Case Presentation: A 50-year-old man with a history of hypertension presented to the emergency department with a three-day history of nonstop hiccups. His systolic blood pressure was more than 200 and chest x-ray imaging was unremarkable. Over the next several days, his blood pressure remained elevated despite multiple medication additions, and he continued to complain only of hiccups. Workup for secondary causes of hypertension was unremarkable. An echocardiogram ordered for evaluation of cardiac abnormalities demonstrated a dissection flap in the descending thoracic and abdominal aorta and possibly into the aortic arch. Computed tomographic scan showed aortic dissection with an intramural hematoma extending from the left subclavian origin into bilateral common iliac arteries without mesenteric or renal vasculature involvement, consistent with a Stanford type B aortic dissection. On review of admission chest x-ray, widened mediastinum had been missed in the setting of severe scoliosis. The patient was initially managed medically with tight blood pressure control and complete resolution of his hiccups. Several days later, his hiccups returned and he was found with continued aneurysmal degeneration of the descending aorta in the setting of new lower extremity motor and sensation loss, for which he underwent successful thoracic endovascular aortic repair without residual deficits.
Discussion: Aortic dissection is a catastrophe that, if undiagnosed, carries a 50% mortality rate within the first 48 hours. In fact, 20% of patients will die before even reaching the hospital. Complicating matters, initial imaging studies may not show characteristics signs of a widened mediastinum on chest x-ray, and patients may present without typical symptoms of chest and upper back pain. In the previous case, the misread of the initial chest x-ray led to delayed ordering of the echocardiogram that ultimately established the diagnosis. Asymptomatic presentation of type B aortic dissection is exceedingly rare, and to date only two other cases in the literature have reported hiccups as the presenting symptom. The mechanism behind this phenomenon is unclear, however it is hypothesized that irritation of the phrenic nerve by the distention of the aorta leads to recurrent hiccups, as seen with this patient. Although the patient ultimately did not suffer residual neurological deficits on discharge, earlier diagnosis of the aortic dissection could have decreased risk for further aneurysmal degeneration.
Conclusions: This case emphasizes the importance of maintaining high clinical suspicion of rare catastrophes despite a negative initial work up and to consider aortic disease in the setting of prolonged hiccups.