Oral Burning With Dysphagia and Weight Loss
A 78-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-specialty hospital. The patient also complained of having gradually increasing trouble in swallowing for the past three weeks. Upon admission, her blood pressure was slightly increased 145/80 mmHg and the heart rate was 90 beats/min. She had a well-known history of hypertension, 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.
The most likely diagnosis of this presentation is
Iron and Vit B12 deficiency
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.1,2 According to American College of Rheumatology (ACR) criteria, FM is defined as chronic, widespread pain for at least 3 months, and the presence of 11 out of 18 tender points.2 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.1 Moreover, the multifaceted nature of the syndrome and coocurence of other painful conditions makes it more complicated.3
Physical examination revealed a paucity of expression suggesting scleroderma; however, Raynaud's phenomenon, skin induration, or teleangiectasia was not reported. No oral or pharyngeal lesions were present. Blood examinations showed elevated levels of white blood cells and C-reactive protein, while low levels of hemoglobin 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, x-ray of pelvic region revealed osteoarthrosis. Plasma levels of zinc and vitamin B12 were normal, suggesting no deficiency of micronutrients that might be causing these oral symptoms. After exclusion of cardiac disease and upper digestive tract lesions, the diagnosis of fibromyalgia was put forward.
Upon admission to the emergency department, 10 mg metoclopramide (intravenous) was administered that improved the nausea and vomiting immediately. Referring to the patient’s complex medical history and the persistent pain and dysphagia, she was referred to the internal medicine unit. Intravenous hydration and parenteral nutrition was 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 hemoglobin 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.3 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.2
Treatment of FM may involve a wide range of medications, including antidepressants, opioids, nonsteroidal antiinflammatory drugs, sedatives, muscle relaxants, and antiepileptics. Nonpharmaceutical approaches, including exercise, physical therapy, massage, acupuncture, and cognitive behavioral 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.3
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 symptoms are present without any known underlying cause. According to a literature review, FM occasionally presents with oral-esophageal pain and hypersensitivity. Orofacial symptoms include xerostomia, ulcerations, orofacial pain, temporomandibular joint dysfunction, glossodynia, dysphagia, and dysgeusia. Since depression and anxiety are common among patients with FM, amitriptyline was prescribed to this patient.4
It is important to consider the odynophagia, dysphagia, and glossodynia as the prevalent symptoms at presentation of fibromyalgia. Considering these symptoms while confirming the diagnosis of fibromyalgia can be helpful to design most appropriate treatment approach and also can minimize the unnecessary diagnostic examinations.
Arnold LM, Gebke KB, Choy EH. Fibromyalgia: management strategies for primary care providers. Int J Clin Pract. 2016 Feb;70(2):99-112.
Silverman S, Sadosky A, Evans C, Yeh Y, Alvir JM, Zlateva G. Toward characterization and definition offibromyalgia severity. BMC Musculoskelet Disord. 2010 Apr 8;11:66.
Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005 Aug;75:6-21.
Seccia TM, Rossitto G, Calò LA, Rossi GP. Oral Burning With Dysphagia and Weight Loss. Medicine (Baltimore). 2015 Aug;94(31):e1163.