Pneumonia presenting as singultus.

To the Editor: Singultus ("hiccups") is a common complaint in the emergency department (ED). The causes are extensive, but most cases of singultus are caused by conditions that are not of clinical significance. (1-4) However, we present a case of community-acquired pneumonia presenting as singultus.

A 73-year-old male presented to the ED with 4 days of persistent singultus. The patient also complained of a cough with yellow sputum, as well as fatigue and anorexia. The patient denied fever, chills, night sweats, rigors, chest pain, dyspnea or other complaints. His past medical history was significant for coronary artery disease, hypertension, and diabetes. Medications included furosemide, potassium chloride, valsartan, pravastatin, atenolol, digoxin, and nateglinide.

Vital signs at admission were: temperature 96.2[degrees]F, pulse 77, respiratory rate 32, blood pressure 142/62 mm Hg, and oxygen saturation of 95% on ambient air. Physical examination was significant for tactile fremitus and crackles over the right mid- and lower-lung fields. Laboratory values were significant for sodium of 126 meq/L, blood urea nitrogen of 71 mg/dL, creatinine of 1.6 mg/dL, and glucose of 173 mg/dL. His white cell count was 20,500 cells/m[m.sup.3] with 52% neutrophils and 41% bands. A chest radiograph showed a dense infiltrate in the right middle and lower lobes. Blood and sputum cultures were negative, as were influenza nasal swab and legionella urine antigen. The patient was treated with gaitfloxacin, which subsequently led to resolution of singultus and overall improvement.

The above-mentioned patient is an excellent teaching case, in that he is an example of how a common disease can present in an uncommon way, especially in the elderly. A review of the literature did not reveal any prior case reports of pneumonia presenting as singultus. The pathophysiology of singultus in this case may have involved inflammatory pneumonic irritation of the phrenic nerve and the pericardial branch of the phrenic nerve, which are located along the superior portion of the diaphragm and right heart border respectively. (1,5) Although our patient did not experience any complications, this case should serve as a reminder that singultus can be a symptom of a potentially significant intrathoracic process, such as pneumonia.

References

1. Rouseseau P: Hiccups. South Med J 1995;88:175-180.

2. Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med 1991;20:565-573.

3. Schreiber LR, Brown MR, et al. Hiccups due to gastroesophageal reflux. South Med J 1995;88:217-218.

4. Viera AJ, Sullivan SA. Remedies for prolonged hiccups (letter). Am Fam Physician 2001;63:1684-1685.

5. Netter FH. Thorax, in Atlas of Human Anatomy, 1st ed. Summit, NJ, CIBA-CEIGY Corp, 1989, plate 182.

Steven D. Burdette, MD

Mark A. Marinella, MD, FACP, CNSP

Division of Infectious Diseases

Division of General Medicine

Wright State University

School of Medicine

Dayton, OH

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