of the diaphragm causing a quick inhalation, which is then cut short by an involuntary closing of the glottis. Mostly these episodes are transient and benign. Hiccups lasting more than 48 hours are considered persistent. If they last longer than a month, they are termed intractable. The longest recorded bout of hiccups lasted 60 years.
Hiccups have many causes: anything that can irritate the nerves that innervate the diaphragm can cause these little spasms. It can come from something as benign as eating too much, so that the stomach irritates the nearby diaphragm, to the more serious, like an abscess or tumor on any of the structures near the nerves that run from the brain to the diaphragm. Hiccups after surgery are thought to be due to a mild injury of this nerve (called the vagus nerve) caused by the tube that is used to help the patient breathe during surgery. Injuries to certain parts of the brain — from trauma or disease — also can cause hiccups. Toxins, most commonly alcohol, can do it. So can stress.
Since the patient didn’t seem to have any other symptoms, Mr. Ferrante thought the hiccups were probably due to the surgery he’d had a few days earlier. Mr. Ferrante gave the patient a shot of one of the most effective and widely used medication to treat hiccups – an antipsychotic called Thorazine. Moments later the hiccups stopped. Cautiously optimistic, Mr. Ferrante watched the man for a while. When the hiccups didn’t return, he sent him home.
The patient walked out of the emergency room; moments later he was back. So were the hiccups.
New Symptoms:
The patient was given a second dose of Thorazine. Within minutes the patient began to feel weak and dizzy. He lay back on the stretcher, too weak to hold himself upright. As the man lay there, the churning chaos of the emergency department seemed to move further away — as if it were in another room. Then suddenly he felt his legs began to jerk and move. Now his arms too; they seemed to take on a life of their own. He felt as he couldn’t hold them still.
Mr. Ferrante quickly checked the man’s blood pressure. It had been normal but now was dangerously low. An I.V. was started and the man was given fluids to bring up his blood pressure. Blood was drawn and sent to the lab and chest X-rays were taken. The results were unremarkable. (Click on the document viewer to see the lab report.)
The Challenge:
Can you solve the case of the hiccuping luggage salesman?
Rules and Regulations: Post your diagnosis and questions for Dr. Sanders in the Comments section below. The correct answer will appear tomorrow on the Well blog. Winners will be contacted. Select reader comments may also appear in a coming issue of the New York Times Magazine.
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