Search the bmj bmj bmj journals bmj careers bmj learning evidence centre doc2doc bmj group search this site advanced search an international peer-reviewed journal for health professionals and researchers in all areas of neurology and neurosurgery online first current issue archive about the journal submit a paper subscribe help online first current issue archive supplements eletters topic collections patients's choice rss home > volume 76, issue 1 > article j neurol neurosurg psychiatry 2005; 76: 146 doi:10. 1136/jnnp. 2003. 033605 letter an unusual cause of dysphagia s payne , d wilkins , r howard st thomasâ€™ hospital, london correspondence to: dr sarah payne st bartholomewâ€™s hospital, west smithfield, london ec1a 7be; sarah_146hotmail. cheap generic viagra Com lambert-eaton myasthenic syndrome (lems) dysphagia paraneoplastic syndromes â next section we report a case of a patient with lambert eaton myasthenic syndrome (lems) associated with small cell lung cancer (sclc) presenting with a 2 year history of dysphagia. generic viagra This presentation has not been described in previous literature. Previous section next section case a 71 year old right handed deck worker initially presented with a 6 month history of dysphagia, weight loss, nausea, and fatigue. He was cachetic with no other clinical signs to be found on examination. viagra online Baseline blood tests were unremarkable. Upper gastrointestinal (gi) endoscopy revealed a small hiatus hernia only. generic viagra no rx Subsequent investigations included a barium swallow, computer tomography (ct) scans of the chest and abdomen, oesophageal manometry, small bowel follow through, and laparoscopy, which were all normal. average age to use viagra He was empirically started on cisapride and managed on an appropriate pureed diet. generic viagra online canada pharmacy Eighteen months after his initial presentation the patient complained of a gradual deterioration in his speech and problems with proximal muscle weakness. Clinical examination demonstrated an obvious dysarthria and broad based gait. generic viagra canada There was no limb weakness or sensory neuropathy and reflexes were preserved with no post-tetanic potentiation. There was no disturbance of extraocular eye movements or ptosis. The patient did not display any cognitive impairment. viagra side effects ejaculation He subsequently developed involuntary choreo-athetoid movements. Baseline blood tests and chest x ray (cxr) were again normal. pills4u viagra Magnetic resonance imaging of the brain demonstrated evidence of small vessel disease. Electromyography and nerve conduction studies were performed. Sensory conduction velocities were within normal limits. viagra 100mg pills Motor conduction velocities demonstrated a clear and reproducible decremental response.