Rare clinical manifestation of community-acquired pneumonia

Abstract

A 71-year-old patient was admitted due to fever and persistent (>48 hours) hiccups. History and physical examination were not instructive. Lab tests were not specific, showing an inflammatory response. Chest film did not demonstrate opacities. The patient was treated with chlorpromazine with no relief. Fever and hiccups persisted, and therefore neck and chest CT was performed revealing a right lower lobe infiltrate, a finding consistent with pneumonia. Antibiotics were initiated and within 48 hours fever and hiccups resolved and patient recovered. Although hiccups are rarely described as a clinical manifestation of community acquired pneumonia, one should consider this diagnosis in a patient with unexplained fever.

Background

Hiccups are involuntary, intermittent, spasmodic contractions of the diaphragm and intercostal muscles with closures of the glottis. They are usually benign, short-lived and self-limited, however, when persistent (>48 hours) they cause significant discomfort to patient and doctor. For the patient: hiccups are difficult to treat; often leaving patient to endure the discomfort until the underlying cause is detected. For the frustrated clinician, due to misinterpretation, this manifestation may reflect malignant aetiologies, among others, irritating the phrenic and vagal nerves, somewhere from vertebrae C3–C5 where the phrenic nerves exit the spine, traversing the mediastinum on both sides to the diaphragm and intercostal muscles.^{1 2}

Rarely, pneumonia is manifested as intractable hiccups; the latter resolving with antibiotic treatment.^{3 4} A review of the literature (PUBMED search included: Pneumonia and (singultus or hiccups)) reveals only four reported cases in the past 15 years of lung infection/pneumonia presenting with hiccups (table 1).^4–7

Table 1.

Cases reported with pneumonia presenting with hiccups

Age	Gender	Patient background	Lung side	Fever present	Cough present	When hiccups resolved?	Syndrome/pathogen identified
71	Male	Hypertension	Right	+	−	Only after resolution of the infective trigger	−	Our case 2018
71	Male	Ethylism	Right	+	−		Legionellosis	2011
75	Male	S/P CVA	Right	−	−		Aspiration	2008
44	Male	Kidney transplant	Right	NA	NA		MRSE abscess	2005
73	Male	NA	Right	−	+		−	2004

CVA, cerebrovascular accident; MRSE, methicillin resistent staphylococcus epiderdimis; NA, not available; S/P, state post.

It is possible that even when hiccups accompany pneumonia, the latter may be under-rated or overlooked. Therefore, we thought that sharing this case may draw attention to this medical complaint.

Case presentation

A 71-year-old man presented to the emergency department with fever, general weakness and intractable hiccups (singultus) which started 3 days prior to his admission (March, 2018). He denied shortness of breath or coughing or any other symptoms pointing to the source of fever. He also denied recent contacts with relatives with infectious respiratory illnesses.

The patient is a lifetime non-smoker, though his wife is an active smoker. He lives in a rural area and grows sheep as part time job. He reported that he was immunised for influenza and pneumococcal disease earlier this year.

Physical examination was notable for spikes of fever and hiccups. ECG was normal. Elevated C reactive protein (155 mg/L) and mild hyponatraemia (132 meq/L) were the only abnormal initial lab tests. Chest X-ray was negative for opacities or pleural fluid (figure 1). The patient was hospitalised, suffering mainly from hiccups and therefore was treated with chlorpromazine (25 mg, three times daily). With the latter, the patient experienced no relief. Antibiotics were not administered on admission.

Figure 1.

Patient upright posterior-anterior (upper) and lateral (lower) chest film on admission. Negative for pneumonia-related findings. The arrow is a technical symbol denoting the upright posture of the patient during chest x-ray.

Investigations

Further blood tests investigating source of fever were performed. Blood and urine cultures were sterile; PCR for influenza A, B and respiratory syncytial virus was negative; urine Legionella antigen was negative; serology for Epstein barr virus (EBV), cytomegalo virus (CMV), Brucella and Q-fever was negative. As fever and hiccups persisted, on the third day of admission patient underwent neck and chest CT scan in search of the pathology underlying hiccups.

Differential diagnosis

At that time, differential diagnoses included²:

• Fever due to malignancy which also impinged on the phrenic nerve (neck and/or chest). Chest or abdominal tumours may cause intractable hiccups and fever.

• Pneumonia/pleuropneumonia. In the elderly clinical manifestation of pneumonia may be atypical without cough or shortness of breath.

• Pericarditis causing both fever and irritation of phrenic nerve. This was unlikely as patient did not complain of chest pain and ECG was normal.

• Central nervous system (CNS) infection or tumour. Our patient was free of neurological complaints; nuchal rigidity was not demonstrated.

• Tuberculosis. Our patient had low risk for tuberculosis; moreover, he had no respiratory complaints including cough and haemoptysis. Disease time frame was consistent with acute presentation.

• Pharyngitis. Our patient had no sore throat; pharynx examination revealed normal tonsils; neck palpation did not reveal lymphadenopathy.

• Pancreatitis or abdominal abscess. In the absence of abdominal discomfort and tenderness or any major lab abnormalities (eg, alkaline phosphatase, lipase) this diagnosis was unlikely.

Chest CT revealed infiltration, bronchiectasis and pleural effusion in the medial basal segment of the right lower lobe (RLL), consistent with pneumonia (figure 2).

Figure 2.

Coronal (upper) and axial sections of a CT scan demonstrating opacity consistent with right lower lobe pneumonia.

A diagnosis of RLL community acquired pneumonia (CAP) was made.

Treatment

Local regimen for CAP with intravenous ampicillin (2 g, three times daily) and doxycycline (100 mg, two times per day) was initiated. Fever and hiccups resolved within 48 hours. The patient completed a 5-day antibiotic regimen at the hospital.

Outcome and follow-up

The patient was discharged home. Two weeks after discharge, the patient resumed his normal daily life, free of complaints.

Discussion

The diagnosis of pneumonia in the elderly can be challenging at time, due to atypical clinical presentations and absence of radiological findings on chest radiograph. The sensitivity of chest radiograph for pneumonia is limited and ranges from 46% to 77%.^{8 9} Burdette and Marinella suggested that the inflammatory pneumonic irritation of the phrenic nerve and its pericardial branch, which are located along the superior portion of the diaphragm and right heart border, respectively, may be the pathophysiological cause of singultus in a similar case.⁴

When comparing our case with the four cases found in the literature, there are notable similarities. All patients were men, and this is not surprising as 80% of persistent hiccups occur in men.¹⁰ The patients previously described were older than 70 years of age (with the exception of one younger individual). Hiccups subsided only after the infective trigger was treated, and the most important feature, lung lesion was on the right side.^4–8

Learning points.

• Diagnosis of pneumonia can be challenging, as this very common disease sometimes manifests by unusual symptoms (eg, absence of opacities on chest radiograph).

• Persistent or intractable hiccups are a cause of great discomfort to the patient and can indicate a significant intrathoracic lesion. All patients with persistent hiccups should be investigated to identify organic pathology.

• One should consider community acquired pneumonia in a male elderly patient presenting with fever with no obvious source and persistent hiccups.