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Singultus is the sudden onset of erratic diaphragmatic and intercostal muscle contraction immediately followed by laryngeal closure. Pathophysiology involves afferent, central and efferent components. Bilateral phrenic nerve block was performed to a 46-year-old woman with a brain tumor with persistent hiccups, with initially positive response but later symptom recurrence. Bilateral pulsed radiofrequency of the phrenic nerve was performed guided by ultrasonography (US). In the follow-up, absence of hiccups was confirmed. The patient was discharged 24 h later. Persistent or untreatable singultus is an infrequent condition that should not be dismissed. This approach is a safe, accurate and effective therapeutic approach for patient's refractory to conservative treatment. Further studies are needed to establish safety and effectiveness of the treatment.

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Se describe el caso de un paciente que instaló un hipo persistente luego de recibir una inyección epidural transforaminal lumbar de corticoides. Se destaca que es una complicación raramente reportada y por ende poco conocida por quienes practican intervencionismo en dolor. Se discuten los posibles mecanismos por los que puede presentarse, se reseña la evolución observada, y se describe el tratamiento instituido. Se señala el impacto que el hipo puede tener sobre la calidad de vida.

The case of a patient who installed a persistent hiccup after receiving a lumbar transforaminal epidural injection of corticosteroids is described. It is highlighted that it is a rarely reported complication and little known by those who practice interventional pain medicine. Possible mechanisms by which it may occur are discussed, the evolution observed and the treatment instituted are reviewed. The impact that hiccups can have on quality of life is pointed out.

Descrevemos o caso de um paciente que desenvolveu soluços persistentes após receber uma injeção peridural transforaminal lombar de corticosteróides. Ressalta-se que é uma complicação pouco relatada e, portanto, pouco conhecida por quem pratica o intervencionismo na dor. Discutem-se os possíveis mecanismos pelos quais pode ocorrer, revisa-se a evolução observada e descreve-se o tratamento instituído. O impacto que os soluços podem ter na qualidade de vida é apontado.

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BACKGROUND: The coronavirus disease 2019 (COVID-19) is a systemic illness that implies neurological features and complications. Persistent (>48 hours) hiccups (ie, singultus or hiccoughs) have been recently described as a rare presentation of COVID-19. Even when considered benign, the frequency and duration of hiccup spells can be burdensome and sometimes difficult to treat. CASE PRESENTATION: We report the case of a 62-year-old man known by the treating physicians for vascular cognitive impairment, who consulted for progressive persistent hiccups that commenced 5 days earlier, about 24 hours after testing positive for the severe acute respiratory syndrome coronavirus 2 by real-time reverse transcription polymerase chain reaction. The patient could barely sleep because the hiccups reached the highest rate of 47 per minute in a spell lasting almost 72 hours. The patient initially received levomepromazine 25 mg by mouth, but sedation and delirium impeded the continuation of treatment, which only reduced the frequency of the hiccup spells by about 25%. Afterward, the patient was offered levosulpiride 25 mg thrice a day by mouth, resulting in a steady reduction in the hiccups rate, as well as the duration and daily frequency of spells, which disappeared after 3 days of levosulpiride treatment. COVID-19 pneumonia was moderate by chest computed tomography scan imaging and biomarkers, meriting continuous oxygen therapy, dexamethasone 6 mg once a day by mouth for 10 days, and enoxaparin 40 mg once a day, subcutaneously, for 7 days (due to elevated D-dimer serum concentration). Oxygen therapy was gradually withdrawn after 12 days. CONCLUSIONS: Oral levosulpiride is a suitable option in persistent hiccups that occur in patients with COVID-19 pneumonia. To our knowledge, this is the fourth published case of persistent hiccups as a clinical feature of COVID-19.

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El hipo persistente (singultus) es aquel que se presenta en forma de un ataque prolongado o ataques recurrentes durante un tiempo determinado, generalmente más de 48 horas, suele resolverse sin tratamiento farmacológico, pero puede ser necesario administrarlo y plantear su estudio etiológico. Esta entidad infrecuente se presenta en un hombre de 63 años, con historia de singultus desde hace tres años, que aparece fundamentalmente posterior a la ingestión de alimentos y persiste durante varios minutos u horas, todos los días. Las causas del singultus pueden ser gastrointestinales (reflujo gastroesofágico, hernia del hiato, esofagitis, úlcera gástrica, pancreatitis, carcinoma esofágico, masas hepáticas, ascitis, cirugía abdominal), neurológicas, vasculares, torácicas, metabólicas, tóxicas, fármacos y otras. Se le realiza interrogatorio y examen físico minucioso, electrocardiograma, rayos X de tórax y abdomen, analítica sanguínea, ultrasonido abdominal, Endoscopia superior, tomografía de tórax y abdomen, además de Manometría esofágica y la prueba terapéutica con omeprazol, diagnosticándose una enfermedad de reflujo gastroesofágico. Se pone tratamiento basado en medidas populares, y medicamentos del síntoma fundamental con cloropromacina (tabletas de 25mg): 1 tableta cada 8 horas, obteniendo mejoría ostensible del mismo, hasta el momento en que se diagnóstica la causa etiológica, donde se pone tratamiento específico de la enfermedad de reflujo gastroesofágico con omeprazol (20mg): 1 Cápsula cada 12 horas y domperidona, obteniendo la desaparición del síntoma que causó la consulta inicial del paciente.

