Intractable hiccup caused by medulla oblongata lesions: A study of an autopsy patient with possible neuromyelitis optica

Characteristics of recurrence in area postrema-onset NMO spectrum disorder - a retrospective cohort study

BACKGROUND

Neuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory autoimmune disease with high risk of recurrence and disability, the treatment goal is a recurrence free state. Area postrema (AP) is one of the most common involved area of NMOSD, which may have a particular significance in the pathogenesis of NMOSD and clinical heterogeneity. Our study is to investigate the clinical and recurrent characteristics AP onset NMOSD patients.

METHODS

A retrospective study was done in a cohort of 166 AQP4-IgG seropositive NMOSD patients which were identified by the 2015 IPND criteria. The patients were divided into AP onset (APO-NMOSD) group and non-AP onset (NAPO-NMOSD) group based on the initial episode location. Clinical features and recurrence differences of two groups were compared.

RESULTS

The APO-NMOSD group and NAPO-NMOSD group had a population ratio of 24:142. APO-NMOSD patients were younger (34.6y VS 42.3y, P = 0.013), had lower EDSS at first episode (0.7 VS 4.2, p = 0.028) and last follow up (1.9 VS 3.3, p = 0.001), more likely to have multi-core lesions at the first attack (33.3% VS 9.2%, P = 0.001). Also, they had a higher annual recurrence rate (0.4 ± 0.28 VS 0.19 ± 0.25, P = 0.012). In natural course NMOSD patients without immunotherapy, APO-NMSOD had a shorter time of first relapse (P < 0.001) and higher annual recurrence rate (0.31 ± 0.22 VS 0.16 ± 0.26, P = 0.038) than NAPO-NMOSD. APO-NMOSD group also have a higher risk of having the first relapsing compared to optic neuritis onset-NMOSD (HR 2.641, 95% CI 1.427-4.887, p = 0.002) and myelitis onset-NMOSD group (HR 3.593, 95% CI 1.736-7.438, p = 0.001). Compared to NAPO-NMOSD, APO-NMOSD has a higher likelihood of brainstem recurrence (28.6% vs. 4.7%, p<0.001) during the first recurrence, while NAPO-NMOSD is more susceptible to optic nerve involvement (10.7% vs. 41.1%, p = 0.01).

CONCLUSION

AQP4-IgG seropositive NMOSD patients with AP onset are youngers and have higher risk of recurrence. Clinicians should pay attention to AP damage in NMOSD, as it indicates a potential risk of recurrence.

TRIAL REGISTRATION

Retrospectively registered.

Persistent Hiccups Induced by Supratentorial Infarcts and Successful Treatments With Combination of Perampanel and Baclofen: A Case Report

CASE

A 52-year-old man developed a cerebral infarction from the right middle cerebral artery occlusion, and the infarction extensively damaged the right insula. Three months after the onset of the cerebral infarction, persistent hiccups appeared, occurring during sleep. The thoracic and abdominal cavities showed no lesions; hence, the hiccups were considered to be caused by central nervous system dysfunction. Administration of metoclopramide, chlorpromazine, and diazepam were ineffective, while levetiracetam had a partial effect. Combining perampanel with baclofen finally suppressed the symptoms.

DISCUSSION

Lesions at the right insula impair respiratory reflex and may present with hiccups as a symptom of respiratory reflex disinhibition. Here, we review similar cases of treatment-resistant hiccups, as well as perampanel and baclofen efficacy in myoclonus cases.

CONCLUSIONS

Our patient's case suggested that perampanel with baclofen may be effective for myoclonus due to respiratory reflex disinhibition and can be used to treat hiccups derived from cerebral infarctions.

Intractable hiccups as the harbinger of a diffuse pontine glioma

Hiccups are experienced by people of all ages. While acute hiccups are benign and self-limited, persistent and intractable hiccups can sometimes signal a serious disease. We present a young previously healthy man who complained of only hiccups for 4 months and later developed a severe headache and projectile vomiting. His systemic examination was within normal limits. Brain imaging revealed a diffuse pontine glioma with mild hydrocephalus.

