Persistent Hiccups as atypical presentation of COVID-19: a Case Report

The recent outbreak of SARS-CoV-2 has become pandemic since it began in late 2019. Typical symptoms include cough, shortness of breath or diculty breathing, fever, myalgia and sore throat. There are other unusual or atypical presentations of COVID-19 in ORL practice. We report a 64-year-old male patient presenting with hiccups as the only symptom. Chest x-ray ray revealed new ground-glass opacities in both lung elds and he was found to be COVID-19 positive by RT-PCR. Early recognition of the COVID-19 atypical presentations by the Otolaryngologist facilitates subsequent management and case isolation to eliminate the risk of viral transmission.


Introduction
The recent outbreak of SARS-CoV-2 has become pandemic since it began in late 2019 (1) . Due to the high virulence via aerosol transmissions, to date COVID-19 has infected more than 7 million people all over the world, causing more than 400,000 con rmed deaths (2) .
People with COVID-19 have had a wide range of symptoms ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Typical symptoms include cough, shortness of breath or di culty breathing, fever, myalgia, sore throat Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea. (3) We report a 64year-old male patient presenting with hiccups as the only symptom and he was found to be COVID-19 positive with real time polymerase chain reaction (RT-PCR). The Ethics Committee at The University Hospital approved this study and informed consent was obtained.

Case Report
A 64-year-old patient presented to the outpatient clinic with persistent hiccups for 72 hours. He is nonsmoker with no other comorbidities or past history of pulmonary disease. He had no other symptoms like dyspnea, cough or fever. Due to the incidental nding of mild rhonchi, chest x-ray was done. Chest x-ray ray revealed new ground-glass opacities in both lung elds and the left costo-phrenic angle (Fig. 1).
Further laboratory work-up was done and leucopenia was the only abnormal nding detected. Due to the current pandemic, COVID-19 was suspected and the patient was transferred to the isolation Hospital.
COVID-19 nasopharyngeal swab was obtained and the result came as COVID-19 positive. The patient condition was stable and he received only symptomatic treatment. The hiccups improved 7 days after admission and he was discharged on the 14 th day after the second swab result came as negative.

Discussion
To our knowledge, this is the second case report of persistent hiccups as atypical presentation of COVID-19. Prince et al. (4) reported a similar nding in 62-year old man with a four-day history of persistent hiccups. He had abnormal chest x-ray and CT scan with ground-glass opacities scattered throughout the lungs.
Hiccups (hiccoughs) are de ned as sudden inspiration immediately followed by an active closure of the glottis. Hiccups lasting longer than 48 hours are referred to as persistent hiccups and those lasting more than 2 months are considered intractable .The exact mechanism of hiccups is not completely understood. Hiccups result from a stimulation of the central or peripheral components of a hiccup re ex arc. Multiple physiologic or pathologic factors have been suggested to cause hiccups. The most common are of gastrointestinal origin, such as gastric distention or GERD Metabolic abnormalities and drugs are also frequent causes for hiccups (5) .
It is crucial for the Otolaryngologist to be familiar with the atypical presentations of COVID-19. Early recognition of COVID-19 facilitates subsequent management and case isolation to eliminate the risk of viral transmission. COVID-19 should be considered in the differential diagnosis of any case of persistent hiccups.

Declarations Ethics' Approval
The study was approved by Alexandria University ethical committee. An informed consent was obtained from the patient. epidural steroid injection and analgesia with bupivacaine. Anesthesia & Analgesia, 2005; 100(6), 1834-6. Figure 1 Chest X-ray with ground-glass opacities featuring COVID-19 pneumonia