SciELO - Scientific Electronic Library Online

 
vol.63 número5Comparación de características clínicas de sobrevivientes y no sobrevivientes a SARS-CoV-2 en un hospital de segundo nivelEl papel de la vacuna SARS-CoV-2 en población con trasplante hepático índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados

Revista

Articulo

Indicadores

Links relacionados

  • No hay artículos similaresSimilares en SciELO

Compartir


Salud Pública de México

versión impresa ISSN 0036-3634

Salud pública Méx vol.63 no.5 Cuernavaca sep./oct. 2021  Epub 27-Feb-2023

https://doi.org/10.21149/12516 

Cartas al editor

What is the frequency of singultus as unique symptom in patients with Covid-19?

Cual es la frecuencia del singulto como síntoma único en pacientes con Covid-19?

Armando Totomoch-Serra, PhD, MD1  2 

Concepción B Ibarra-Miramon, MD3 

Carlos Manterola, MD, PhD1  2 

(1) PhD Program in Medical Sciences, Universidad de La Frontera. Temuco, Chile.

(2) Center of Morphological and Surgical Studies, Universidad de La Frontera. Temuco, Chile.

(3) Departamento de Evaluación y Tratamiento, Centro Nacional Modelo de Atención, Investigación Capacitación para la Rehabilitación e Integración Educativa Gaby Brimmer. Mexico City, Mexico.


Dear editor: In the first days of 2020, a new coronavirus identified as SARS-CoV-2 was declared to cause atypical pneumonia in some Latin American countries. Common symptoms are highlighted in this disease such as: cough, dyspnea, fever, odynophagia, and it can manifest as a common cold or develop severe pneumonia with potentially fatal acute respiratory distress syndrome, multiple organ failure, septic shock, and venous thromboembolism, among others. Additionally, atypical symptoms have been identified in the elderly and immunocompromised patients, such as delirium/confusion, decreased function, reduced mobility, syncope, persistent hiccups, and absence of fever.

Singultus is usually a self-limited disorder caused by the sudden onset of erratic diaphragmatic and intercostal muscles contraction and immediately followed by laryngeal closure. However, when it is prolonged beyond 48 hours, it is considered persistent whereas episodes longer than two months are called intractable. A reflex arc involving peripheral phrenic, vagal, and sympathetic pathways and central midbrain modulation is likely responsible for hiccup. SARS-CoV-2 has a neurogenic tropism recognized, the main mechanism known states that after binding to the receptors of the angiotensin converting enzyme II (ACE2) in the nasal epithelium, it invades the olfactory nerve and the bulb, progressing, to later invade the respiratory centers of the brainstem. To date, we have found in the literature six cases of persistent singultus in men positive to SARS-CoV-2 infection of different ethnic origin in the range of 48-62 years (table I),1,2,3,4,5,6 three of them Mexican with comorbidity.

Table 1: Descriptive and clinical data of six patients reported in the literature with singultus as the predominant symptom in Covid-19 infection 

Characteristics

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Age

60 years

48 years

54 years

62 years

48 years

52 years

Sex

Male

Male

Male

Male

Male

Male

Country

Mexico

Mexico

Mexico

USA

Egypt

Iran

Pathological personal history

Obesity, sedentary lifestyle,

dyslipidemia

Orthopedic surgery at L5 vertebral level

Obesity,

hypertension,

type 2 Diabetes

Type 2 diabetes,

hypertension,

coronary artery disease,

weight loss in the previous four months

Hypertension

Congenital factor V deficiency,

type 2 diabetes

Covid-19 Test Result

Positive

Positive

Positive

Positive

Positive

Positive

Main symptoms

Persistent singultus

Persistent singultus

Persistent singultus

Persistent singultus

Persistent singultus

Persistent singultus

Symptoms associated

Dysgeusia,fever,

rhinorrhea, dry cough, asthenia, adynamic state

Increased heart rate,

increase in blood pressure,

normal temperature

Asthenia,

adynamic state,

cough with spectoration,

dyspnea,

hypertension

Fever 38.4 C,

tachycardia and increase in blood pressure

Fever 39.3 C,

sore throat,

increase in blood pressure, and breathing rate

Episodes of epistaxis and increase in blood pressure

Oxygen

saturation

87%

93%

90%

97%

98%

Not reported

Laboratory testing results

Dimero D 1.16 pg/mL,

cholesterol, l 56 U/L,

high-density cholesterol, 27.1 mg/dL,

sodium, 132 mmol/L,

calcium, 7.9 mmol/L

Glucose 182 mg/dl,

platelets 81 000/mcl, leukocytes 4 000/mcl,

lymphocytes 700/mcl absolute count

Hemoglobin

12.10 g/dL; C-reactive protein 64.9 mg/dL,

albumin 3.2 g/dL; erythrocyte sedimentation rate 34 mm/h;

procalcitonin 0.059 ng/mL; fibrinogen 593 mg/dL; brain natriuretic peptide 1296 pg/mL