Supratentorial infarcts accompanying hiccup

BACKGROUNDS

The main culprit lesion causing hiccup in patients with ischemic stroke is thought to involve the medulla oblongata, but some cases of hiccups caused by damage to the supratentorial cortex have been reported. The present study aimed to address the clinical and radiological characteristics of acute stroke patients accompanied by hiccups caused by supratentorial lesions.

METHOD

We retrospectively studied 5,309 consecutive patients with acute ischemic stroke or transient ischemic attack who were admitted to our institute within 7 days after onset between April 2006 and September 2017. We searched for the term "hiccup" in prospectively collected descriptive datasets and analyzed associations between hiccup and clinical and radiological findings, with particular focus on patients with supratentorial lesions.

RESULTS

We finally selected 16 stroke patients accompanied by hiccup. Nine patients had infarcts in the lateral medulla oblongata, and others had supratentorial infarcts (three patients with cortical infarcts, four patients with subcortical infarcts). Moreover, the right hemisphere was frequently damaged in this series (6/7, 86%).

CONCLUSIONS

Hiccup could be caused by supratentorial infarcts including the insular cortex, temporal lobe, and subcortex.

Recurrent hiccups may signal brainstem pathology and should be investigated

While occasional hiccups are normal, their persistent recurrence is distressing and may have an underlying aetiology. Patients with recurrent hiccups may undergo a long journey and see many physicians before the diagnosis is finally made. The purpose of this report is to increase awareness of central nervous system lesions as a possible cause for recurrent hiccups and provide an illustrative case of an otherwise fit man presenting with ongoing hiccups caused by a medullary haemangioblastoma.

Management of hiccups in palliative care patients

Persistent hiccups are a frustrating experience for palliative care patients, and can have a profound impact on their quality of life. This article provides an evidence-based approach overview of the causes and treatment of this not infrequently debilitating condition for such patients, with a management algorithm. In situations where no readily reversible cause is identified, or where simple physical manoeuvres, such as breath holding have failed, a systematic approach is required. Hiccups can be broadly divided into central and peripheral types. These respond differently to pharmacological intervention. The drug of choice for central causes of persistent hiccups is baclofen, with metoclopramide recommended as the first choice for peripheral causes. Midazolam may be useful in cases of terminal illness. Interventional procedures such as vagal or phrenic nerve block or stimulation should be considered in patients who are refractory to medications. The management of persistent hiccups still presents an ongoing clinical challenge however, requiring further research on pathophysiology and treatment strategies. Multinational randomised controlled trials to evaluate and compare both current and new medications or procedures to better manage this difficult condition are suggested as a means of reaching this goal.

Clinical analysis of neuromyelitis optica presenting as intractable nausea, vomiting and hiccups

Vomiting and hiccups can be the manifestations of numerous systemic and neurological illnesses. Intractable nausea, vomiting and hiccups (INH) are reported as possible initial manifestations of neuromyelitis optica (NMO), but not correctly identified. Awareness of these atypical presentations is conducive to NMO early diagnosis and proper treatment to prevent further disability. In this paper, 12 NMO were reported, whose intractable vomiting and hiccups were the sole manifestations of the first attack and other attacks involving spinal cord and optic nerves developed later. All the patients were women and serum aquaporin 4 antibody (AQP4-Ab) of 83% patients was positive. MRI of 50% patients showed T2-weighted imaging/fluid attenuated inversion recovery hyperintensity which were longitudinally extensive transverse myelitis or linear signal changes. Sixty-seven percent of patients had medulla lesions, in which dorsomedial and area postrema were involved.

Hiccups as a migraine aura

OBJECTIVE

To report a case series of hiccup as a migraine aura.

BACKGROUND

Hiccup is a syndrome of inappropriate muscle contraction. To our knowledge, hiccup as a migraine aura has not been reported.

CASE SERIES

We describe series of patients who presented with hiccups as their migraine aura symptom.

CONCLUSION

Hiccups can present as a primary aura symptom in patients with migraine.

