A retired man in his 60s had been well until December 1998 when he had let out a sudden involuntary cry and then a yawn, and for a few seconds found that his speech was quiet and breathy. Over the following 8 weeks he developed slurring of speech and swallowing difficulties with regurgitation. He noticed generalized weakness and fatigue, with symptoms fluctuating from week to week. By March 1999 he had taken to using a buggy to get around his local 18-hole golf course. In April, he had a barium swallow, which showed aspiration (Fig. 1). Nerve conduction studies (NCS) and electromyography (EMG) were normal, and computerized tomography (CT) of his brain showed ‘small vessel disease’. By July 1999 he had swollen legs and had lost 6 kg in weight. He was found to be in fast atrial fibrillation (AF). A transthoracic echocardiogram was normal. In October he
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