A 77 year old man with a background of Crohns disease requiring ileostomy, pernicious anaemia and hypertension, presented with a 4month history of dysphagia to solids, hoarseness of voice, anorexia and marked weight loss of 30 kg. He was initially referred to gastroenterology, who performed an endoscopy which was normal. Subsequently he was referred to the ENT and speech and language therapy departments. A video fluoroscopy confirmed severe oropharyngeal dysphagia with effortful initiation and reduced hyolaryngeal elevation, resulting in decreased airway protection and aspiration. Thyroid ultrasound, CT neck/thorax and whole body FDG PET scans were all normal. Thereafter he was referred to neurology, who noted marked generalised wasting, although no fatigability, a weak cough, but a preserved gag reflex. An anti-mACh antibody was negative and nerve conduction studies and EMG were unremarkable. At this time at around 6months after presentation, he was also noted to be in atrial fibrillation and his blood tests revealed that he had Graves Thyrotoxicosis : TSH <0.05 (NR 04.3 mU/l) , fT4 42.5 (NR 926 pmol/l) and fT3 18.5 (NR 2.55.7 pmol/l), TSH receptor Antibody 7 (NR 00.4 u/ml), TPO antibody 148 (NR 075 u/ml). He was commenced on anti-thyroid medications and anticoagulation with warfarin for his cardiovascular risk. Within 6 weeks, his appetite had normalised, his swallowing and voice had virtually normalised and he had gained 8 kg in weight. Discussion: Thyrotoxicosis may commonly result in skeletal proximal myopathy, however rarely it may cause marked wasting of the bulbar muscles resulting in dysphagia, dysphonia and dysarthria. The incidence of bulbar muscle involvement in thyrotoxicosis is not clear, however may range from 1680% of patients. (1,3) Most patients have antecedent generalised skeletal muscle wasting, although rarely dysphagia may occur in the absence of chronic generalised thyroid myopathy. (2) Oropharyngeal dysphagia is more commonly encountered than oesophageal dysmotility. (3) The dysphagia usually resolves within 14weeks as the patient is rendered euthyroid with antithyroid medication and a quicker response may be elicited with the addition of B-blockade. (3) This case highlights the need to consider thyrotoxicosis in patients with new onset dysphagia and marked weight loss in order to avoid unacceptable delays in diagnosis and therapy.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
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