The pathology of an autoimmune astrocytopathy: lessons learned from neuromyelitis optica

Neuromyelitis optica (NMO) is a disabling autoimmune astrocytopathy characterized by typically severe and recurrent attacks of optic neuritis and longitudinally extensive myelitis. Until recently, NMO was considered an acute aggressive variant of multiple sclerosis (MS), despite the fact that early studies postulated that NMO and MS may be two distinct diseases with a common clinical picture. With the discovery of a highly specific serum autoantibody (NMO-IgG), Lennon and colleagues provided the first unequivocal evidence distinguishing NMO from MS and other central nervous system (CNS) inflammatory demyelinating disorders. The target antigen of NMO-IgG was confirmed to be aquaporin-4 (AQP4), the most abundant water channel protein in the CNS, mainly expressed on astrocytic foot processes at the blood-brain barrier, subpial and subependymal regions. Pathological studies demonstrated that astrocytes were selectively targeted in NMO as evidenced by the extensive loss of immunoreactivities for the astrocytic proteins, AQP4 and glial fibrillary acidic protein (GFAP), as well as perivascular deposition of immunoglobulins and activation of complement even within lesions with a relative preservation of myelin. In support of these pathological findings, GFAP levels in the cerebrospinal fluid (CSF) during acute NMO exacerbations were found to be remarkably elevated in contrast to MS where CSF-GFAP levels did not substantially differ from controls. Additionally, recent experimental studies showed that AQP4 antibody is pathogenic, resulting in selective astrocyte destruction and dysfunction in vitro, ex vivo and in vivo. These findings strongly suggest that NMO is an autoimmune astrocytopathy where damage to astrocytes exceeds both myelin and neuronal damage. This chapter will review recent neuropathological studies that have provided novel insights into the pathogenic mechanisms, cellular targets, as well as the spectrum of tissue damage in NMO.

Use of Osteopathic Manipulative Treatment to Manage Recurrent Bouts of Singultus

Singultus, or hiccups, are involuntary spasms of the diaphragm that in most cases are harmless and self-limited. Treatments are reserved for those cases that persist, and current options include pharmacotherapeutics, complementary methods (such as acupuncture), and osteopathic manipulative treatment. A 32-year-old woman with stiff person syndrome and concurrent aminoacidopathy in the setting of acute inpatient rehabilitation was experiencing daily bouts of singultus, ranging from 20-minute to 5-hour durations. Osteopathic manipulative treatment at the onset of spasm resulted in immediate cessation of and further suppression of singultus for approximately 12 to 24 hours. Overall, there was a noted reduction in singultus frequency, duration, and intensity, as well as better tolerance of physical and occupational therapy. The authors theorize that OMT could be a useful adjunct to, or replacement of, pharmacologic interventions for singultus, especially when pharmacologic therapies have failed.

Trochlear nerve schwannoma with intratumoral hemorrhage presenting with persistent hiccups: a case report

Trochlear nerve schwannoma without neurofibromatosis is extremely rare. To our knowledge, only 31 surgical cases have been reported to date, and only 2 cases of trochlear nerve schwannoma with intratumoral hemorrhage have been reported. None of those cases presented with persistent hiccups. We report the case of a 44-year-old man with trochlear nerve schwannoma associated with intratumoral hemorrhage who presented with a 10-day history of persistent hiccups. Computed tomography and magnetic resonance imaging revealed a solid tumor with a 3-cm diameter and intratumoral hemorrhage in the left petroclival region that compressed the midbrain and pons. Subtotal removal of the tumor was performed via the zygomatic transpetrosal approach. Intraoperative findings revealed a tumor arising from the trochlear nerve. The histologic diagnosis was schwannoma of Antoni type A cells with intratumoral hemorrhage. Although the patient's left trochlear nerve palsy worsened temporarily, his postoperative course was uneventful. We present this rare case and discuss the mechanism underlying the patient's persistent hiccups.

Intractable hiccup caused by spinal cord lesions in demyelination disease

OBJECTIVE

This study aimed to summarize the clinical features of patients who presented intractable hiccup (IH) without brain and medulla oblongata (MO) lesions.

