Rationale: High-dose melphalan is known to cause encephalopathy, loss of consciousness, and seizures within 30 days of administration. We present a case of rapid-onset, atypical focal aware seizures manifesting as intractable hiccups within hours of melphalan therapy in a patient with no prior history of epilepsy.
Methods:
A 70-year-old male was admitted for a planned autologous bone marrow transplant following conditioning chemotherapy with melphalan for IgG kappa multiple myeloma. Within a few hours of chemotherapy, he developed new-onset persistent hiccups occurring 1–2 times every 5 minutes, accompanied by jaw clenching, bilateral platysma spasms, and palatal myoclonus. These episodes briefly interfered with speech but occurred without any alteration in awareness.
Initially, these symptoms were considered to be either neck dystonia or a psychogenic response to the stress of the transplant. However, EEG revealed midline frontocentral low-voltage fast activity evolving into higher-amplitude polyspikes, followed by slowing and cessation, lasting 5–10 seconds. The presence of electrographic evolution, clear onset and offset, and time-locked clinical events raised suspicion for an underlying ictal phenomenon.
Results: More than 50 electrographic seizures were recorded within one hour. The patient was treated with a loading dose of levetiracetam (30 mg/kg) and started on maintenance therapy, resulting in complete resolution of both clinical and electrographic seizures. Brain MRI was unremarkable for structural abnormalities.
Conclusions:
Complex partial seizures can present with a wide range of ictal behaviors, though hiccups are rarely reported. Only a few cases have described hiccups originating from temporal lobe epileptogenic foci, suggesting autonomic involvement. Hiccups are typically benign myoclonic reflexes caused by sudden, involuntary diaphragmatic contractions, leading to abrupt glottic closure and the characteristic “hic” sound.
Given the overlap between abnormal movement disorders and seizures, clinicians should maintain a low threshold for EEG evaluation when assessing atypical motor behaviors. Careful correlation of clinical and electrographic findings is essential for accurate diagnosis.
Funding: None