Dropped head syndrome and diagnostic delay

CLINICAL CASE: A 23 year-old woman went to the ED because she was unable to maintain her head in the right position. She worked in a supermarket and the symptoms developed at the end of the day together with a feeling of “weekness” in both arms.

EVOLUTION: At least in three occasions she was discharged from the ED with diagnoses such as: torticollis, muscle contracture. At the last visit a complete medical interview and physical examination evidenced a youg patient with an absolute impairement to keep her head and neck up, with no other main signs after a neurological examination.

FINAL DIAGNOSIS: Dropped head syndrome. The clinical picture was coincident with a mild enlargement of her thymus, suggesting a myasthenic problem, but antibodies has been negative.

ANALYSIS:

TYPE OF  DIAGNOSTIC ERROR: Diagnostic Delay

Cognitive aspects: doctors that see young  patients  in  the ED with uncommon symptoms and with a good general health status could think that there is not an important problem, putting “labels” on these patients.

Improving strategy: A complete anamnesis  and physical examination together with an open attitude is a key aspect for making a correct diagnosis.

DEFINITIONS:

Dropped head syndrome (DHS) is characterized by severe kyphotic deformity of the cervico-thoracic spine. It is a relatively rare condition with a broad differential diagnosis. The conditions linked with DHS can be categorized into neurological, neuromuscular, muscular, and other causes.

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