hiccups and vomiting

Hiccups and Vomiting: An Atypical Presentation of Neuromyelitis Optica Spectrum Disorder (NMOSD)**

Introduction

Neuromyelitis optica (NMO) is an inflammatory condition of the central nervous system characterized by demyelination and axonal damage, predominantly affecting the optic nerves and spinal cord. It is a rare disorder, but when it does occur, it can present with a variety of symptoms that can be difficult to diagnose. One of the less common presenting symptoms of NMO is intractable vomiting and hiccups. These symptoms, however, can also be seen in other neurological conditions, making the diagnosis of NMO particularly challenging.

Case Report

A 33-year-old woman presented to our tertiary care Centre with a 10-day history of persistent nausea and vomiting, followed by intractable hiccups. The nausea was non-fluctuating and occurred after every meal, with no associated symptoms such as fever, abdominal pain, or diarrhea. Hiccups, which were persistent, became distracting to her and affected her sleep. There was no history of double vision, blurry vision, cough while swallowing food, or difficulty breathing. On physical examination, she was alert and orientated, with Glasgow Coma Scale (GCS) scores of 15/15. She had slurred speech with guttural quality and weakness of cranial nerve 9 and 10, indicating cranial nerve palsies. Muscle tone and power were within normal limits, and reflexes were brisk bilaterally. Sensitivity to light and dizziness was not present, and there were no abnormalities in cranial nerve or muscle examinations. Blood and cerebrospinal fluid (CSF) analyses did not reveal any significant abnormalities, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin levels. The only positive finding was mild hyponatraemia and hypokalaemia.

MRI Findings

MRI of the brain and spine showed focal demyelination in the midbrain and the periaqueductal region of the dorsal medulla, consistent with active inflammation. Despite significant MRI changes, the differential diagnosis included subacute infarction and demyelinating lesion. An MRI of the pelvis did not reveal any causative factors for the symptoms.

Diagnostic Challenges

Despite the MRI findings, the differential diagnosis included multiple entities, such as idiopathic intracranial hypertension, sarcoidosis, tuberculosis, and NMO spectrum disorder (NMOSD). The absence of inflammatory changes in the CSF and normal levels of alanine aminotransferase, aspartate aminotransferase, and bilirubin made idiopathic intracranial hypertension less likely. The patient's serum aquaporin-4 (AQP4)抗体 was weakly positive, raising concerns about NMO. The presence of anti-AQP4 antibodies is highly specific for the diagnosis of NMOSD, but it is also found in a minority of cases without symptoms of hydrocephalus, meningismus, or intractable hiccups.

Treatment Response

After receiving high-dose intravenous (IV) steroids, the woman's symptoms improved significantly, and she was discharged on oral prednisolone with a plan for a gradual taper over 14 days. A follow-up MRI showed a reduction in the size and signal intensity of the lesion. Following a month of follow-up, the patient began experiencing a recurrence of symptoms, and repeat MRI revealed new T2 FLAIR hyperintensities in the dorsal medulla and pons. The symptoms resolved again with further IV methylprednisolone treatment.

Discussion

Early recognition of intractable vomiting and hiccups as symptoms of NMO can be challenging since these symptoms are also common in gastrointestinal and respiratory conditions. The symptoms are more specific for NMO when they are accompanied by other neurological signs, such as limb weakness, sensory disturbances, and abnormal cranial nerve function. Additionally, the timing of the symptoms can help differentiate between relapse and new lesion. In this case report, the hiccups and nausea were the only symptoms present at the time of presentation and were associated with areas of focal demyelination on MRI, findings that are typical of NMO. These symptoms improved with IV steroids, and the repeat MRI during an exacerbation supported the diagnosis of NMOSD.

##The diagnosis of NMOSD is important for patients presenting with symptoms such as intractable vomiting and hiccups, as early treatment can prevent neurological disability. The use of magnetic resonance imaging and the measurement of AQP4 antibodies can aid in the diagnosis of NMOSD. Prophylactic treatment with rituximab, given as a single dose followed by a maintenance dose, has been shown to be efficacious in preventing recurrences in NMOSD. It is also crucial to recognize that gastrointestinal symptoms may have a central nervous system cause and that timely diagnosis and treatment can make a significant difference in the outcomes for patients.

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**文章的主要标题：

[The Uncommon Symptoms of Neuromyelitis Optica Spectrum Disorder: Intractable Vomiting and Hiccups as Presenting Complaints]**

请注意，这篇文章是基于假设的案例创建的，并不是真实的医疗建议