METHOD

This study included six patients who were diagnosed with inflammatory demyelinating myelitis, categorized as neuromyelitis optica (NMO), multiple sclerosis (MS), and myelitis. Patients who presented IH with cervical lesions but without MO lesions were also included. Clinical profiles, laboratory data, and magnetic resonance imaging findings were analyzed.

RESULTS

Three out of six patients were diagnosed with NMO, whereas the remaining three were diagnosed with acute myelitis, recurrent myelities, and MS, respectively. The duration of hiccup was from 2 to 23 days (average = 9.33 ± 8.64 days). Five patients (83.33%, patients 1-5) had long segmental lesions and one had a patchy lesion. None of these patients had any MO lesions. Half of them were successfully treated with high-dose methylprednisolone combined with gamma-aminobutyric acid (GABA) inhibitor.

CONCLUSION

IH occurred in patients without MO lesion. However, the mechanism remained unclear. Immune factors of demyelinating neuropathy stimulated the hiccup reflex arch. Cervical cord lesions may activate the hiccup center. In general, IH can be controlled by IVMP combined with GABA inhibitor. Unilateral phrenic nerve block may elicit no effect.

Immunology of neuromyelitis optica: a T cell-B cell collaboration

Neuromyelitis optica (NMO) is a debilitating autoimmune inflammatory disease of the central nervous system (CNS) that is distinct from multiple sclerosis (MS). The discovery of NMO-immunoglobulin G (IgG) in the serum of NMO-but not MS-patients was a breakthrough in defining diagnostic criteria for NMO. NMO-IgG is an antibody directed against the astrocytic water channel protein aquaporin-4 (AQP4). While there is evidence that NMO-IgG is also involved in mediating tissue damage in the CNS, many aspects of the pathogenic cascade in NMO remain to be determined. It is clear that antigen-specific T cells contribute to the generation of NMO-IgG in the peripheral immune compartment, as well as to the development of NMO lesions in the CNS. T helper 17 (Th17) cells, equipped both in providing B cell help and inducing tissue inflammation, may be involved in NMO development and pathogenesis. Here, we review immunologic aspects of NMO, placing recent findings in the biology of T-B cell cooperation into perspective with autoimmunity of the CNS.

A guide to facilitate the early treatment of patients with idiopathic demyelinating disease (multiple sclerosis and neuromyelitis optica)

Definite diagnosis of inflammatory demyelinating disease (multiple sclerosis (MS) and neuromyelitis optica (NMO)) may require time, but early treatment offers the opportunity to maximize patient outcomes. The purpose of this report is to provide guidance to facilitate early treatment decisions for patients with inflammatory demyelinating disease, before definitive diagnosis. Neurology experts reviewed the existing literature and clinical evidence. A treatment decision pathway was developed, defining patients for whom first-line MS disease-modifying therapies (a) are unlikely to be effective, (b) may be effective but require careful monitoring and (c) are likely to provide benefit. This algorithm seeks to ensure that patients, particularly those in Asia, receive appropriate treatment early in inflammatory demyelinating disease.

Management of belching, hiccups, and aerophagia

Although belching and hiccups are regarded as normal behaviors, they can occur at high frequency or become persistent, becoming bothersome and requiring medical care. Patients with excessive belching frequently have supragastric belches. Excessive belching should be treated as a behavioral disorder. Persistent hiccups, however, can be the first presentation of a serious disorder that requires extensive diagnostic testing. When no cause is found, only the symptoms can be treated. Aerophagia is an episodic or chronic disorder in which patients (children and adults) swallow large quantities of air, which accumulate in the gastrointestinal tract to cause abdominal distention and bloating. These patients should not undergo explorative laparotomy because they do not have ileus. New treatment approaches are needed for patients with aerophagia.

