2020 Volume 24 Issue 1 Pages 69-76
A 69-year-old man had been suffering from dysphagia, arthralgia, limb muscle weakness and weight loss. He was hospitalized, and diagnosed with dermatomyositis and interstitial pneumonia. His dysphagia worsened in spite of drug therapy such as prednisolone and immunosuppressor, so he was referred to us for swallowing rehabilitation. He had poor pharyngeal contraction in videofluoroscopic examination. Videoendoscopic evaluation of swallowing (VE) revealed residue in the vallecula and aspiration after swallowing of water and jelly. Nasal feeding was used to improve the nutritional status. We used thickened water and jelly for swallowing rehabilitation, and did not let him do indirect swallowing training to prevent exacerbation of dermatomyositis.
After 2 weeks, pneumomediastinum was found by computerized tomography. Due to the risk of pneumomediastinum becoming worse and in view of mediastinitis, the jelly was stopped and only thickened water was applied. By examining the fatigue during swallowing, amount of water, serum creatine kinase (CK) value and VE findings, we changed his food and water. After 3 months, he finally could eat by swallowing enough assisting food and water, without thickening or nasal feeding.
For patients suffering from dysphagia, severe dermatomyositis and interstitial pneumonia, we should plan swallowing rehabilitation to prevent pneumomediastinum. It is considered that severe dysphagia with dermatomyositis needs a long time until recovery. In addition, rehabilitation treatment for dysphagia becomes more difficult in the presence of interstitial pneumonia and pneumomediastinum. In this case, to prevent exacerbation of dermatomyositis by overuse, we did not let the patient do indirect swallowing training. We performed nutritional management using nasal feeding from an early stage. By devising the contents of direct swallowing training, we prevented exacerbation of the pneumomediastinum and onset of the mediastinitis. When interstitial pneumonia merges with dermatomyositis, an elaborate plan is necessary for swallowing rehabilitation to prevent pneumomediastinum.
