Clinical Conundrum: Dysphagia in a Patient with COVID-19 and Progressive Muscle Weakness
- PDF / 397,752 Bytes
- 2 Pages / 595.276 x 790.866 pts Page_size
- 103 Downloads / 168 Views
CLINICAL CONUNDRUM
Clinical Conundrum: Dysphagia in a Patient with COVID‑19 and Progressive Muscle Weakness Amy Ishkanian1 · Alla Mehl1 Received: 20 August 2020 / Accepted: 22 October 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
A 58-year-old woman with a history of diabetes presented to an acute care hospital with 6 weeks of shortness of breath, cough, and fatigue as well as a 2-week history of sudden onset of slurred speech, left upper extremity weakness, nausea/vomiting, and difficulty with ambulation. Workup was consistent with COVID-19 pneumonia and hypoxic respiratory failure. Upon admission, she required supplemental oxygen via facemask and nasal cannula, with advancement to room air. A CT of the head was unremarkable and the patient’s neurological exam was largely non-focal. On the initial Speech-Language Pathology (SLP) evaluation, she was found to have hoarse and wet vocal quality, a report of recent vomiting and overt signs of aspiration with PO (per os) trials. Nursing also reported that the patient was unable to swallow oral medication. Over the following 5 days, she developed worsening dysphagia, with poor management of oropharyngeal secretions and with reduced cough strength suspected. She required frequent self-suctioning of her oral cavity and had persistent wet, gurgly vocal quality. She was receiving nutrition via nasogastric tube. The patient was subsequently noted to develop right eye ptosis, facial weakness, and hypernasal dysarthria. Cognitive and language skills were normal. Given worsening of the patient’s symptoms, Neurology investigated various etiologies including peripheral neuromuscular weakness, myasthenia gravis, Guillain Barre Syndrome, myositis, central venous sinus thrombosis, and brainstem stroke. Initial testing, including MRI of the brain and EMG, was unrevealing. Based on repeated SLP assessments over the course of 2 weeks, the patient continued to
* Amy Ishkanian [email protected] Alla Mehl [email protected] 1
Kings County Hospital Center, Rehabilitation Medicine C11, 451 Clarkson Avenue, Brooklyn, NY 11207, USA
have severe pharyngeal dysphagia with an inability to trigger a swallow or manage her secretions. What is causing the patient’s dysphagia and what is her prognosis? How should her dysphagia be managed? Due to a lack of improvement in swallow function at 3 weeks post-admission, a PEG was placed. Continued neuromuscular workup included total spine MRI, bilateral thigh MRI, and a thigh biopsy. Results of these tests were suggestive of myositis. In particular, the thigh biopsy result was suspicious for myositis secondary to viral infection vs idiopathic myositis with dermatomyositis. The patient was ultimately diagnosed with COVID-19-associated myositis. Four weeks after admission, the patient was transferred to Acute Rehab. The patient continued to present with persistent pharyngeal dysphagia, however, showed some improvement in secretion management. Hyolaryngeal excursion was often absent, and the patient had persistent ove
Data Loading...
