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Dysphagia & Floppy Neck

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 62-year-old male presents to the ED for progressive neck weakness, leading to a head drop, dysphagia and dysarthria.  He states he has had gradually worsening weakness in his shoulders and neck area and trouble swallowing for the last 4 to 5 days. He went to another ED 2 days ago and sent home with a neck brace but he denies any neck pain. He denies any fever headache or other complaints. Denies any injection drug use or hiking camping. He does have some mild trouble breathing but denies  or other complaints

Vital Signs & Physical Exam:

Vital signs are normal.   Physical exam is otherwise normal except for weakness to neck flexion and sniff.

Initial Differential Diagnosis:

  • Syphilis, the great imitator

Initial Diagnostic Testing:

  • EKG: none
  • Labs: normal
  • Imaging: CXR was normal, CT chest shown below

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows a thymoma.  See below.
  2. What should you do next?  Consult neurology.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: He was diagnosed with generalized myasthenia gravis and associated thymoma.
AntiACH receptor antibodies were positive for both blocking and binding.  He was treated with Mestinon, thymectomy and a course of IVIG.

CASE LESSONS: With dysphagia or dysphonia or weak neck or jaw always consider the causes of bulbar palsy:

  1. Vascular: brainstem CVA
  2. Degenerative: ALS, syringobulbia
  3. Infectious: polio, Lyme disease, botulism
  4. Malignant: brain-stem glioma, malignant meningitis
  5. Toxic: Centruroides scorpion, certain snakes
  6. Autoimmune: myasthenia gravis, Miller-Fisher variant of Guillain–Barré
  7. Genetic: Kennedy’s disease, porphyria
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