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Indian Journal of Medical Sciences, Vol. 59, No. 10, October, 2005, pp. 458-460 Letter To Editor An elderly man with dysphagia and dysarthria Bankar RN, Kohnke A Department of Medicine, Scarborough and North East Yorkshire Healthcare NHS Trust Code Number: ms05071 Sir, An 81-year-old man was admitted to hospital with a 2-day history of slurred speech and swallowing difficulty. There was no history of weakness in the limbs, diplopia or difficulty in breathing. He had enjoyed good health up until this event and his only medical problem was hypertension. He was taking losartan 50 mg, bendrofluazide 2.5 mg and aspirin 75 mg. He was a smoker and consumed little alcohol occasionally. He was well built, alert and oriented. He had good strength in all limbs and there was no focal weakness, reflexes were normal with downgoing plantars. There were no cerebellar signs. However, he was dysarthric and also had difficulty swallowing. The blood pressure on admission was 220/100 mm Hg. Full blood count, inflammatory markers and biochemical profile were within the normal range. Electrocardiogram and chest x-ray were normal. Computed tomography (CT) scan of brain showed moderate generalised cerebral and cerebellar atrophy. With the background of hypertension and smoking in an elderly man a diagnosis of stroke was made, and the patient was transferred to stroke ward for rehabilitation. Assessment by speech and language therapist revealed reduced tongue movements with severe dysarthria, and poor swallow with no laryngeal elevation during swallow. Due to poor swallow and high risk of aspiration a Nasogastric (NG) tube was inserted for feeding. On the third day from admission the patient became short of breath and was unable to get out of bed. He had severe dysarthria and was almost unable to speak. During examination he developed bilateral ptosis, became hypoxic (pulse-oximeter-saturation 70%) and had a periarrest. A presumptive diagnosis of myasthenia gravis was made, the patient was resuscitated and pyridostigmine was administered via the NG tube. The patient showed dramatic response to pyridostigmine and was then transferred to high dependency unit for further management. His acetylcholine receptor antibodies were elevated at 388.7 units (< 4.0). With the diagnosis of myasthenia gravis he was commenced on pyridostigmine 60 mgs six times a day along with prednisolone 60 mg daily. He had a normal CT scan of thorax and remains well at 8 months follow-up. Myasthenia Gravis (MG) is a potentially serious but treatable disorder of neuromuscular transmission associated with acetylcholine receptor antibodies. The hallmark of the disease is fatigable weakness, however, the spectrum can range from mild ocular symptoms to severe generalised form and respiratory failure.[1],[2] Due to vague symptoms and associated co-morbidities diagnosis of MG in the elderly can be difficult and MG can mimic stroke in elderly patients.[3] Kluin et al have described their experience of dysphagia and dysarthria in elderly patients with MG.[4] Presentation with dysphagia and dysarthria as in our patient is not a common feature of MG. Our case demonstrates that MG can be misdiagnosed as stroke in the elderly, and delay in the diagnosis can be life-threatening. MG is substantially underdiagnosed in older people[5] and should be considered as a diagnostic possibility in elderly patients with neurological features. Early and correct diagnosis may prevent complications from this treatable disease. References
Copyright 2005 - Indian Journal of Medical Sciences |
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