A 45-year-old woman was admitted with aspiration pneumonia. She was found to have progressive dysphagia and severe dysarthria. Neurological examination showed a hypernasal voice, diminished gag reflex, and marked tongue atrophy with weakness (Fig. 1A). Limb strength, tone, and reflexes were normal, with mild paresthesia in all four limbs. One month earlier, she had unexplained nausea, vomiting, and hiccups lasting one week that resolved spontaneously. Three weeks later, aspiration pneumonia led to further evaluation.
