Correspondence

Pseudolithiasis and Intractable Hiccups in a Boy Receiving Ceftriaxone

N Engl J Med 1994; 331:1532December 1, 1994

Article

To the Editor:

A 10-year-old boy was hospitalized for high-grade fever and treated with intravenous ceftriaxone (50 mg per kilogram of body weight per day). After two days cholelithiasis was diagnosed by ultrasound examination. On the same day the patient had recurring bouts of hiccups, which resisted various therapeutic maneuvers. Ceftriaxone was continued for seven more days. After 12 days of recurring hiccups, the patient was referred to our clinic. His bouts of hiccups lasted 2 to 3 minutes, with pauses varying from 10 minutes to a few hours. The hiccups stopped completely during sleep.

Before the current illness, there was no history of gallbladder disease or hiccups. The neurologic examination, the chest film, and a computed tomographic study of the brain were normal. Sonographic examination of the gallbladder demonstrated intraluminal echoes with shadows that were mobile when the patient was repositioned. Treatment with domperidone did not modify the bouts of hiccups. The frequency and intensity of the hiccups were reduced with high doses of baclofen (up to 1 mg per kilogram per day). Serial sonographic examinations showed progressive reduction of the echoes in the gallbladder. After seven weeks there was very little echogenic material left in the gallbladder, and the hiccups had ceased completely. After two more weeks no trace of echogenic material remained.

Prolonged treatment with high doses of ceftriaxone has been reported to be associated with the transient appearance of a particular biliary sludge (the calcium salt of ceftriaxone).1 Biliary sludge occurs in various situations2; ultrasonographically, it is usually characterized by low-amplitude echoes within the lumen, without postacoustic shadows and with layering toward the most dependent part of the gallbladder. By contrast, the ceftriaxone-associated sludge has a striking similarity to gallstones in that it is brightly echogenic, with posterior shadowing; however, unlike gallstones, it usually moves when the patient is repositioned.3 Schaad et al.4 found reversible biliary pseudolithiasis in 40 percent of children treated with ceftriaxone; only 19 percent of these patients had biliary symptoms.

In our patient with ceftriaxone-associated pseudolithiasis, the temporal relation to the hiccups suggests a cause-and-effect relation; moreover, biliary lithiasis is well known as a cause of intractable hiccups.2

Eugenio Bonioli, M.D.
Carlo Bellini, Ph.D.
Paolo Toma, M.D.
Istituto di Clinica Pediatrica dell'Universita di Genova, 16147 Genova, Italy

4 References

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   Kirejczyk WM, Crowe HM, Mackay IM, Quintiliani R, Cronin EB. Disappearing “gallstones”: biliary pseudolithiasis complicating ceftriaxone therapy. Am J Radiol 1992;159:329-330
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   Schaad UB, Wedgwood-Krucko J, Tschaeppeler H. Reversible ceftriaxone-associated biliary pseudolithiasis in children. Lancet 1988;2:1411-1413
   CrossRef | Web of Science | Medline

Citing Articles (6)

Citing Articles

1. 1

   Scott V Monte, William Allan Prescott, Kristin K Johnson, Lori Kuhman, Joseph A Paladino. (2008) Safety of ceftriaxone sodium at extremes of age. Expert Opinion on Drug Safety 7:5, 515-523
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2. 2

   2006. Cephalosporins. , 688-701.
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3. 3

   F. Jover, J. M. Cuadrado, J. Merino. (2005) Possible azithromycin-associated hiccups. Journal of Clinical Pharmacy and Therapeutics 30:4, 413-416
   CrossRef

4. 4

   Rita Moretti, Paola Torre, Rodolfo M. Antonello, Maja Ukmar, Giuseppe Cazzato, Antonio Bava. (2004) Gabapentin As A Drug Therapy of Intractable Hiccup Because of Vascular Lesion: A Three-Year Follow Up. The Neurologist 10:2, 102-106
   CrossRef

5. 5

   Ay?e Palanduz, I??k Yal?n, Erdem Tongu, Nermin Gler, lker ne?, Nuran Salman, Ayper Somer. (2000) Sonographic assessment of ceftriaxone-associated biliary pseudolithiasis in children. Journal of Clinical Ultrasound 28:4, 166-168
   CrossRef

6. 6

   &NA;. (1994) Ceftriaxone. Reactions Weekly &NA;:531, 5
   CrossRef