fibromyalgia is one of the most common disorders seen by primary care physicians , with a prevalence of 2% in the us population . the incidence of fibromyalgia rises with aging , with a maximum at the age above 60 years , and is typically 7 times more prevalent in women than in men . after several unsuccessful efforts aimed at proving the existence of muscle and connective inflammation , in the 1980s , the term fibromyalgia definitely replaced the older term currently fibromyalgia is seen as one of several disorders referred to as central sensitivity syndrome ( css ) , which are all characterized by an abnormal pain regulation ( table 1 ) . the overlapping of 2 such disorders supports the contention that central sensitization is the unifying mechanism of such array of diseases . conditions associated with central sensitivity syndrome widespread pain , fatigue , and sleep disturbance are the characterizing core symptoms of fibromyalgia . when unusual symptoms for fibromyalgia are overbearingly predominant at clinical presentation , the diagnosis becomes challenging . an 80-year - old caucasian woman presented at the emergency department because of diffuse pain at the anterior chest and epigastric region , dysphagia , odynophagia , vomiting , and fever . her blood pressure on presentation was 145/80  mmhg , with a heart rate of 90  beats / min . blood tests showed mild increase of white blood cells ( 12.42    10  cells / l ) and c - reactive protein ( 7.2  mg / l ) . an ekg documented subtle st - segment depression in v3 to v6 with normal troponin i ( tni ) levels . an abdomen x - ray failed to show signs of bowel obstruction or free intra - abdominal gas . because of her history of coronary artery bypass grafting , and the persistence of pain and dysphagia , she was referred to our internal medicine unit . the patient was a housewife , and her medical history included high blood pressure for 25 years , type 2 diabetes mellitus , chronic kidney disease ( ckd ) , osteoporosis , arthrosis , and cholecystectomy . she was assuming pantoprazole , ticlopidine , atenolol , nitroglycerin , doxazosin , simvastatin , metformin , alendronate , and non - steroidal anti - inflammatory drugs . at admission , she complained dysphagia and oral burning ( glossodynia ) . the patient reported that the difficulty in swallowing started 1 month prior hospitalization , and progressively increased so that nourishment and fluid intake were impeded . her face showed paucity of expression suggesting scleroderma , but raynaud 's phenomenon , skin induration , or teleangiectasia was not detected . serial tni tests were normal , and a transthoracic echocardiogram showed normal ejection fraction with no regional wall motion abnormalities . serum urea ( 14.30  mmol / l ) and creatinine ( 172  mol / l ) levels ( egfr 24  ml / min/1.73  m calculated with ckd - epi formula ) after an early worsening , improved with intravenous hydration . because of bacteriuria and fever , antibiotic treatment was started , with remission of fever in 2 days . since the epigastric pain was associated with low levels of hemoglobin ( 110 g / l ; red blood cells 3.63    10  cells / l ) and iron ( 8.5  mol / l ) , an esophagogastroduodenoscopy was performed , which disclosed only few microerosions of the antral mucosa that could not explain dysphagia and glossodynia . to investigate whether oral symptoms were caused by micronutrient deficiency , we measured plasma levels of zinc ( 13.0  mol / l ) and vitamin b12 ( 481  ng / l ) , but they both were normal . because ace - inhibitors are a well - known cause of dysgeusia , we also investigated whether the patient assumed such drugs in last years , but she denied . odynophagia and glossodynia persisted , and became the predominant symptoms . because the patient rejected water and food for days , parenteral nutrition was started . in the next days , she also complained dysgeusia and abnormal sensitivity to some odors with nausea . poor short - term memory was noticed , and the patient often complained to be confused  as being in the clouds .  after exclusion of cardiac disease and upper digestive tract lesions , the diagnosis of fibromyalgia was put forward . we therefore calculated the widespread pain index ( wpi ) as recommended by the american college of rheumatology ( acr ) . wpi of 7 plus symptom severity ( ss ) scale score of 5 , or alternatively , wpi of 3 to 6 and ss scale score of 9 are the 2 criteria required for diagnosis of fibromyalgia . wpi , calculated by summing up patient 's reports of pain in 19 separate regions of the body as recommended by acr guidelines , was 6 in our patient , and ss scale score , calculated by grading pain , fatigue , and awaking unrefreshed  on a severity scale from 0 ( no problem ) to 3 ( severe , pervasive , continuous , life - disturbing problems ) , was 9 ( figure 1 ) . the american college of rheumatology recommends to assess pain and severity of symptoms using the widespread pain index ( wpi ) and symptom severity ( ss ) scale , which both exploit a self - report questionnaire . wpi requires that the patient localizes the sites of pain or tenderness during the past 7 days , and then the physician assigns 1 point to each site . the red boxes correspond to painful sites , whereas the blue to painless areas , with a score of 6 . the ss scale consists of 2 sections . in the first , that is , section a , the severity during the past 7 days is indicated for each symptom by the following scale : no problem ( point 0 ) ; slight problem : generally mild or intermittent ( point 1 ) ; moderate problem : considerable problems , often present and/or at a moderate level ( points 2 ) ; severe problem : continuous , life - disturbing problems ( points 3 ) . in the second section the symptoms listed in section b , if present during the past 6 months , are indicated by  yes  ( corresponding to point 1 ) . in our patient the total score , which is calculated as the sum of wpi and ss , and ranges from 0 to 31 points , when 13 points is consistent with diagnosis of fibromyalgia . additional informations are included in the survey ( bottom ) because they can be helpful for diagnosis , but no points are assigned to them . the total score of self - report survey was 15 in our patient , thereby supporting fibromyalgia ( modified from clauw d.j . the american college of rheumatology recommends to assess pain and severity of symptoms using the widespread pain index ( wpi ) and symptom severity ( ss ) scale , which both exploit a self - report questionnaire . wpi requires that the patient localizes the sites of pain or tenderness during the past 7 days , and then the physician assigns 1 point to each site . the red boxes correspond to painful sites , whereas the blue to painless areas , with a score of 6 . the ss scale consists of 2 sections . in the first , that is , section a , the severity during the past 7 days is indicated for each symptom by the following scale : no problem ( point 0 ) ; slight problem : generally mild or intermittent ( point 1 ) ; moderate problem : considerable problems , often present and/or at a moderate level ( points 2 ) ; severe problem : continuous , life - disturbing problems ( points 3 ) . in the second section the symptoms listed in section b , if present during the past 6 months , are indicated by  yes  ( corresponding to point 1 ) . in our patient the total score , which is calculated as the sum of wpi and ss , and ranges from 0 to 31 points , when 13 points is consistent with diagnosis of fibromyalgia . additional informations are included in the survey ( bottom ) because they can be helpful for diagnosis , but no points are assigned to them . the total score of self - report survey was 15 in our patient , thereby supporting fibromyalgia ( modified from clauw d.j . the final diagnosis was fibromyalgia , and treatment with amitriptyline 10  mg bid was started . both odynophagia and glossodynia improved within some days , and diffuse pain , dysgeusia , and fibro - fog ( ie , feeling of being in the clouds ) gradually weakened in 2 weeks . at that time , the levels of hemoglobin ( 114 g / l ) and iron ( 9.5  mol / l ) persisted low and , therefore , we could exclude that oral symptoms were caused by anemia . the patient gave her informed consent to diagnostic procedures , therapy , and data collection at the admission to our unit . she was not explicitly asked for the consent to the present case report because no element allows her identification . the patient was a housewife , and her medical history included high blood pressure for 25 years , type 2 diabetes mellitus , chronic kidney disease ( ckd ) , osteoporosis , arthrosis , and cholecystectomy . she was assuming pantoprazole , ticlopidine , atenolol , nitroglycerin , doxazosin , simvastatin , metformin , alendronate , and non - steroidal anti - inflammatory drugs . at admission , she complained dysphagia and oral burning ( glossodynia ) . the patient reported that the difficulty in swallowing started 1 month prior hospitalization , and progressively increased so that nourishment and fluid intake were impeded . her face showed paucity of expression suggesting scleroderma , but raynaud 's phenomenon , skin induration , or teleangiectasia was not detected . serial tni tests were normal , and a transthoracic echocardiogram showed normal ejection fraction with no regional wall motion abnormalities . serum urea ( 14.30  mmol / l ) and creatinine ( 172  mol / l ) levels ( egfr 24  ml / min/1.73  m calculated with ckd - epi formula ) after an early worsening , improved with intravenous hydration . because of bacteriuria and fever , antibiotic treatment was started , with remission of fever in 2 days . since the epigastric pain was associated with low levels of hemoglobin ( 110 10  cells / l ) and iron ( 8.5  mol / l ) , an esophagogastroduodenoscopy was performed , which disclosed only few microerosions of the antral mucosa that could not explain dysphagia and glossodynia . to investigate whether oral symptoms were caused by micronutrient deficiency , we measured plasma levels of zinc ( 13.0  mol / l ) and vitamin b12 ( 481  ng / l ) , but they both were normal . because ace - inhibitors are a well - known cause of dysgeusia , we also investigated whether the patient assumed such drugs in last years , but she denied . odynophagia and glossodynia persisted , and became the predominant symptoms . because the patient rejected water and food for days , poor short - term memory was noticed , and the patient often complained to be confused  as being in the clouds .  after exclusion of cardiac disease and upper digestive tract lesions , the diagnosis of fibromyalgia was put forward . we therefore calculated the widespread pain index ( wpi ) as recommended by the american college of rheumatology ( acr ) . wpi of 7 plus symptom severity ( ss ) scale score of 5 , or alternatively , wpi of 3 to 6 and ss scale score of 9 are the 2 criteria required for diagnosis of fibromyalgia . wpi , calculated by summing up patient 's reports of pain in 19 separate regions of the body as recommended by acr guidelines , was 6 in our patient , and ss scale score , calculated by grading pain , fatigue , and awaking unrefreshed  on a severity scale from 0 ( no problem ) to 3 ( severe , pervasive , continuous , life - disturbing problems ) , was 9 ( figure 1 ) . figure 1self - report survey for the assessment of fibromyalgia in our patient . the american college of rheumatology recommends to assess pain and severity of symptoms using the widespread pain index ( wpi ) and symptom severity ( ss ) scale , which both exploit a self - report questionnaire . wpi requires that the patient localizes the sites of pain or tenderness during the past 7 days , and then the physician assigns 1 point to each site . , the red boxes correspond to painful sites , whereas the blue to painless areas , with a score of 6 . the ss scale consists of 2 sections . in the first , that is , section a , the severity during the past 7 days is indicated for each symptom by the following scale : no problem ( point 0 ) ; slight problem : generally mild or intermittent ( point 1 ) ; moderate problem : considerable problems , often present and/or at a moderate level ( points 2 ) ; severe problem : continuous , life - disturbing problems ( points 3 ) . in the second section the symptoms listed in section b , if present during the past 6 months , are indicated by  yes  ( corresponding to point 1 ) . in our patient the total score , which is calculated as the sum of wpi and ss , and ranges from 0 to 31 points , when 13 points is consistent with diagnosis of fibromyalgia . additional informations are included in the survey ( bottom ) because they can be helpful for diagnosis , but no points are assigned to them . the total score of self - report survey was 15 in our patient , thereby supporting fibromyalgia ( modified from clauw d.j . the american college of rheumatology recommends to assess pain and severity of symptoms using the widespread pain index ( wpi ) and symptom severity ( ss ) scale , which both exploit a self - report questionnaire . wpi requires that the patient localizes the sites of pain or tenderness during the past 7 days , and then the physician assigns 1 point to each site . the red boxes correspond to painful sites , whereas the blue to painless areas , with a score of 6 . the ss scale consists of 2 sections . in the first , that is , section a , the severity during the past 7 days is indicated for each symptom by the following scale : no problem ( point 0 ) ; slight problem : generally mild or intermittent ( point 1 ) ; moderate problem : considerable problems , often present and/or at a moderate level ( points 2 ) ; severe problem : continuous , life - disturbing problems ( points 3 ) . in the second section the symptoms listed in section b , if present during the past 6 months , are indicated by  yes  ( corresponding to point 1 ) . in our patient the total score , which is calculated as the sum of wpi and ss , and ranges from 0 to 31 points , when 13 points is consistent with diagnosis of fibromyalgia . additional informations are included in the survey ( bottom ) because they can be helpful for diagnosis , but no points are assigned to them . the total score of self - report survey was 15 in our patient , thereby supporting fibromyalgia ( modified from clauw d.j . the final diagnosis was fibromyalgia , and treatment with amitriptyline 10  mg bid was started . both odynophagia and