occurring secondary to high-doses of corticosteroids are a
well-recognized problem in the field of neurosurgery. Numerous
reports of oral, intravenous and intraarticular corticosteroids
inducing hiccups exist in the literature. To date, there is
only one case of anabolic steroids inducing hiccups. We now
present a case of a patient who underwent a suboccipital craniotomy
for resection of a cerebellar pontine angle meningioma. Postoperatively
the patient was on high doses of Decadron and Oxandrin, an
anabolic-anticatabolic agent used to combat the deleterious
effects of corticosteroids. The patient suffered intractable
hiccups postoperative day one, resistant to Thorazine. Oxandrin
was discontinued to assess the possibility of a anabolic steroid-induced
singultus. The hiccups resolved within 24 hours. This report
validates the previous report on anabolic steroids inducing
hiccups and exemplifies the ability for steroids as a class,
due to there backbone structural homology, to induce function
even as competitive inhibitors.
mg = milligrams
b.i.d. = twice a day
t.i.d. = three times per day
q = every
hrs. = hours
p.o. = by mouth
years hiccups or singultus have been reported to be associated
with high-doses of corticosteroids .
The mechanisms of action for steroid-induced hiccups are yet
to be elucidated. We recently reported the first case of anabolic
steroid induced-hiccups in an elite power lifter .
We now report on a case of anabolic steroid-induced hiccups
associated with concomitant corticosteroid treatment in a
postoperative patient. This case demonstrates the partial
antagonistic effect of certain steroids and further elucidates
the complex molecular mechanisms of steroid-induced hiccups.
40 year-old male presented to the neurosurgery clinic for
resection of a cerebellar-pontine angle mass that was causing
progressive hearing loss. Neurologically the patient was intact
except for decreased high-pitched hearing in the left ear.
The patient was taken to the operating room for a standard
suboccipital craniotomy and resection of a cerebellar-pontine
angle meningioma. The surgery was uneventful and there were
no changes in brainstem-auditory evoked potentials during
surgery. Postoperatively the patient was on high doses of
Dexamethasone (Decadron) 8 mg p.o. q 6hrs. with a decreasing
taper of 2 mg q 48 hours for postoperative edema. He was also
on Oxandrolone (Oxandrin) 10 mg b.i.d., an anabolic
steroid, to combat some of the deleterious metabolic effects
of the Decadron. On postoperative day one the patient began
suffering intractable hiccups and was given Thorazine (Chlorpromazine)
50 mg t.i.d. for 24 hours without benefit. Based on previous
experience a decision was made to discontinue the Oxandrolone
and within 24 hours the hiccups resolved without any other
medication alterations. The patient was discharged two days
later on a Dexamethosone taper and Oxandrolone. The patient
denied any further hiccups at his two week postoperative follow-up
hiccup reflex arc is a complex system involving an afferent,
efferent, and central limb. In brief, the afferent limb involves
the sympathetic chain from thoracic segments T6-T12, the phrenic
and vagus nerves. The efferent limb is primarily the phrenic
nerve and its involvement with the glottis, accessory
respiratory muscles and interaction with the brainstem and
hypothalamus . The central connection
of the afferent and efferent limbs is a nonspecific location
between C3-C5 and the brainstem [2,6].
Previous reports have demonstrated that oral, intravenous
and intraarticular corticosteroids can induce hiccups [2,3,5].
There is also a report of oral progestins causing hiccups
which were thought to occur via corticosteroid receptor pathways
. It has been proposed that corticosteroids
may lower the synaptic threshold in the brainstem, thus permitting
hiccups to arise . Corticosteroids, mineralocorticosteroids
and progestins have been shown to bind to steroid-receptors
within the efferent limb of the hiccup reflex arc [11,
We previously proposed in our case of intractable hiccups
occurring in an athlete using supraphysiologic doses of anabolic
steroids that stimulation of the corticosteroid receptor was
occurring via competitive binding . We
postulated that competitive binding to the corticosteroid-receptor
within the afferent limb of the hiccup reflex arc was occurring
based on the rapid resolution of symptoms after discontinuing
anabolic steroids . Interestingly, the
athlete in the case was not using Oxandrolone but a more potent
oral anabolic-androgenic steroid Methandrostenolone (Dianabol)
. The present case further supports our
previous theory of androgens competitively binding to the
corticosteroid-receptor in the afferent limb of the reflex
arc, as symptoms resolved within 24 hours after discontinuing
the Oxandrolone .
Oxandrolone is both structurally and functionally an anabolic
steroid yet it is also considered an anticatabolic steroid
due to its ability to bind competitively to corticosteroid
receptors . We routinely place our patients
on Oxandrolone postoperatively to combat the deleterious effects
of Dexamethasone and to improve wound healing [14,15].
The ability of androgens to bind to corticosteroid receptors
is the thesis of this report which is supported by our previous
case of androgen-induced hiccups [6,8,10].
Lastly, one may question whether the hiccups could have resulted
secondary to brainstem irritation from retraction during the
surgical approach to the tumor. The tumor did not encase any
of the cranial nerves and there were no changes in brainstem-auditory
evoked potentials during the case. Postoperatively the patient
had no new deficits and his hearing progressively improved.
is our general consensus that this case which involves an
anabolic steroid that has been shown to competitively bind
to corticosteroid-receptors and our previous case of intractable
hiccups occurring with anabolic steroids demonstrates that
competitive binding to the corticosteroid receptor is a highly
plausible explanation . We continue to
use Oxandrolone in our postoperative patients to combat the
deleterious effects of corticosteroids and hope that this
report will educate other physicians on the complicated molecular
actions of anabolic steroids.
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