Progressive Weakness

A 60-year-old man was referred to the neurology clinic for progressive swallowing issues that had been ongoing for around 24 months. The patient and GP were concerned about motor neuron disease. The patient was initially reviewed by an Ear, Nose, and Throat doctor suspecting a pharyngeal pouch, but tests revealed normal anatomy of the pharynx. Videofluoroscopy did not show any abnormal coordination of the swallow. Eventually, he developed mobility issues and difficulty walking. He became aware that he could no longer walk with friends, even though they were substantially older. He felt that his legs and arms were getting weaker. There was no family history of neurodegenerative disorder. In screening bloods, there was an increased ALT level (172 IU/L (0–50 range)).