Intractable hiccups as the presenting symptom of toxic nodular goiter

Hiccups differential diagnosis is a challenging one often being inconclusive and sometimes attributed to malignancies, and so of extreme importance to an internist. Seventy-five-year-old man with history of alcohol abuse, hypertension, and hyperlipidemia presented to the emergency department after having initiated diarrhea, hiccups, and vomiting for 4 days. Physical examination revealed signs of dehydration and persistent hiccups at rest. Laboratory investigations revealed acute renal failure (creatinine 3.7 mg/dl, reference value: 0.7-1.3 mg/dl; urea 195 mg/dl, reference value: 18-55 mg/dl) and no elevation of inflammatory parameters. Findings were consistent with a gastroenteritis, it was started fluids and the patient was admitted in the internal medicine ward. As the gastroenteritis symptoms ceased and the acute renal failure was resolved, the hiccups continued and physical examination revealed 2 palpable thyroid nodules. Laboratory findings shew subclinical hyperthyroidism (serum TSH 0.02 uUI/ml, reference value: 0.35 -4.94 uUI/ml; free T4 levels 18.5 pmol/L, reference value: 9.0-19 pmol/L). It was conducted an ultrasonography that revealed an increase of thyroid dimensions and 2 nodules. One nodule in the right lobe with 32 mm of dimension and one nodule in the left lobe with 58 mm of dimension. Both nodules were hypoechoic. Patient started antithyroid medication with propylthiouracil (PTU), 200 mg every 12 hours, and a cervical CT scan was conducted. CT scan revealed images compatible with diving goiter (Fig. 1) and tracheal deviation, for the right side (Fig. 2), inducted by the thyroid left nodule. Patient was discharged with antithyroid medication and hiccups were meliorated with chlorpromazine although persisting. After thyroid function normalization thyroidectomy was conducted, a few months later, and hiccups ceased.