{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T10:49:38Z","timestamp":1791370178055,"version":"4.3.1"},"reference-count":14,"publisher":"SMC Media","issue":"10","license":[{"start":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T00:00:00Z","timestamp":1790294400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Progressive dysphagia in older adults presents a diagnostic challenge with a broad differential including neuromuscular, structural and malignant causes. Dysphagia associated with aspiration may lead to significant respiratory compromise requiring intensive care management. We report the case of a 78-year-old patient with rheumatoid arthritis treated with methotrexate who presented with progressive dysphagia to solids and liquids, weight loss, and cough. She subsequently developed aspiration pneumonia complicated by repeated type 2 respiratory failure and required mechanical ventilation. Initial investigations focused on aspiration pneumonitis and possible neuromuscular disease, particularly myasthenia gravis, given the presence of bulbar symptoms and an insensate epiglottis on nasendoscopy. However, subsequent magnetic resonance imaging of the brain demonstrated a glioma explaining the progressive bulbar dysfunction. This case demonstrates diagnostic overshadowing, as recurrent type 2 respiratory failure was repeatedly managed as aspiration pneumonia, delaying the diagnosis of glioma. Early neuroimaging should be considered in patients with progressive dysphagia when initial investigations fail to explain symptoms.<\/jats:p>","DOI":"10.12890\/2026_007466","type":"journal-article","created":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T13:57:37Z","timestamp":1790344657000},"source":"Crossref","is-referenced-by-count":0,"title":["Progressive dysphagia revealing glioma: diagnostic overshadowing by suspected myasthenia gravis"],"prefix":"10.12890","volume":"13","author":[{"given":"Smeelah","family":"Rathore","sequence":"first","affiliation":[{"name":"Internal medicine, Bedford Hospital, Bedford, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cliffin","family":"Adu-Gyamfi","sequence":"additional","affiliation":[{"name":"Internal medicine, Bedford Hospital, Bedford, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hasna","family":"Janali","sequence":"additional","affiliation":[{"name":"Internal medicine, Bedford Hospital, Bedford, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maya","family":"Baroudi","sequence":"additional","affiliation":[{"name":"Internal medicine, Bedford Hospital, Bedford, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10397","published-online":{"date-parts":[[2026,9,25]]},"reference":[{"key":"10.12890\/2026_007466_ref1","doi-asserted-by":"crossref","unstructured":"Ebihara T. Comprehensive approaches to aspiration pneumonia and dysphagia in the elderly on the disease time-axis. J Clin Med. 2022;11(18):5323. doi:10.3390\/jcm11185323.","DOI":"10.3390\/jcm11185323"},{"key":"10.12890\/2026_007466_ref2","doi-asserted-by":"crossref","unstructured":"Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124(1):328\u201336. doi: 10.1378\/chest.124.1.328.","DOI":"10.1378\/chest.124.1.328"},{"key":"10.12890\/2026_007466_ref3","doi-asserted-by":"crossref","unstructured":"Simpson AJ, Allen JL, Chatwin M, Crawford H, Elverson J, Ewan V, et al. BTS clinical statement on aspiration pneumonia. Thorax. 2023;78(Suppl 1):s3\u2013s21. doi: 10.1136\/thorax-2022-219699.","DOI":"10.1136\/thorax-2022-219699"},{"key":"10.12890\/2026_007466_ref4","doi-asserted-by":"crossref","unstructured":"Mangrio SM, Faisal S, Malik Z, Naeem A, Saeed U. Unilateral ptosis and bulbar symptoms as the initial presentation of late-onset acetylcholine receptor antibody-positive myasthenia gravis mimicking acute ischemic stroke in an 82-year-old man. Cureus. 2025;17(12):e99832. doi: 10.7759\/cureus.99832.","DOI":"10.7759\/cureus.99832"},{"key":"10.12890\/2026_007466_ref5","doi-asserted-by":"crossref","unstructured":"Park KH, Waters P, Woodhall M, Lang B, Smith T, Sung JJ, et al. Myasthenia gravis seronegative for acetylcholine receptor antibodies in South Korea: autoantibody profiles and clinical features. PLoS One. 2018;13(3):e0193723. doi: 10.1371\/journal.pone.0193723.","DOI":"10.1371\/journal.pone.0193723"},{"key":"10.12890\/2026_007466_ref6","unstructured":"Peterson LK, Smith T. Myasthenia gravis - MG. ARUP Consult. Last literature review March 2025; last update March 2026. Available from: https:\/\/arupconsult.com\/content\/myasthenia-gravis. 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J Med Case Rep. 2009;3:87. doi: 10.1186\/1752-1947-3-87.","DOI":"10.1186\/1752-1947-3-87"},{"key":"10.12890\/2026_007466_ref10","doi-asserted-by":"crossref","unstructured":"Tiwari V, Ganji SK, An Z, Pinho MC, Davis LT, McKnight CD, et al. Magnetic resonance spectroscopy of 2-hydroxyglutarate and glycine in adult subjects with brainstem gliomas. NMR Biomed. 2025;38(11):e70153. doi: 10.1002\/nbm.70153.","DOI":"10.1002\/nbm.70153"},{"key":"10.12890\/2026_007466_ref11","doi-asserted-by":"crossref","unstructured":"In A, Stopa BM, Cuoco JA, Stump MS, Apfel LS, Rogers CM. Central nervous system lymphoproliferative disorder secondary to methotrexate: a systematic literature review and case illustration. World Neurosurg. 2023;179:118\u201326. doi: 10.1016\/j.wneu.2023.08.018.","DOI":"10.1016\/j.wneu.2023.08.018"},{"key":"10.12890\/2026_007466_ref12","doi-asserted-by":"crossref","unstructured":"Kawazoe M, Kaneko K, Nanki T. Methotrexate-associated lymphoproliferative disorders in the central nervous system and stomach. Medicine (Baltimore). 2020;99(15):e19850. doi: 10.1097\/MD.0000000000019850.","DOI":"10.1097\/MD.0000000000019850"},{"key":"10.12890\/2026_007466_ref13","doi-asserted-by":"crossref","unstructured":"Hallyburton A. Diagnostic overshadowing: an evolutionary concept analysis on the misattribution of physical symptoms to pre-existing psychological illnesses. Int J Ment Health Nurs. 2022;31(6):1360\u201372. doi: 10.1111\/inm.13034.","DOI":"10.1111\/inm.13034"},{"key":"10.12890\/2026_007466_ref14","unstructured":"Lazris A, Roth A, Haskell H, James J. Diagnostic overshadowing: when cognitive biases can harm patients. Am Fam Physician. 2023;108(3):292\u20134. Available from: https:\/\/www.aafp.org\/pubs\/afp\/issues\/2023\/0900\/lown-right-care-diagnostic-overshadowing.html. 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