Pearls & Oy-sters: A cause of intractable vomiting

A 50-year-old Chinese woman with hypertension and hyperlipidemia presented with 2 months of progressive intractable vomiting. She was previously evaluated by 2 gastroenterologists who found no abnormalities on esogastroduodenoscopy and diagnosed her with a functional disorder. Her symptoms progressed to dysphagia to solids and liquids as well as spastic dysarthria over the week prior to neurologic evaluation. At that time, her clinical examination revealed a hyperactive gag reflex with tongue fasciculation and a left hypoglossal palsy. She had spastic dysarthria but a normal jaw jerk reflex.