Intractable vomiting and hiccups as the presenting symptom of neuromyelitis optica.
Intractable vomiting and hiccups as the presenting symptom of neuromyelitis optica
Abstract
Vomiting and hiccups can be due to peripheral or central causes. Neurological diseases causing vomiting and hiccups are due to lesions of medulla involving area postrema and nucleus tractus solitarius. Neuromyelitis optica (NMO) is one such disease which involves these structures. However refractory vomiting and hiccups as the presenting symptom of NMO is unusual. Here we report a patient with NMO in whom refractory vomiting and hiccups were the sole manifestation of the first attack. Diagnosis can be missed at this stage leading to delay in treatment and further complications. This case demonstrates the importance of considering NMO in any patient presenting with refractory vomiting and hiccups and with local and metabolic causes ruled out and linear medullary lesion on magnetic resonance imaging may indicate the diagnosis even when the classical clinical criteria are not met. Anti NMO antibody testing should be done and if positive appropriate treatment should be initiated to prevent further neurological damage.
Introduction
The definition of typical neuromyelitis optica (NMO) according to Wingerchuk’s revised diagnostic criteria includes patients with optic neuritis, acute myelitis, and at least two of the following three supportive criteria: Longitudinally extensive spinal cord lesions contiguous over three or more vertebral segments; lack of brain lesions in the magnetic resonance imaging (MRI) fulfilling multiple sclerosis (MS) criteria at the disease onset and serum positivity for aquaporin (AQP-4) antibody.[1] With increasing knowledge about the role and specificity of AQP-4 antibody in this disorder spectrum of NMO has been recognized and usually it is thought to be relapsing disease rather than monophasic. However, many atypical presentations have been recognized like hypersomnia, intractable hiccups, nausea, and vomiting (symptoms lasting for more than 48 hours); transient asymptomatic elevation of creatine kinase levels; and painful tonic spasm during transverse myelitis recovery period.[2] Awareness of these atypical presentations may help in early diagnosis and proper management in the presence of other supportive criteria to prevent disability. We report a patient of NMO who initially had a presenting episode of intractable vomiting and hiccups and later on developed other attacks involving spinal cord and optic nerves.