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Oral burning with dysphagia and weight loss

Oral burning with dysphagia and weight loss Oral burning with dysphagia and weight loss
Oral burning with dysphagia and weight loss Oral burning with dysphagia and weight loss

An 80-year-old woman complaining of pain in the anterior chest and epigastric region, dysphagia, odynophagia, vomiting, oral burning and fever was presented to the emergency department of the multi-speciality hospital. The patient also complained of gradually increasing trouble in swallowing from the past one month. At the time of admission, her heart rate was 90 beats/min and blood pressure was 145/80 mmHg. 

 

The most likely diagnosis of this presentation is

  • Fibromyalgia
  • Telangiectasia
  • Iron and Vitamin B12 deficiency

 

Fibromyalgia (FM) refers to a common chronic pain disorder characterized by widespread pain, may or may not be accompanied by fatigue, localized pain, mood disorders and sleep disturbance. It is a common disorder affecting up to 1 in 20 patients in primary care. According to the American College of Rheumatology (ACR) criteria, FM is defined as chronic, widespread pain for at least three months and the presence of 11 out of 18 tender points. Since the FM is a disorder of unknown etiology, its diagnosis and treatments are challenging and often involves referral to the different specialists, making it more exhaustive. Moreover, the multifaceted nature of the syndrome and co-occurrence of other painful conditions makes it more complicated.

 

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Key take away

Patient presented with dysphagia, odynophagia, and glossodynia was diagnosed with fibromyalgia. Amitryptiline was used. Patient recovered with significant relief in symptoms. 

Medical history

She had a well-known history of hypertension from 25 years, type 2 diabetes, chronic kidney disease, osteoporosis, arthrosis, coronary artery bypass grafting and surgical removal of the gallbladder. She was on medications, including antacids, antihypertensives, antidiabetics, and NSAIDs, for multiple ailments.

Examination & lab investigations

Physical examination revealed a lack of expression suggesting scleroderma; however, Raynaud's phenomenon, skin induration, or telangiectasia was not reported. The patient has no pharyngeal or oral lesions. Blood examinations showed elevated levels of white blood cells and C-reactive protein, while low levels of haemoglobin and iron were reported. Imaging studies of abdomen turned out to be normal, that means there were no signs of obstruction or gas pains. The chest radiograph was normal; however, an x-ray of the pelvic region revealed osteoarthrosis. Plasma levels of zinc and vitamin B12 were normal, suggesting no deficiency of micronutrients that might be causing the oral symptoms. Fibromyalgia was the final diagnosis after eliminating parameters related to upper digestive tract lesions and cardiac disease. 

Management

Upon admission to the emergency department, 10 mg metoclopramide (intravenous) was administered that improved nausea and vomiting immediately. Patient was referred to the internal medicine unit due to her complex medical history and the persistent pain and dysphagia. Intravenous hydration and parenteral nutrition were administered. Bacteriuria and fever were treated using antibiotics that resulted in remission of fever in two-to-three days. The epigastric pain was thought to be linked to lower levels of haemoglobin and iron. Therefore, an esophagogastroduodenoscopy was undertaken. In the next few days, the patient showed some additional symptoms such as dysgeusia, poor memory, confusion and increased sensitivity to some odors. Therefore, the widespread pain index (WPI) was undertaken that revealed WPI of ≥7 plus symptom severity (SS) scale score of ≥5, which are suggestive of fibromyalgia. Finally, the diagnosis of fibromyalgia was confirmed, and the treatment with 10 mg amitriptyline, twice a day was initiated. The employed treatment approach successfully improved the symptoms, including, odynophagia, glossodynia, pain, dysgeusia, and poor memory/ confusion.

Discussion

Although the etiology of FM is poorly understood, it is hypothesized to trigger factors such as stress, medical illness, and a variety of pain conditions. However, the similar symptoms might be associated with a variety of neurotransmitter and neuroendocrine disturbances such as reduced levels of biogenic amines, increased concentrations of excitatory neurotransmitters, including substance P, and dysregulation of the hypothalamic-pituitary-adrenal axis. Chronic pain is the symptom of FM that is of primary importance to patients and clinicians and is routinely evaluated as an endpoint in clinical trials and clinical practice.

Treatment of FM may involve a wide range of medications, including antidepressants, opioids, nonsteroidal anti-inflammatory drugs, sedatives, muscle relaxants, and antiepileptics. Nonpharmaceutical approaches, including exercise, physical therapy, massage, acupuncture, and cognitive behavioural therapy, can be helpful. Because of the multifaceted nature of FM, multimodal individualized treatment programs may be necessary to achieve optimal outcomes in patients with FM.

The present case with FM was presented with multimodal symptoms, including difficulty in swallowing thereby impairing the food intake. Symptoms like oropharyngeal are often overlooked while diagnosing FM. Therefore, the present case testifies the need to consider the diagnosis of fibromyalgia when such signs are present without any known underlying cause. According to a literature review, FM occasionally presents with oral-oesophagal pain and hypersensitivity. Orofacial symptoms include ulcerations, temporomandibular joint dysfunction, glossodynia, dysphagia orofacial pain, xerostomia,and dysgeusia. Since depression and anxiety are common among patients with FM, amitriptyline was prescribed to this patient.

Learning

It is important to consider glossodynia odynophagia and dysphagia as the prevalent symptoms at presentation of fibromyalgia. Recognising these symptoms while confirming the diagnosis of fibromyalgia can be helpful to design the most appropriate treatment approach and can also minimize the unnecessary diagnostic examinations.

References

    1. Arnold LM, Gebke KB, Choy EH. Fibromyalgia: management strategies for primary care providers. Int J Clin Pract. 2016 Feb;70(2):99-112.
    2. Silverman S, Sadosky A, Evans C, Yeh Y, Alvir JM, Zlateva G. Toward characterization and definition of fibromyalgia severity. BMC Musculoskelet Disord. 2010 Apr 8;11:66.
    3. Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005 Aug;75:6-21.
    4. Seccia TM, Rossitto G, Calò LA, Rossi GP. Oral Burning With Dysphagia and Weight Loss. Medicine (Baltimore). 2015 Aug;94(31):e1163.

Source:

Medicine (Baltimore). 2015 Aug;94(31):e1163

Article:

Oral Burning With Dysphagia and Weight Loss

Authors:

Seccia TM Rossitto G et al.

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