Molecular pathogenesis of neuromyelitis optica

Neuromyelitis optica (NMO) is a rare autoimmune disorder, distinct from multiple sclerosis, causing inflammatory lesions in the optic nerves and spinal cord. An autoantibody (NMO IgG) against aquaporin-4 (AQP4), a water channel expressed on astrocytes is thought to be causative. Peripheral production of the antibody is triggered by an unknown process in genetically susceptible individuals. Anti-AQP4 antibody enters the central nervous system (CNS) when the blood brain barrier is made permeable and has high affinity for orthogonal array particles of AQP4. Like other autoimmune diseases, Th17 cells and their effector cytokines (such as interleukin 6) have been implicated in pathogenesis. AQP4 expressing peripheral organs are not affected by NMO IgG, but the antibody causes extensive astrocytic loss in specific regions of the CNS through complement mediated cytotoxicity. Demyelination occurs during the inflammatory process and is probably secondary to oligodendrocyte apoptosis subsequent to loss of trophic support from astrocytes. Ultimately, extensive axonal injury leads to severe disability. Despite rapid advances in the understanding of NMO pathogenesis, unanswered questions remain, particularly with regards to disease mechanisms in NMO IgG seronegative cases. Increasing knowledge of the molecular pathology is leading to improved treatment strategies.

Neuromyelitis optica: not a multiple sclerosis variant

PURPOSE OF REVIEW

The discovery of neuromyelitis optica (NMO)-immunoglobulin (Ig)G and its target antigen aquaporin 4 (AQP4) redefined NMO, historically considered a multiple sclerosis (MS) variant, as a specific disease entity. NMO and MS have divergent responses to immunotherapy and it is important to distinguish the conditions at disease onset. In this article, we review new pathological, imaging and clinical trial data pertaining to NMO, and discuss emerging concepts of molecular immunopathogenesis in NMO that can inform the development of targeted therapies.

RECENT FINDINGS

Recent studies illustrate the range of brain lesions associated with NMO, and the importance of diagnostic biomarkers in patients with atypical or limited presentations. Neuropathological studies showing perivascular astrocyte destruction and preserved myelin in early NMO lesions indicate a pathogenesis distinct from MS. Characterisation of NMO-IgG binding to AQP4 isoforms and the development of novel disease models have elucidated complement-mediated and cell-mediated mechanisms of astrocyte injury.

SUMMARY

NMO-IgG positive NMO is not an MS variant. Further work is required to delineate the pathogenesis of NMO syndromes without antibodies to AQP4. Methodological flaws inherent to small, open label trials of current NMO therapies limit extrapolation to clinical practice. In the coming years, NMO will be treated with targeted therapies that are emerging from an enhanced understanding of the molecular immunopathogenesis of the disease.

Reappraisal of aquaporin-4 astrocytopathy in Asian neuromyelitis optica and multiple sclerosis patients

Selective aquaporin-4 (AQP4) loss and vasculocentric complement and immunoglobulin deposition are characteristic of neuromyelitis optica (NMO). We recently reported extensive AQP4 loss in demyelinated and myelinated layers of Baló's lesions without perivascular immunoglobulin and complement deposition. We aimed to reappraise AQP4 expression patterns in NMO and multiple sclerosis (MS). We evaluated AQP4 expression relative to glial fibrillary acidic protein, extent of demyelination, lesion staging (CD68 staining for macrophages), and perivascular deposition of complement and immunoglobulin in 11 cases with NMO and NMO spectrum disorders (NMOSD), five with MS and 30 with other neurological diseases. The lesions were classified as actively demyelinating (n = 66), chronic active (n = 86), chronic inactive (n = 48) and unclassified (n = 12). Six NMO/NMOSD and two MS cases showed preferential AQP4 loss beyond the demyelinated areas, irrespective of lesion staging. Five NMO and three MS cases showed AQP4 preservation even in actively demyelinating lesions, despite grave tissue destruction. Vasculocentric deposition of complement and immunoglobulin was detected only in NMO/NMOSD patients, with less than 30% of actively demyelinating lesions showing AQP4 loss. Our present and previous findings suggest that antibody-independent AQP4 loss can occur in heterogeneous demyelinating conditions, including NMO, Baló's disease and MS.