Neurology Case Challenge: Drooling and Dysphagia in a Man Who Can’t Speak

Elena Cecilia Rosca, MD, PhD; Cristina Dijmarescu, MD; Mihaela Simu, MD


April 04, 2022

Physical Examination and Work-up

Upon physical examination, the patient appears well and has a temperature of 98.1°F (36.7°C). His blood pressure is 170/87 mm Hg. He has an irregular pulse of 92 beats/min. The respiratory and abdominal examination findings are normal.

Neurologic examination reveals a wide-based gait with small steps, mild ataxia of the left limbs, brisk tendon reflexes on the right side, and a right Babinski sign. Sensation is unremarkable. On cranial nerve assessment, he has bilateral loss of voluntary movement of muscles supplied by cranial nerves V, VII, IX, X, and XII.

The patient is anarthric, unable to volitionally open his mouth or smile; he can minimally move his tongue in the mouth but cannot protrude it. The mouth is slightly open. The patient is drooling and has severe dysphagia. The jaw jerk is increased, and the gag reflex is absent. The automatic movements of the face are preserved. The patient can open his mouth and retract his tongue with yawning. Cranial nerves I-IV and VI are normal. Taste, corneal reflex, trapezius, and sternocleidomastoid muscles are unremarkable.

The patient communicates by writing, with intact grammar, and he understands spoken and written language. He is emotionally appropriate, without involuntary laughter or crying.

Laboratory analysis findings, including complete blood cell count; erythrocyte sedimentation rate; and liver, renal, thyroid, and lipid panel are normal.

Electrocardiography reveals atrial fibrillation, with a heart rate of 96 beats/min and chronic ischemic cardiomyopathy changes. MRI of the brain shows multiple infarcts, bilaterally in the frontal, parietal, and occipital lobes, and cerebellar and cortical atrophy (Figures 1-3).

Figure 1.

Figure 2.

Figure 3.


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