Platelets, 15 000/mcl,

leukocytes, 4 200mcl,

sodium 131 mmol/L,

chloride 98 mmol/L

C-reactive protein 51 mg/L, ferritin

2 600 ng/mL lactate dehydrogenase 856 U/L

Erythrocytes 5.62 x109/L,

glucose 138 mg/dL,

aspartate aminotransferase 51 U/L, alanine aminotransferase 73 U/L, alkaline phosphatase 318 U/L

Image studies

Chest X-ray with decreased radiolucency and probable parabronchial thickening

Chest CT shows multiple areas of diffuse alveolar damage in both lungs

Chest CT with bilateral patchy consolidation in lower zones on chest and report of ground glass areas

Chest CT with report of regional, peripheral

ground-glass opacities in both lungs

Chest CT shows subpleural areas in ground glass and “crazy-paving” pattern

Chest CT with report of ground glass areas

Treatment received in diverse phases

Ilaprazol;

Metoclopramide;

Aluminum-Magnesium-hydroxide;

Lidocaine;

Haloperidol;

Clonazepam;

Dexamethasone; Paracetamol

Metoclopramide;

Omeprazole;

Ondansetron;

Oral frappe magaldrate/simethicone

Analgesics, antipyretics and oxygen with not specification

Ceftriaxone;

Azithromycin;

Hydroxychloroquine

Proton-pump inhibitor;

Domperidone;

Baclofen;

Ceftriaxone;

Azithromycin;

Hydroxychloroquine;

Oseltamivir;

Anticoagulant, and antipyretics not specified

Metoclopramide;

Chlorpromazine

Place of the study and date of journal submission

State of Mexico, Mexico

June 3rd, 2020

Mexico City, Mexico, July 27th, 2020

Nuevo León, Mexico, June 8th, 2020

Illinois, USA,

April 8th, 2020

Cairo, Egypt,

July 22nd, 2020

Tehran, Iran,

August 18th, 2020

Statistics by country (Mexico, USA, Egypt and Iran) as of now March 2, 2021; Total population (millions):127.5, 322.2, 95.7, 80.3; Total reported cases (millions): 2.09, 29.4, 0.183, 1.65; Cases in last seven days: 37 015, 401 689, 3 603, 49 074; Total Deaths: 186 152, 529 045, 10 778, 60 267.

It is important to know better the atypical clinical manifestations of Covid-19 to understand its pathophysiology, so it is necessary to carry out retrospective and prospective studies focused in this symptom to be able to answer the question: What is the frequency of singultus as unique symptom in patients with Covid-19?; With the previous information, the following can be mentioned: 1) A greater number of evidence on atypical neurological data is required; 2) The information published on singultus as the only manifestation is scarce, but it is grouped in an age range of male patients of different ethnic origin with comorbidity where Mexicans are majority. An early identification of this isolated symptom associated with Covid-19 could help to avoid dissemination of the emergent virus.

References

Totomoch-Serra A, Ibarra-Miramon CB, Manterola C. Persistent hiccups as main COVID-19 symptom. Am J Med Sci. 2021;S0002-9629(21):00001-X. https://doi.org/10.1016/j.amjms.2021.01.001 [ Links ]

Alvarez-Cisneros T, Lara-Reyes A, Sansón-Tinoco S. Hiccups and psychosis: two atypical presentations of COVID-19. Int J Emerg Med. 2021;14(1):8. https://doi.org/10.1186/s12245-021-00333-0 [ Links ]

Boland-Rodríguez E, Estrada-Jaime MA, Soto-Salazar LG. Singultus as initial symptom of infection due to SARS-CoV-2. Med Int Mex. 2020;36(5):745-748. https://doi.org/10.24245/mim.v36i5.4380 [ Links ]

Prince G, Sergel M. Persistent hiccups as an atypical presenting complaint of COVID-19. Am J Emerg Med. 2020; 38(7):1546.e5-1546.e6. https://doi.org/10.1016/j.ajem.2020.04.045 [ Links ]

Bakheet N, Fouad R, Meguidassem A, Kassem AM, Hussin W, El-Shazly M. Persistent hiccup: A rare presentation of COVID-19. Respir Investig. 2021;59(2):263-5. https://doi.org/10.1016/j.resinv.2020.11.003 [ Links ]

Dorgalaleh A, Dabbagh A, Tabibian S, Bahraini M, Rafieemehr H. Persistent hiccups in a patient with mild congenital factor V deficiency and COVID-19; clinical and laboratory finding of a rare bleeding disorder. Int J Lab Hematol. 2021;43(2):e87-8. https://doi.org/10.1111/ijlh.13385 [ Links ]

Declaration of conflict of interests. The authors declare that they have no conflict of interests.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License