In a 54-year-old man with gastroesophageal reflux disease (GERD) who has had hiccups for three days accompanied by chills, sore throat, cough, ageusia, and recent exposure to upper respiratory infections but a negative COVID-19 test, can the hiccups be attributed solely to GERD?

No, you cannot assume GERD is solely causing the hiccups in this clinical context

Given the constellation of acute upper respiratory symptoms (chills, sore throat, cough, ageusia) with recent exposure to respiratory infections, the hiccups are more likely related to an acute viral illness rather than GERD alone, even with a negative COVID-19 test. The timing and symptom cluster strongly suggest an infectious etiology that requires further evaluation.

Why GERD Alone is Unlikely

While GERD can cause hiccups through esophageal-bronchial reflex stimulation, this typically occurs in the context of severe erosive esophagitis 1. The key distinguishing features that argue against GERD as the sole cause include:

• Acute onset with systemic symptoms: The 3-day duration of hiccups coinciding with fever/chills, sore throat, and ageusia suggests an acute infectious process rather than chronic reflux 2
• Ageusia (loss of taste) is highly specific for viral upper respiratory infections, particularly COVID-19 and related viral syndromes, and is not a typical GERD manifestation 3
• The temporal relationship with sick contacts makes infectious etiology far more probable 2

COVID-19 and Viral Considerations Despite Negative Test

A single negative COVID-19 test does not definitively rule out SARS-CoV-2 infection:

• COVID-19 can present with intractable hiccups as an atypical manifestation, particularly in patients with comorbidities, with hiccups sometimes being the sole or predominant complaint 2
• The combination of hiccups, cough, and ageusia is highly suggestive of COVID-19, even with negative initial testing, as test sensitivity varies with timing and specimen quality 2
• Other respiratory viruses (influenza, RSV, adenovirus) can also present with similar symptom clusters and may cause hiccups through phrenic nerve irritation or diaphragmatic inflammation 3

Recommended Diagnostic Approach

Immediate steps should focus on confirming or excluding infectious etiologies:

• Repeat COVID-19 testing (preferably PCR if initial test was antigen-based) given the high clinical suspicion with ageusia and exposure history 3
• Check inflammatory markers (CRP, ferritin, CBC with differential) as elevated levels support acute infection and are commonly seen in COVID-19 patients with atypical presentations like hiccups 2
• Assess for electrolyte abnormalities (particularly sodium, potassium, calcium) which can both cause hiccups and occur with viral illnesses 2
• Chest imaging if respiratory symptoms worsen to evaluate for infiltrates or complications, as 31% of COVID-19 patients with hiccups had associated cough 2

When to Consider GERD as Contributing Factor

GERD should be reconsidered as a primary cause only if:

• Infectious workup is negative and symptoms persist beyond the typical viral illness timeframe (>2 weeks) 1
• Patient develops typical GERD symptoms (heartburn, regurgitation, nocturnal symptoms) though notably, up to 75% of patients with reflux-related extraesophageal manifestations lack these classic symptoms 4, 5
• An empiric trial of high-dose PPI therapy (e.g., omeprazole 40 mg twice daily) for 8-12 weeks can be considered if infectious causes are excluded, as extraesophageal GERD manifestations require prolonged treatment 5
• If PPI trial fails after 12 weeks, pursue objective testing with pH-impedance monitoring rather than continuing empiric therapy 6, 5

Critical Clinical Pitfall to Avoid

Do not attribute acute symptoms with clear infectious features to chronic GERD without first excluding acute infectious etiologies. The presence of known GERD does not preclude concurrent acute illness, and the symptom pattern here (acute onset, systemic symptoms, exposure history, ageusia) overwhelmingly favors infection 2. Missing an acute viral illness—particularly COVID-19—has implications for infection control, treatment decisions, and monitoring for potential complications 3.

Management Pending Workup

While awaiting test results:

• Symptomatic management of hiccups with chlorpromazine, metoclopramide, or baclofen if severe and affecting quality of life 2
• Supportive care for upper respiratory symptoms
• Isolation precautions until infectious etiologies are excluded given the exposure history and symptom constellation 3
• Monitor for warning signs requiring escalation: dyspnea, hypoxia, altered mental status, or persistent symptoms beyond expected viral course 3, 2