First he was hoarse. Then he couldn’t chew

|     Sandra G Boodman     |

WASHINGTON (The Washington Post) – Larry Weller didn’t want to spoil the party.

Surrounded by relatives gathered to celebrate his oldest granddaughter’s 18th birthday at a favourite Italian restaurant, he fervently hoped that no one, other than his wife who murmured her concern, noticed what he was doing.

Weller had been enjoying the crusty bread and accompanying olive oil. But a few bites into his favourite short ribs, he felt a wave of fatigue engulf his jaw. Chewing became laborious. Swallowing was an impossibility. Weller surreptitiously spit food into his napkin, relieved to see the others weren’t paying attention to him.

Then he pushed his uneaten dinner around his plate before asking for a take-home container.

That unsettling incident in November 2017 was part of a string of seemingly unrelated problems that had dogged the retired agronomist for more than a year. A month after that dinner, a specialised blood test requested by Weller – not the half-dozen doctors he had seen – would reveal the reason for his inability to chew and swallow. It would also explain why his once-vigorous health had taken a precipitous nose-dive.

Larry Weller (R) with his granddaughter. – THE WASHINGTON POST

“I knew something was really wrong,” said Weller, who lives in Bloomington, Illinois, 130 miles south of Chicago. “I feel like my doctors weren’t asking enough questions.”

Beginning in the summer of 2016, Weller, then 70, experienced bouts of laryngitis, even though he hadn’t had a respiratory infection. His family physician referred him to an ear, nose and throat (ENT) specialist who ramped up the dose of his acid-blocking medicine. Acid reflux can sometimes cause a hoarse voice. Weller had been diagnosed with reflux years earlier and had taken medication that controlled the problem.

But after three months on a high dose of the drug, his hoarseness lingered. The ENT told him it might take time to work, so for eight months Weller continued taking the medicine and altered his diet.

“It didn’t change anything,” he recalled.

In October 2017, the ENT performed a videostroboscopy, a procedure that uses a scope to inspect the vocal cords. He discovered leukoplakia, a typically benign condition characterised by white patches, in Weller’s larynx. The doctor told Weller he thought the patches looked suspicious for cancer and scheduled a biopsy.

The biopsy showed no cancer but did reveal signs of an airborne infection common in the Midwest called blastomycosis. The fungal infection, which can be caused by inhaling decaying leaves or soil, is often harmless. But some people, especially those with weakened immune systems, can develop flulike symptoms that are sometimes severe. Weller had been hauling bags of seeds in his car and soon afterward was short of breath.

The ENT prescribed a potent antifungal drug to knock out the infection.

It didn’t help. A week later, Weller experienced a severe sore throat. The doctor prescribed azithromycin, an antibiotic, for a possible strep infection. He also switched antifungal drugs.

Still no better, Weller was referred to a second otolaryngologist, who sent him to an infectious disease specialist, who in turn advised that he see a gastroenterologist. Other than suspected blastomycosis, nothing was found.

With the help of his wife, a veteran nurse, Weller tried to coordinate care with his family physician. That was hard, he said. The doctor was ill and her group practice seemed severely overloaded.

“It was very difficult to get in to see anyone,” Weller recalled. “And they would often cancel appointments at the last minute. I was very frustrated.”

Other than prescribing more drugs, some of which made him feel worse, no doctor seemed to know what might be causing Weller’s proliferating symptoms.

A week after the incident in the Italian restaurant, Weller saw his primary care doctor. His ability to chew and swallow had returned, although he could consume only soft food. And if he wasn’t careful, he would choke, sometimes aspirating what he was eating.

His fatigue had worsened to the point that he was unable to walk across his average-sized yard without stopping several times to rest. And his gait was off: When he walked, Weller said, his feet flapped. His doctor ordered a chemical stress test and an echocardiogram, a test that uses sound waves to check cardiac function.

“The cardiologist told me it’s not your heart – it’s fine,” Weller recalled. “You’re going to have to look elsewhere.”

Weller, feeling increasingly desperate, decided to see what he could unearth online. While taking azithromycin for possible strep, he had read the warning label. It cautioned that the drug should not be taken by people who have myasthenia gravis because it can aggravate the disorder. Weller had never heard of myasthenia gravis (MG), a chronic neuromuscular autoimmune disorder that causes weakness in the muscles responsible for breathing and movement. But he had felt dramatically worse after taking the drug – and it turned out he hadn’t even had strep.

His search led him to the Mayo Clinic website and a description of symptoms that sounded awfully familiar: Muscle weakness, fatigue, shortness of breath, difficulty chewing and swallowing, and gait disturbances. Symptoms typically improve with rest.

Weller discovered that he had nearly every MG symptom listed except the most common: Double vision and droopy eyelids known as ptosis. The disorder, caused by a transmission error between nerves and muscles, can be diagnosed through a blood test. The test measures the level of an antibody that disrupts normal communication at the neuromuscular junction – the place where nerve cells connect with the muscles they control.

Weller called the Mayo Clinic but was unable to wangle an appointment with the neurology department in Rochester, Minnesota, a six-hour drive he was not eager to make in the winter. He decided to see what he could accomplish locally.

He was scheduled to see his family doctor in mid-December, but the appointment was cancelled at the last minute. He arranged instead to see a nurse practitioner. Then he compiled a list of symptoms – numbering more than a dozen – along with a page of questions. His goal was to get a blood test used in the diagnosis of MG.

His strategy worked. The nurse practitioner ordered a test for acetylcholine receptor antibodies, which can help distinguish MG from other neuromuscular disorders.

“I really credit her with listening and doing what I asked,” Weller said.

Five days later, Weller learnt that his hunch was correct.