We present a case of a patient with asthma
who developed yawning associated with anterior
chest pain. She was admitted due to severe
anterior chest pain, wheezing and dyspnea.
Although the frequency of the symptoms
decreased, she began to experience frequent
episodes of yawning at night accompanied by
tears. While she experienced yawning, although
PEF (peak expiratory flow) decreased, no
asthmatic symptoms, such as wheezing or dyspnea
were observed. The yawning was improved markedly
by bronchodilators and a leukotriene receptor
antagonist, and moderately improved by
corticosteroids. We speculated that yawning is a
clinical manifestation of asthma that responds
to treatment.
Case Report
A 64-year-old woman was admitted to our
hospital in February 1993, due to severe
anterior chest pain, wheezing and dyspnea. She
experienced sudden chest pain that gradually
became more severe, accompanied by vomitting,
wheezing, coughing and dyspnea. She had been
asymptomatic until two years prior to admission,
when wheezing and dyspnea began. Her serum IgE
level was 2139 IU/ml, and both a skin test and a
radioallergosorbent test (RASP were positive
against house dust mites. According to episodic
symptoms of wheezing and dyspnea, the patient
showed a reversible airway response with an
increase in forced expiratory volume in one
second (FEV1) exceeding 20% in response to beta
2-agonist and showed increased bronchial
hyperresponsiveness to methacholine (PC2O; the
concentration of methacholine causing a 20%
decline of FEV1, 390 µg/ml). She was
diagnosed as having bronchial asthma. Other
potential causes of the chest pain were ruled
out according to the findings of upper
gastrointestinal endoscopy, chest radiography,
chest computed tomography, electrocardiogram and
ultrasonic cardiography. Coronary angiography
also failed to reveal either stenosis or
atherosclerotic changes.
Gastroesophageal reflux disease was also
concluded to be an unlikely cause of the chest
pain given that a proton pump inhibitor was not
effective in reducing the chest pain. After
being admitted, she was treated with
corticosteroids, nebulized beta 2-agonist and
intravenous aminophylline for her wheezing and
dyspnea, and a nonsteroidal anti- inflammatory
suppository for the chest pain.
Following discharge, although the frequency
of chest pain decreased, she began to
experience frequent episodes of yawning at night
accompanied by tears. Her yawning occurred
once every thirty to forty minutes, especially
on cold nights from November to March with no
sensation of dyspnea or chest pain. Her
pulmonary function was normal (114,5 % of
predicted forced vital capacity (FVC) , 113.8 %
of predicted FEV,) when she was
asymptomatic.
While she experienced yawning, although PEF
(peak expiratory flow) decreased somewhat
(50-80% of her maximum level), no asthmatic
symptoms, such as wheezing or dyspnea were
observed. The yawning was improved markedly
by bronchodilators and a leukotriene receptor
antagonist, and moderately improved by
corticosteroids. In summary, three different
symptoms, namely wheezing and dyspnea, anterior
chest pain and yawning, were observed in the
present case.
Yawning is a complex behavioral event that
depends largely on the autonomic nervous system,
which has been reported to be associated with a
sympathetic suppression that favours a
parasympathetic dominance (1). Yawning is under
the control of several neurotransmitters and
neuropeptides at the central level. Substances
that induce yawning include dopamine, excitatory
amino acids, acetylcholine, serotonin, nitric
oxide, adrenocorticotropic hormone-related
peptides and oxytocin. Opioid peptides are known
to inhibit yawning (2). Despite recent progress,
little is known of the neurochemical mechanisms
underlying yawning at the central level. The
administration of dexamethasone altered yawning
behavior induced by cholinergic but not
dopaminergic agonists (3). Further research is
needed to identify these factors.
Asthma shows a wide variety of clinical
manifestations, one of which is chest pain.
Three reported cases of chest pain variant
asthma have suggested its importance as a
clinical entity for patients who initially
present with chest pain. Two patients required a
short course oral corticosteroid treatment to
achieve symptom ablation (4). Asthma symptoms
(cough, dyspnea, wheeze, chest tightness, sputum
production and nocturnal awakening) correlated
poorly with the level of airway obstruction (5).
However, the present case developed nocturnal
yawning associated with noncardiac and
nonesophageal chest pain and airway obstruction.
The reason for the occurrence of yawning and
chest pain remains obscure, but the autonomic
nerve system may have played an important role
in their occurrence. Our case suggests that
yawning is a clinical manifestation of asthma
that responds to treatment.
References
1 .
Askenasy JJ, Askenasy N. Inhibition of
muscle sympathetic nerve activity during
yawning. Clin Auton Res 1996;6:237-239.
2. Argiolas
A, Meus MR. The neuropharmacology of
yawning. Eur J Pharmacol 1998;343:1-16.