The persistent hiccup (singultus) is the one that shows up as a prolonged attack or recurrent attacks during a determinant period of time, generally, more than 48 hours. It uses to resolve without a pharmacological treatment, but it could be necessary a treatment and posing its etiological study. This infrequent entity is presented in a man, aged 63 years, with a history for three years, appearing mainly after the food intake and persisting for several minutes or hours, every day. The singultus’s causes may be gastrointestinal (gastro-esophageal reflux, hiatal hernia, esophagitis, gastric ulcer, pancreatitis, esophageal carcinoma, hepatica masses, ascites, abdominal surgery), neurological, vascular, thoracic, metabolic, toxic, medicine, and others. We performed a questioning and a meticulous physical examination, an electrocardiogram, thorax and abdominal X-rays, blood analyses, abdominal ultrasound, superior endoscopy, thoracic and abdominal tomography, in addition to esophageal manometry and the therapeutic test with Omeprazol, diagnosing a gastro-esophageal reflux disease. We prescribed a treatment based on popular measures, and medication for the main symptom with chlorpromazine (25 mg tablets): 1 tablet each 8 hours, achieving a clear improvement of the symptom until the moment when the etiological cause was diagnosed and a specific treatment for the gastro-esophageal reflux disease was ordered with omeprazole (20 mg): 1 capsule each 12 hours and domperidona, reaching the disappearance of the symptom that caused the patient´s initial consultation.

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BACKGROUND: Although common and usually benign, hiccups can be an extremely uncomfortable disease. There is not much information about persistent and refractory hiccups. AIM: To report clinical features of patients admitted in a hospital due to hiccup. PATIENTS AND METHODS: A retrospective study and prospective follow up of patients admitted for hiccup in Hospital Clínico de Santiago de Compostela between January 1998 and May 2005. RESULTS: Twenty four patients (age 47 to 91 years, 23 males) were studied. Nineteen (79%) were admitted because of persistent hiccups. In twenty one patients, at inverted exclamation markeast one organic etiology was identified, and thirteen patients presented two or more possible associated conditions. The most common possible causes were digestive tract disorders, followed by central nervous system diseases. Twelve patients had a history of exposure to drugs that potentially could cause hiccups, mainly corticosteroids and benzodiazepines. Chlorpromazine was the first choice treatment in 23 patients, but seven required a second line drug. Average hospital stay was 13 days (range 3-90 days). Twelve patients died during follow up. Death occurred during the first three months of follow up in 61%. CONCLUSIONS: Persistent hiccup is often associated with organic conditions, specially advanced tumors of the digestive tract. It is usually associated with a bad prognosis.

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Background: Although common and usually benign, hiccups can be an extremely uncomfortable disease. There is not much information about persistent and refractory hiccups. Aim: To report clinical features of patients admitted in a hospital due to hiccup. Patients and Methods: A retrospective study and prospective follow up of patients admitted for hiccup in Hospital Cl¡nico de Santiago de Compostela between January 1998 and May 2005. Results: Twenty four patients (age 47 to 91 years, 23 males) were studied. Nineteen (79 percent) were admitted because of persistent hiccups. In twenty one patients, at ¡east one organic etiology was identified, and thirteen patients presented two or more possible associated conditions. The most common possible causes were digestive tract disorders, followed by central nervous system diseases. Twelve patients had a history of exposure to drugs that potentially could cause hiccups, mainly corticosteroids and benzodiazepines. Chlorpromazine was the first choice treatment in 23 patients, but seven required a second line drug. Average hospital stay was 13 days (range 3-90 days). Twelve patients died during follow up. Death occurred during the first three months of follow up in 61 percent. Conclusions: Persistent hiccup is often associated with organic conditions, specially advanced tumors of the digestive tract. It is usually associated with a bad prognosis.

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