In a 54-year-old male with three-day hiccups (singultus), chills, sore throat, cough, ageusia, and gastroesophageal reflux treated with magnesium, what is the next step in management?

COVID-19 Testing is the Immediate Next Step

This patient requires immediate SARS-CoV-2 testing given the constellation of chills, sore throat, cough, ageusia (loss of taste), and persistent hiccups—a recognized atypical presentation of COVID-19. 1, 2, 3

Why COVID-19 Testing Takes Priority

Persistent Hiccups as a COVID-19 Presentation

• Persistent hiccups (>48 hours) have been documented as an atypical initial presentation of COVID-19, particularly in middle-aged to older males with comorbidities 1, 2, 3
• Analysis of 29 published cases shows that 96.55% of COVID-19 patients presenting with persistent hiccups were male, with mean age 58.28 years—matching this patient's demographic 3
• In 31.03% of COVID-19 cases with hiccups, intractable hiccups were the sole presenting complaint, though this patient has additional classic COVID symptoms 3
• Cough was the most frequently associated symptom (31.03%) in COVID-19 patients with persistent hiccups 3

Classic COVID-19 Symptoms Present

• Ageusia (loss of taste) is a highly specific symptom for COVID-19 and strongly supports this diagnosis 1
• The combination of chills, sore throat, and cough represents the typical respiratory syndrome caused by SARS-CoV-2 1
• Fever, fatigue, and dry cough are the most common COVID-19 symptoms, though this patient's presentation includes additional atypical features 1

Immediate Management Algorithm

Step 1: Isolation and Testing

• Immediately isolate the patient to prevent potential viral transmission, even before test results return 1
• Perform RT-PCR testing for SARS-CoV-2 as the definitive diagnostic test 1
• Consider rapid antigen testing if available, though PCR remains the gold standard 1

Step 2: Imaging if Clinically Indicated

• Obtain chest X-ray if respiratory symptoms are prominent (dyspnea, significant cough, hypoxia) 1, 2
• If chest X-ray is abnormal, chest CT may reveal peripheral ground-glass opacities characteristic of COVID-19 1, 2
• In documented COVID-19 cases with hiccups, imaging commonly showed infiltrates and ground-glass opacities 3

Step 3: Laboratory Assessment

• Check inflammatory markers (CRP, ferritin, D-dimer) and complete blood count, as elevated inflammatory markers are common in COVID-19 patients with persistent hiccups 3
• Assess electrolytes, as imbalances were documented in COVID-19 hiccup cases 3
• Monitor oxygen saturation continuously 1

Step 4: Symptomatic Treatment While Awaiting Results

• Initiate symptomatic treatment for hiccups with chlorpromazine 25-50 mg three to four times daily if hiccups persist beyond 2-3 days 4
• Provide supportive care for respiratory symptoms 1
• Most COVID-19 patients with persistent hiccups demonstrated substantial improvement through symptomatic and medical management 3

Critical Clinical Context

The GERD Connection—A Red Herring in This Case

• While this patient has known GERD treated with magnesium, GERD-related hiccups would not explain the acute onset of chills, sore throat, cough, and ageusia 5
• Up to 75% of patients with extraesophageal GERD manifestations lack typical heartburn or regurgitation, but GERD does not cause systemic symptoms like chills or ageusia 6, 7
• Chronic cough and sore throat can be extraesophageal manifestations of GERD, but the acute presentation with constitutional symptoms points away from GERD as the primary etiology 5

Prognosis and Monitoring

• The mean duration of hiccup symptoms in COVID-19 cases was 3.9 days 3
• Mortality was documented in only 2 of 29 cases (6.9%), indicating generally favorable outcomes with appropriate management 3
• Hiccups typically improved within 3-4 days of initiating COVID-19 treatment protocols 1, 2

Common Pitfalls to Avoid

• Do not attribute persistent hiccups solely to GERD when acute respiratory and systemic symptoms are present—this delays COVID-19 diagnosis and risks viral transmission 1, 2
• Do not dismiss ageusia as insignificant—it is a highly specific COVID-19 symptom that should trigger immediate testing 1
• Do not assume hiccups are always benign—in the context of respiratory symptoms during ongoing COVID-19 circulation, they warrant thorough evaluation 3
• Emergency physicians must maintain vigilance for atypical COVID-19 presentations to prevent missed diagnoses and nosocomial transmission 2