Swollen Tongue Case
Although her symptoms at face value were vague and chronic, a psychiatric diagnosis (A) must come after evaluation of a possible organic cause of symptoms or signs. Simply gathering more clinical information on history and a general exam were enough to entertain medical causes of her complaints.
Discharging the patient home at this time (B) would not likely be dangerous, given chronicity of symptoms. However, this would delay proper work up and referral.
There is no evidence that this woman has a history of ingestion or a mood disorder that would put her at risk for this (C). In addition, readily available drug levels could not adequately explain her history and findings.
There is no report or evidence of spider bite (D), and she has no headache, body aches, nausea, vomiting, abdominal pain, change in vital signs (tachycardia, hypertension), or diaphoresis. Furthermore, treatment with calcium is no longer recommended. Antivenom is given in moderate to severe cases; analgesics and benzodiazepenes treat symptoms.
This patient has a long history of involuntary muscle contraction with slow spontaneous resolution, after minor local irritation (minor/trivial trauma or stimulation). This is an example of myotonia, which can be elicited with light percussion.
She has myotonic dystrophy, the most common form of muscular dystrophy found in adults. Type 1 is more common, affecting the head and neck as well as the distal muscles. Type 2 affects the limb girdle muscles. Both types are associated with muscle wasting, dysphagia, respiratory insufficiency, insulin resistance, cataracts, and cardiac conduction abnormalities.
Diagnosis is often elusive, and these patients may be seen by cardiologists, endocrinologists, rheumatologists, and psychiatrists before the neurologist sees them and evaluates with genetic testing, EMG, and/or biopsy. Treatment is often unsatisfactory; some are started on mexilitine, an antiarrhythmic.
Emergency medicine assessment consists of evaluating respiratory function, dysrythmias, and potential metabolic disturbances.
Below is a video of this patient’s percussion test:
http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMicm1014605&aid=NEJMicm1014605_attach_1&area=
Another patient’s percussion test:
http://www.youtube.com/watch?v=Wg1SVoa-8JE&feature=player_detailpage
Wang ZJ, Huang XS. Myotonia of the tongue. N Engl J Med 2011;365:e32.
Discharging the patient home at this time (B) would not likely be dangerous, given chronicity of symptoms. However, this would delay proper work up and referral.
There is no evidence that this woman has a history of ingestion or a mood disorder that would put her at risk for this (C). In addition, readily available drug levels could not adequately explain her history and findings.
There is no report or evidence of spider bite (D), and she has no headache, body aches, nausea, vomiting, abdominal pain, change in vital signs (tachycardia, hypertension), or diaphoresis. Furthermore, treatment with calcium is no longer recommended. Antivenom is given in moderate to severe cases; analgesics and benzodiazepenes treat symptoms.
This patient has a long history of involuntary muscle contraction with slow spontaneous resolution, after minor local irritation (minor/trivial trauma or stimulation). This is an example of myotonia, which can be elicited with light percussion.
She has myotonic dystrophy, the most common form of muscular dystrophy found in adults. Type 1 is more common, affecting the head and neck as well as the distal muscles. Type 2 affects the limb girdle muscles. Both types are associated with muscle wasting, dysphagia, respiratory insufficiency, insulin resistance, cataracts, and cardiac conduction abnormalities.
Diagnosis is often elusive, and these patients may be seen by cardiologists, endocrinologists, rheumatologists, and psychiatrists before the neurologist sees them and evaluates with genetic testing, EMG, and/or biopsy. Treatment is often unsatisfactory; some are started on mexilitine, an antiarrhythmic.
Emergency medicine assessment consists of evaluating respiratory function, dysrythmias, and potential metabolic disturbances.
Below is a video of this patient’s percussion test:
http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMicm1014605&aid=NEJMicm1014605_attach_1&area=
Another patient’s percussion test:
http://www.youtube.com/watch?v=Wg1SVoa-8JE&feature=player_detailpage
Wang ZJ, Huang XS. Myotonia of the tongue. N Engl J Med 2011;365:e32.