Weight Loss and Wheezing A 78 yearold woman

Weight Loss and Wheezing

A 78 -year-old woman presented because of daily episodes of shortness of breath.

medical history • She described periods of wheezing that typically occurred during or immediately after her evening meal. • This was not associated with coughing. She was able to do her daily chores without dyspnea or respiratory problems. • She also complained about dysphagia for liquids and solids and chest discomfort, • which had started about 2 years prior to her clinic visit.

• She described her symptoms as burning retrosternal pain. • In the past she had used H 2 receptor blockers for presumed heartburn, which improved her symptoms slightly. • Occasionally, she "choked" right after swallowing her food. • She had lost about 7 kg over the last 2 years.

prior medical history • Her prior medical history was remarkable for Parkinson disease • three myocardial infarctions.

physical examination • On physical examination, she had dentures, • a normal cardiovascular, pulmonary and abdominal examination. • The neurological examination revealed a resting tremor and mild rigor with cogwheel phenomenon. • The cranial nerves were intact and she was able to swallow some water without aspiration or regurgitation.

The history described • The history described above was consistent with bronchopulmonary complications due to dysphagia with microaspiration. • An elderly person with Parkinson disease and dentures is certainly at risk for aspiration because of oro-pharyngeal dysphagia. However, the chest discomfort and significant weight loss pointed more at an esophageal etiology.

• To further differentiate between these two potential causes, a cine-esophagram was obtained. • It demonstrated a significantly dilated esophagus without primary peristalsis

• The lower esophageal sphincter only partially relaxed, leading to pooling of contrast material in the esophagus. • On endoscopy, the esophagus was tortuous and had a sigmoid appearance

• The distal esophageal mucosa was slightly erythematous without focal lesions

• The lower esophageal sphincter remained closed but could easily be passed with the endoscope. • The retroflexed view did not demonstrate any abnormalities. • Biopsies obtained from the GE junction only revealed mild esophagitis.

Manometric • Manometrically, the patient had no contractile activity in the tubular esophagus and incomplete relaxations of the lower esophageal sphincter

diagnosis • the diagnosis of achalasia.

• In view of her comorbidity, she initially underwent local therapy with botulinum toxin, which did not lead to symptomatic improvement. • Therefore, a balloon dilation was performed, alleviating her pulmonary and esophageal symptoms.

Discussion • More recently, extraintestinal manifestations of esophageal diseases have attracted significant attention. • Due to its high prevalence reflux disease is probably the most common esophageal cause for laryngeal or tracheo-bronchial problems. • However, patients with achalasia are at much higher risk for passive regurgitation with aspiration.

• Camara et al. found evidence for pneumonia at the time of autopsy in about one third of patients with megaesophagus. • Dysphagia or other esophageal symptoms may be overlooked as patients adjust to the chronically impaired swallowing function and focus on the more acute symptoms related to pulmonary complications.