A 68‐year‐old white male patient presented with progressive dyspnea on exertion, weakness, and an unintentional 50‐pound weight loss over the prior 6 months. He had a history of coronary artery disease, hypertension, and hyperlipidemia with coronary artery bypass grafting in 2007. Extensive outpatient evaluation was unrevealing, and he requested admission for a second opinion. The patient denied depression, the working outpatient diagnosis, and was unable to tolerate antidepressant trials secondary to excessive gagging. He had no chest pain, no productive cough, no vomiting, and no diarrhea. His dyspnea was exertional and progressive. Outside records indicated routine lab and thyroid tests. CT of chest, abdomen, and pelvis was negative as was esophagogastro‐duodenoscopy, colonoscopy, and total‐body bone scan. Cardiac echocardiogram demonstrated no valve abnormality and normal ejection fraction. On presentation, the patient was frail with mild slurred speech. Admission vitals were normal except for a pulse of 106 and a respiratory rate of 24. The patient had a normal cardiac and lung examination, a soft and nontender abdomen, and there was no edema. Cranial nerve testing was normal, with normal reflexes and only mild upper‐ and lower‐extremity weakness (4/5). Diffuse fine fasciculations were noted across his forearms and around the shoulders. Initial chest x‐ray and electrocardiogram were negative, although a troponin T was elevated, at 0.11 ng/mL (refernce, < 0.03 ng/mL). Cardiac catheterization did not show new obstructive disease, and medical management was recommended. A brain MRI and CTA chest were normal. Bedside spirometry was performed, demonstrating severe restrictive ventilatory defect. Electromyogram (EMG) of the right upper and lower extremities was performed, showing findings consistent with amyotrophic lateral sclerosis (ALS). The patient was referred to a specialty care center for further treatment.
In the presentation of dyspnea and weight loss, several diagnoses need to be considered by a hospitalist. This patient presented with chronic and progressive dyspnea with a positive troponin, initially thought to be an anginal equivalent. The presence of muscular fasciculations indicated a possible neuromuscular basis for the progressive dyspnea. In this scenario, spirometry and EMG were effective, high‐yield tests for establishing the diagnosis in this patient.
The purpose of reporting this case is to increase general awareness of neuromuscular causes of dyspnea that would otherwise be overlooked in patients with chronic coronary artery disease. Also, a detailed review of medication side effects can often give clues to the presentation of certain neuromuscular diseases—in this case, an accentuated gag reflex is often seen in ALS patients with pseudobulbar palsy. Although depression plays a significant comorbid role in any chronic illness, including cardiac disease, this patient did not meet criteria for depression, thus, alternate diagnoses should be pursued.
B. Miller ‐ none
To cite this abstract:Miller B. Dyspnea Can Be a Long‐Winded Story. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 341. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/dyspnea-can-be-a-longwinded-story/. Accessed March 20, 2019.