glossodynia improved within some days , and diffuse pain , dysgeusia , and fibro - fog ( ie , feeling of being in the clouds ) gradually weakened in 2 weeks . at that time , the levels of hemoglobin ( 114 g / l ) and iron ( 9.5  mol / l ) persisted low and , therefore , we could exclude that oral symptoms were caused by anemia . the patient gave her informed consent to diagnostic procedures , therapy , and data collection at the admission to our unit . she was not explicitly asked for the consent to the present case report because no element allows her identification . clinical presentation of fibromyalgia includes pain associated with an array of other symptoms , for example , fatigue , sleep disturbance , headache , or morning stiffness . the paucity of objective findings in contrast to the abundance of subjective ailments makes the diagnosis difficult . however , when an unusual symptom dominates the picture , the diagnosis becomes even more challenging . pain in fibromyalgia is widespread , entailing jaws , shoulders , arms , buttocks , legs , back , chest and abdomen , and usually is protean , being described as throbbing , stabbing , burning , cramping , or gnawing . acr criteria require that pain is present at a similar level for at least 3 months , and that no disorder would otherwise explain it . in our 80-year - old patient presenting with chest pain , ischemic disease was excluded , and pain at pelvis and bilaterally at the inferior limbs was at a first glance referred to osteoarthrosis . the association of glossodynia and odynophagia with dysgeusia , sensitivity to odors , and fibro - fog finally unveiled fibromyalgia . a search of the literature revealed that patients with fibromyalgia occasionally complain oral - esophageal pain and hypersensitivity . orofacial symptoms include xerostomia , ulcerations , orofacial pain , temporomandibular joint dysfunction , glossodynia , dysphagia , and dysgeusia . such symptoms have been seldom investigated in fibromyalgia patients , and therefore rarely reported : in a small study of 67 fibromyalgia patients who were systematically examined for orofacial symptoms , dysphagia was present in 37.3% , glossodynia in 32.8% , and dysgeusia in 34.2% . fibromyalgia was also found to be commonly associated with esophageal motility disorders , nausea , and/or dyspepsia . hence , orofacial symptoms are more common than believed in fibromyalgia . of interest , in our patient , odynophagia and glossodynia were the major symptoms , and their severity impeded oral nutrition , thus requiring parenteral nutrition . we decided to use amitriptyline in our patient because depression and anxiety involve about half of the patients with fibromyalgia , and use of antidepressants is strongly advised . gabapentinoids , serotonin norepinephrine reuptake inhibitors , and -hydroxybutyrate were also found to be effective in patients with fibromyalgia . in contrast , because of the hyperactivity of the endogenous opioid system in such patients , opioids may lead to paroxysmal hyperalgesia . after 7-month follow - up , the patient is in good health with no major illness development . in conclusion , odynophagia , dysphagia , and glossodynia can be the prevalent symptoms at presentation of fibromyalgia patients although often overlooked . the recognition of these symptoms could be determinant for a physician to pursue the diagnosis of fibromyalgia with this presentation , helpful to offer relieve of pain and avoid unnecessary tests for patients affected .
abstractfibromyalgia is a disorder characterized by an abnormal pain regulation 
 . widespread pain , fatigue , and sleep disturbance are the prevalent symptoms . 
 when unusual symptoms are overbearingly predominant at clinical presentation , the diagnosis becomes challenging.we report on the case of a patient with fibromyalgia , who presented with dysphagia , odynophagia , and glossodynia as prevalent symptoms . 
 difficulty in swallowing gradually developed over a month prior hospitalization , and worsened progressively so that nourishment and fluid intake were impeded.because anemia with mild iron deficiency was found , esophagogastroduodenoscopy was performed , but no lesions were seen in the upper digestive tract . 
 levels of zinc and vitamin b12 were normal . 
 intense pain at pelvis and the inferior limbs , which was at a first glance referred to as osteoarthrosis , associated with oral symptoms and feeling of being in the clouds allowed us to diagnose fibromyalgia . 
 amitriptyline was used , with relief of symptoms.although oropharyngeal symptoms were occasionally reported in fibromyalgia , they are often overlooked . 
 the present case , therefore , testifies the need to consider the diagnosis of fibromyalgia when the patient presents with such symptoms that can not be readily explained on other grounds .