{
  "abstract": "Background Atypical prodromal symptoms can delay the recognition of infective and autoimmune encephalitides. Intractable nausea, vomiting or hiccups form an area postrema syndrome (APS) which is typically associated with dorsal medullary lesions, however also postulated to arise from any reflex arc disruption. We describe a case of initial herpes simplex virus 1 (HSV-1) then subsequent anti-N-methyl-D-aspartate receptor (NMDA-R) encephalitis both presenting with intractable hiccups.Case A 48-year-old man presented with 4 days of intractable hiccups, vomiting then confusion. He was febrile, tachycardic, and neurological examination demonstrated left facial weakness.Blood testing showed moderate hyponatraemia and abdominal imaging was normal. MRI brain revealed bilateral mesial temporal changes without brainstem involvement. CSF analysis revealed a lymphocytic pleocytosis with positive HSV-1 PCR. Electroencephalogram detected right temporo-occipital periodic lateralised epileptiform discharges. He recovered following intravenous aciclovir and discharged with mild memory deficits.The patient re-presented 2 months later with 2 days of vomiting, then headaches with the recrudescence of persistent hiccups. Repeat MRI brain revealed new diffuse right hemispheric changes remote to the first insult. Serum anti-NMDA-R antibody was positive. He was treated with intravenous methylprednisolone with oral taper and immunoglobulin before returning home asymptomatic.Conclusion Intractable nausea, vomiting and hiccups often localise to area postrema pathology however, it can represent an atypical prodrome of encephalitides. Separate reported APS cases have been caused by varicella-zoster virus, anti-leucine-rich glioma inactivated 1, and glial fibrillary acidic protein. Our case illustrates this unusual presentation in both HSV-1 then anti-NMDA-R aetiologies.",
  "authors": [
    {
      "affiliations": [
        "Neurology, St John of God Midland Hospital, Midland, WA, Australia"
      ],
      "name": "Jacky Luu"
    },
    {
      "affiliations": [
        "Neurology, St John of God Midland Hospital, Midland, WA, Australia",
        "Neurology, Joondalup Health Campus, Joondalup, WA, Australia"
      ],
      "name": "Thomas Jenkins"
    }
  ],
  "title": "3526 A case of intractable hiccups as the presentation of HSV-1 and anti-NMDA-R encephalitides",
  "uid": "fdd37710-e750-5586-8003-c2646cb6daf4"
}