A 71 year old patient with a past medical history relevant for stage 3 chronic kidney disease attributed to hypertension and insulin-dependent diabetes presented to an outpatient swallow study ordered..
A 71 year old patient with a past medical history relevant for stage 3 chronic kidney disease attributed to hypertension and insulin-dependent diabetes presented to an outpatient swallow study ordered by their PCP due to a multi-month history of dysphagia, beginning with difficulty tolerating solids and worsening to inability to tolerate any solid or liquid oral intake or clear secretions. This was associated with a ~50 pound weight loss. Through this time, the patient denied any pain, physical symptoms of the tongue or throat, or any systemic findings. The swallow study showed severe pharyngeal dysphagia resulting in aspiration of all consistencies and severe residue. Additionally, the patient was noted to be malnourished, weak, dehydrated, hypotensive and orthostatic. He was admitted directly from clinic for resuscitation and diagnostic evaluation. On admission, basic lab work including CBC and BMP were unremarkable - creatinine was 1.5, consistent with the patient's baseline. Conventional dysphagia workup with multiple services consulted was non-revealing: a barium esophagram showed only presbyesophagus. A CT head and neck showed irregular soft tissue edema of the larynx but no definitive findings, no masses nor lymphadenopathy. Direct visualization via flexible laryngoscopy by ENT showed edema of the larynx without other visible abnormalities. An EGD performed by GI, including random esophageal biopsies, was negative. A neurologic workup for paraneoplastic syndromes and neuromuscular disorders was negative. An MRI soft tissue neck was ordered, revealing a non-specific, hypointense mass near the tongue. This was biopsied, showing amyloid deposition. Protein electrophoresis followed by a bone marrow biopsy confirmed the diagnosis of multiple myeloma. A skeletal survey was negative for bone lesions. The patient underwent PEG tube placement and was started on chemotherapy for multiple myeloma. The patient's course was complicated by refeeding syndrome, new-onset major depression, multiple aspiration events necessitating tracheostomy placement, and the incidental finding of pancreatic cancer on a CT chest ordered to evaluate the dysphagia. Though amyloid deposition of various organs, including the tongue leading to enlargement or the esophagus, are known sequelae of multiple myeloma, progressive dysphagia is an exceedingly rare manner of presentation, especially without identifiable bone lesions, pain, worsening kidney function, or other findings typically for multiple myeloma. This case illustrates the importance of complete dysphagia workup including potential utilization of atypical imaging modalities, as well as the medical and psychological complexity of patients with malignancy.