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• W2085285927 abstract "To the Editor: A 75-year-old man with history of diabetes mellitus, hypertension, hyperlipidemia, benign prostatic hypertrophy, and chronic renal failure presented to the emergency department with a 3-month history of progressive dysphagia. Initially, it involved only solids but later progressed to include liquids. He noticed some pooling secretions in the mouth, intermittent slurred speech and mild nonexertional dyspnea. He had no diplopia, drooping eye lids, chewing difficulty, choking, gait disturbances, or focal weakness in the extremities. His initial blood tests, chest X-ray, and computerized tomography brain scan were normal. Magnetic resonance imaging of the brain and neck was not performed because patient could not lie flat. Biphasic esophagogram identified extrinsic mass effect on the esophagus at the level of the cervicothoracic junction with displacement to the right and free flow of barium into the stomach. Computed tomography of neck soft tissue showed a large anterior osteophyte at the C7 vertebral body causing extrinsic compression and deviation of the esophagus (Figure 1). Neurosurgical evaluation recommended further examination to exclude other causes of dysphagia, including cerebral imaging, before consideration of any surgery in view of the disproportionate degree of dysphagia to the imaging findings. The patient's dysphagia worsened, and total parental nutrition was commenced. Serum acetylcholine receptor antibody titers were sent at that time to exclude the possibility of myasthenia. Paraneoplastic examination was negative. Meanwhile, the patient's respiratory status deteriorated acutely, requiring intubation and placement on a ventilator after being transferred to the intensive care unit. At that time, acetylcholine receptor antibody results came back showing high levels (5.49 nmol/L; normal range 0.00–0.03 nmol/L). Repetitive nerve stimulation and edrophonium tests were negative for myasthenia gravis. The patient was treated with intravenous immunoglobulin and high-dose oral prednisone. Hypercarbic respiratory failure, aspiration pneumonia, methicillin-resistant Staphylococcus aureus bacteremia, and atrial fibrillation complicated his course in the intensive care unit. His respiratory status improved within 7 to 10 days, after which he was extubated. He no longer had dysphagia and was subsequently discharged to a local rehabilitation facility. High-dose prednisone was tapered with the addition of mycophenolate mofetil. He has been stable, with no further recurrence of myasthenic symptoms since his discharge. Computed tomography of soft tissue of the neck showed a large anterior osteophyte at the C7 vertebral body causing extrinsic compression and deviation of the esophagus. This case highlights the difficulty in evaluating progressive dysphagia in older adults and the importance of looking for neuromuscular causes in addition to structural pathology in a case with direct extrinsic or intrinsic esophageal obstruction. Here, an atypical presentation of a serious condition is presented. This patient had an extrinsic mass at cervicothoracic junction, which could be a cause of progressive dysphagia. Also, the patient lacked typical features of myasthenia gravis: double vision and ptosis. This case illustrates the importance of considering myasthenia gravis in cases of unexplained dysphagia even when the classical myasthenia gravis presentation is not evident; edrophonium and repeated nerve stimulation tests do not confirm myasthenia gravis. Myasthenia gravis is an uncommon disease, affecting 20.4 per 100,000 population. Although common in younger women, the incidence is greater in men aged 50 and older. Even more-recent diagnostic trends indicate that men present between the sixth and seventh decade.1 In elderly patients, it is frequently misdiagnosed or has a significant delay in the diagnosis.1,2 It has previously been suggested that the average time to diagnosis of myasthenia was 4.5 months in people aged 60 and older, compared with 2.5 months in younger patients.1 For diagnostic purposes, the acetylcholine receptor antibodies are specific, and up to 90% will have antibodies, especially older men.2 The greater survival in the last few decades has been attributed to treatment3 with anticholinesterases, corticosteroids, and other immunosuppressants. It is rare for patients to present with bulbar weakness alone without ocular symptoms, and it is the presenting complaint in only 6%,4 although 28% report some form of dysphagia or dysarthria at some point during the disease.4 One study found that presentation with bulbar symptoms was more common in older adults.5 As with the patient in the current study, weakness of the oropharyngeal muscles produces dysphagia, which is a major cause of morbidity in myasthenia because of the risk of aspiration.6 Over the last decades, the natural history of myasthenia has improved in the diagnostic tests and therapeutic options leading to better survival, provided it is recognized and treated early. Progressive dysphagia is not uncommon in older adults but had varied etiological factors. This case illustrates the importance of considering myasthenia gravis in these patients even without the classical ocular symptoms in view of the significant morbidity and mortality if not recognized. The authors found no previous published cases of older adults with gradual onset dysphagia, numbness of tongue, intermittent dysarthria, and nonexertional dyspnea. The extrinsic mass effect at the cervicothoracic junction in this case was misleading and delayed eventual diagnosis. Myasthenia needs to be considered even in the absence of classical symptoms and in all age groups to be diagnosed and treated appropriately. Myasthenia gravis can present with bulbar symptoms alone without ocular symptoms, recognition of which could be difficult. It is a diagnostic possibility to be considered in patients with bulbar weakness, even when fatigability is not a prominent feature. Older adults are frequently misdiagnosed, which may result in further medical complications. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Dakshinamurty Gullapalli: case formulation and editing. Taral R. Sharma: case writing and editing Sponsor's Role: None." @default.
• W2085285927 created "2016-06-24" @default.
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• W2085285927 date "2010-11-01" @default.
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• W2085285927 title "A 75-YEAR-OLD CAUCASIAN MAN WITH UNUSUAL PRESENTATION OF MYASTHENIA GRAVIS" @default.
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• W2085285927 doi "https://doi.org/10.1111/j.1532-5415.2010.03109.x" @default.
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