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Think you can rely on just symptoms to diagnose a Covid-19 coronavrius infection? Well, here’s yet another hiccup in that plan. Or rather a bunch of hiccups. A case report recently published in the American Journal of Emergency Medicine suggests that persistent hiccups, otherwise known as hiccoughs, could actually be a symptom of Covid-19.

In the case report, Garrett Prince, MD, and Michelle Sergel, MD, from Cook County Health described what happened to a 62-year-old male, who went to the Cook County Health Emergency Department (ED) after experiencing four days of persistent hiccups and an unintentional 25-pound weight loss over a four month period. The case report described these symptoms in an interesting way, saying that the patient, “endorsed a twenty-five-pound unintentional weight loss over the last four months, and more recently, persistent hiccups for four days prompting his visit to the ED.” By the way, endorsing a hiccup is probably not quite the same as endorsing a check or a political candidate.

Nonetheless, these seemed to be the man’s only symptoms. There was no fever, nasal congestion, sore throat, chest pain, or shortness of breath. There were none of the symptoms found on the Centers for Disease Control and Prevention (CDC) “Symptoms of Coronavirus” list. His only other medical problems seemed to be diabetes, hypertension, and coronary artery disease. A physical exam didn’t reveal much either. His body temperature was 37.3 °C, which is about 99.1 °F. That ain’t really a fever.

But the doctors weren’t ready to send the man home. After all, hiccups are like the Baby Shark Song. Hiccups for a few minutes may be OK and even entertaining to others. However, hiccups for four days is something completely different. In fact, once a bout of hiccups has reached the two day- or 48 hour-mark, it’s time to seek medical attention. Don’t keep trying to scare yourself, breath into a paper bag, or hold your breath. Holding your breath for two straight days may actually take care of your hiccups but not in the way that you’d like. You kind of need oxygen to stay conscious and alive. Of course, if the hiccups are so bad that they are impairing your ability to eat, breathe, or sleep, don’t say, “OK, I can’t breathe but will wait for the two-day mark.” Call your doctor as soon as possible. 

 Hiccups are basically spasms of your diaphragm. No, this doesn’t mean that your birth control device is jumping out of its case. Instead, in this case, diaphragm refers to the muscles that sit below your lungs and normally help you inhale when these muscles contract. Contracting these muscles lowers the diaphragm, which then allows your lungs to expand and fill with air. These muscles contract when your phrenic nerve, which runs from your neck to the diaphragm, is activated.

Irritating this nerve may then cause involuntary contractions of your diaphragm and the “hic-hic-hic” in hiccups. An extended bout of hiccups may be a sign that something is continuing to irritate or even damage your phrenic nerve. This could be, for example, a mass somewhere along the phrenic nerve or a nervous system disorder.

Well, that was a word from your sponsors: diaphragms. Back to the case report.

Since the hiccups had persisted for well over two days, the doctors ordered a chest X-ray to check for the presence of a mass or some other abnormality. It’s a good thing that they looked because both of his lungs had “ground glass opacities.” These are hazy appearing areas that look like glass that has been ground. These are not normal findings. Ground glass doesn’t belong in your underwear or on your chest X-ray. On chest imaging, they tend to represent some type of lung inflammation, bleeding, or damage.

A CT scan of his chest confirmed the chest X-ray findings. So perhaps the inflammation in the lungs had triggered the hiccups. Blood tests showed that his white blood cell count, platelet count, sodium levels, and chloride levels were all low. Since something called the Covid-19 coronavirus pandemic is going on right now (just in case you didn’t know), the doctors decided to test him for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) as well and admitted him to the Covid-19 medical unit in the meantime as a precaution.

By the time he had reached the medical unit, his temperature had crept up to 38.4 °C (101.1 °F). In the words of Paris Hilton, that’s hot, and considered a fever. His heart rate had increased too, up to 104 beats per minute. The next day his SARS-CoV2 test came back positive, but not positive in a good, optimistic way. The man had Covid-19. During his stay he received cetriaxone, azithromycin, and hydroxychloroquine. Eventually after three days in the hospital, he was able to leave the hospital in stable condition.

Of note, the case report didn’t say why the man had lost weight. Since it had occurred over a four month period, the Covid-19 coronavirus probably wan’t the culprit.

Now, all of this doesn’t mean that you should freak out the next time that you have hiccups, especially if those hiccups resolve fairly quickly. Remember that many things can trigger hiccups including drinking carbonated beverages or getting excited such as when you see One Direction or when you drink carbonated beverages while seeing One Direction or even better when you and One Direction drink carbonated beverages together. It remains to be seen how rare versus common hiccups may be as Covid-19 symptoms. Remember, something typically becomes a medical case report only when it still is considered to be rare. That’s why you probably won’t see a medical journal case report entitled, “Man Farts, It Smells, End of Story,” anytime soon. Plus a single case report is enough to show that Covid-19 can cause hiccups. It could still have been a coincidence.

Nevertheless, the list of possible Covid-19 symptoms appears to be getting longer and longer. It can seem quite confusing when you are told that Covid-19 can lead to such-and-such symptoms, except when it doesn’t. Or if you have such-and-such symptoms, you may have Covid-19 or you may not. And should such-and-such symptoms appear, you absolutely certainly maybe possibly potentially could have Covid-19, as long as these symptoms aren’t being caused by something else. Well, this virus is still very new and researchers are still learning about what it can do.

All of this is further evidence that relying simply on symptoms to diagnose a Covid-19 coronavirus infection can be like relying on Tinder profiles to determine anything. Sure, diarrhea and vomiting can be bad signs when they are present in either situation. But in either case, just because everything looks OK doesn’t mean that everything is hunky-dory. The only real way to check whether someone is infected with the Covid-19 coronavirus is via testing such as sticking a cotton up his or her nose.

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