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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 (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.
Patient presented with dysphagia, odynophagia, and glossodynia was diagnosed with fibromyalgia. Amitryptiline was used. Patient recovered with significant relief in symptoms.
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.
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.
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.
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.
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.
Medicine (Baltimore). 2015 Aug;94(31):e1163
Oral Burning With Dysphagia and Weight Loss
Seccia TM Rossitto G et al.
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