Annoying Hiccups following Intra-Articular Corticosteroid Injection of Betamethasone Acetate/Betamethasone Sodium Phosphate at the Knee Joint

Hiccups is a type of reflex that could happen secondary to different causes including drugs, especially systemic corticosteroids. Usually, high rather than regular doses of systemic steroids are incriminated, and this could explain the fact that very few cases of hiccups following regional corticosteroid treatment were reported. Here, we report the first case of hiccups in the English literature following intra-articular corticosteroid injection (IACI) at the knee joint and review all the previous reported cases of hiccups following regional corticosteroid treatment. Usually, this phenomenon of hiccups responds to regular antihiccups treatment; however, it is recommended not to repeat an IACI in a patient who had this adverse effect before due to an expected severe recurrent attack of hiccups afterwards. 1. Introduction Hiccups is a reflex of a sudden contraction of the diaphragm and inspiration abruptly terminated by glottis closure. The mechanism behind this phenomenon is the stimulation of the hiccups reflex arc. This arc starts (afferent limb) with phrenic and vagus nerves and ends with the phrenic nerve again, glottis, and accessory muscles (efferent limb). Higher levels of the central nervous system like brain stem and midbrain affect this arc [1]. Hiccups could be induced by different etiologies including drugs, especially steroids [2]. It is believed that steroids trigger this reflex through steroid receptors on the reflex arc [3]. Intra-articular corticosteroid injection (IACI) is a common procedure and has a wide spectrum of systemic effects. Yet, there are very few reports of hiccups following regional steroid injections [4–7] including 3 cases only following IACI [5–7]. 2 of these cases were at the shoulder joint and one at the ankle joint. The knee joint is the most injected joint. To the best of our knowledge, hiccups following IACI at the knee joint was not reported before at the English literature. Here, we report a case of hiccups following IACI at the knee joint and review all the cases of hiccups following regional steroid injection that were reported or abstracted in English. 2. Case Presentation 42-year-old-male who works as a carpenter and started complains of bilateral knee pain, mostly during climbing-up or walking down the stairs. Serology was negative and also X-rays of the knees. MRI studies showed mild degenerative changes involving the cartilage and menisci. Following intolerance to nonsteroidal antiinflammatory drugs (NSAIDs) due to dyspepsia, he received an IACI of betamethasone acetate (3？mg)/betamethasone sodium