Persistent hiccups (singultus) as the presenting symptom of medullary cavernoma

Singultus (hiccup) is common, usually transient, and only rarely indicative of disease. If it persists, it can be highly bothersome, potentially interfering with sleep and leading to depression and physical exhaustion. It is presumed to be due to a disturbance in a reflex arc that includes the brainstem, the phrenic nerve, the vagus nerve, and the sympathetic chain. It can be induced by mechanical irritation (e.g., gastric distention), metabolic or toxic irritation (e.g., alcohol, cigarette smoke), infectious processes, emotional disturbances, and, rarely, neurological diseases.

The patient presented with persistent singultus (by definition, singultus lasting more than 48 hours). Initial diagnostic tests failed to reveal the cause, and the hiccups failed to respond to medications and other attempted treatments. Finally, an imaging study revealed a medullary cavernoma. After neurosurgical resection of this lesion, the patient was asymptomatic and returned to work.

This case shows that singultus, though it may seem trivial, deserves to be taken seriously, particularly when it persists and does not respond to medications. Its cause can be discovered in timely fashion by means of a thorough clinical history, physical examination, and ancillary testing.