A Case of Myopathic Dysphagia Secondary to Thyrotoxicosis

TL;DR

A 70-year-old man with thyrotoxicosis developed severe swallowing difficulties that improved after treating his overactive thyroid.

Contribution

This case highlights myopathic dysphagia as a rare but treatable complication of thyrotoxicosis.

Findings

The patient's dysphagia resolved with carbimazole and propranolol as thyrotoxicosis improved.

Normalization of thyroid hormone levels correlated with clinical improvement in swallowing.

Early euthyroid status is crucial to prevent aspiration and related complications.

Abstract

Myopathic dysphagia is a rare manifestation of thyrotoxicosis. Dysphagia may be isolated or may be associated with preceding proximal myopathy.

We describe a 70-year-old man with newly diagnosed Graves’ disease who presented with acute dysphagia with both liquids and solids for 3 weeks, with free thyroxine >73 pmol/L (reference range 8-16 pmol/L), free triiodothyronine >40 pmol/L (reference range 3.5-6.0 pmol/L), thyroid-stimulating hormone <0.01 mIU/L (reference range 0.45-4.50 mIU/L), and thyroid-stimulating hormone receptor antibody 28.6 IU/L (reference range 0.0-1.0 IU/L). This was associated with heat intolerance, palpitations, diarrhea, proximal weakness, and weight loss.

A video fluoroscopy study confirmed moderate oropharyngeal dysphagia. Evaluation was done to exclude other causes including mechanical compression, neuromuscular causes, and malignancy.

The patient’s dysphagia improved with carbimazole doses of up to 30 mg twice daily, and propranolol doses of up to 20 mg 3 times daily, titrated as thyrotoxicosis improved. He became euthyroid after 5 weeks of treatment, and had clinical improvement in swallowing by 8.5 weeks, improving from requiring nasogastric tube feeding to tolerating regular diet and thin fluids.

We discuss differential diagnosis to consider and exclude, and the pathophysiology involved in myopathic dysphagia. Based on case reports in literature, patients responded well with high doses of thionamides and beta-blockers.

Our patient’s dysphagia resolved rapidly with normalization of free thyroxine and free triiodothyronine. It is important to render the patient euthyroid as soon as possible to minimize risks of aspiration, pneumonia, and other complications.