An unusual cause of speech and swallowing diffi culty

A retired man in his 60s had been well until De-cember 1998 when he had let out a sudden involuntary cry and then a yawn, and for a few seconds found that his speech was quiet and breathy. Over the following 8 weeks he developed slurring of speech and swallowing diffi culties with regurgitation. He noticed generalized weakness and fatigue, with symptoms fl uctuating from week to week. By March 1999 he had taken to using a buggy to get around his local 18-hole golf course. In April, he had a barium swallow, which showed aspiration (Fig. 1). Nerve conduction studies (NCS) and electromyography (EMG) were normal, and computerized tomography (CT) of his brain showed 'small vessel disease'. By July 1999 he had swollen legs and had lost 6 kg in weight. He was found to be in fast atrial fi brillation (AF). A transthoracic echocardio-gram was normal. In October he was admitted to his local hospital with pneumonia and heart failure. Amiodarone and warfarin were given, but he eventually required DC cardioversion. He became so debilitated that he needed help to turn over in bed. The amiodarone was stopped in Figure 1 Barium swallow showing aspiration (arrow).