Sir,India is considered to be the diabetic capital of the world.[1] Hiccups persisting for more than one week in a diabeticpatient are not that common and are difficult to treat. A 50-year-old male chronic tobacco user with uncontrolled diabetes, hypertension, and diabetic foot presented with hiccups for the last 10 days. His left leg was amputated about 22 years back in an accident; it was at this time that he was also diagnosed to be diabetic. His blood investigations including kidney functions were normal except high blood sugars. He did not respond to any of our symptomatic treatment for hiccups till he expectorated a round worm [Figure 1] and got relieved. Although the exact mechanism by which worms cause hiccups is not mentioned in literature, it may be because of the irritation of vagus or phrenic nerve or gastroesophageal reflux.[2-4]
Figure 1
Ascaris lumbricoides vomited out
Ascaris lumbricoides vomited outThis case highlights important epidemiological aspects of our country along with an equally interesting clinical presentation. Here is the phenomenon of “triple whammy,” that is a non-communicable disease like diabetes occurring at a comparatively young age of 28 with its attendant complication like diabetic foot in an individual who already is a below knee amputee. Despite suffering from these complications of diabetes he continues to smoke and suffers with a communicable disease like Ascariasis. Ascariasis may remain asymptomatic for a long period,[5] only to be diagnosed when an individual either vomits out or coughs out or passess the adult worms in stool. But in our case it produced hiccups and the diagnosis could only be made once the patient vomited it and hiccups stopped completely with the expulsion. of the worm. Present case also tells us the importance of inspection at the bed side,[67] a round worm in vomitus giving clue to the intractable hiccup.
Figure 1