While working is his garden, a 59-year-old man noticed pain in his neck and shoulders. He had some difficulty holding his head in an upright position and rising from a squat. The referring neurologist had performed an MRI scan of the cervical spine, which was normal. As his CK activity was moderately elevated and the EMG showed fibrillation potentials, myositis was suggested. On referral – six months after disease onset – he also mentioned difficulty climbing stairs. When walking, he experienced cramps in the calves. In recent weeks, he had developed a slurred speech and had problems fastening buttons. He had lost 10 kg (12% of his original weight). Pseudobulbar affect (forced laughter, yawning, or crying) was not mentioned at the time.

A 63-year-old woman was referred because of decreased strength of her right leg manifesting with buckling of the knee for the past five years. Sometimes this led to falls, which made her feel insecure while walking. She experienced some aching in her right heel and in her right knee after long walks. She was able to walk for two hours. She and her husband loved to walk in the mountains, and during those hikes she used a cane. The previous history is relevant because at age 5 years she had suffered from poliomyelitis anterior acuta, which had affected both legs. She had a partial recovery in the sense that she regained normal strength of her left leg and was left with residual weakness of her right leg. She underwent surgery at age 10 years (ankle arthrodesis on the right and epiphysiodesis of the left leg).

A 70-year-old woman was referred by her GP because of progressive nasal speech and difficulties with chewing and swallowing, shortly after abdominal surgery because of a borderline malignant cystoadenofibroma of the uterus. Weeks later, she also noticed drooping of both eyelids and a tendency for her head to drop at the end of a day. In retrospect, mild nasal speech had been present for some months prior to surgery.

Over a period of months, a 45-year-old woman noticed that she had difficulty raising her arms. She also reported double vision in the evening that, in retrospect, had been present for some years. Three years later, it became difficult to keep her head up without support, to chew, and to swallow, which sometimes worsened over a period of weeks.

At about the age of 40, the patient noticed difficulty playing tennis. He could no longer hop easily from one leg to the other. After a game, he experienced pain in both legs. At age 43, he stopped taking part in competition, and five years later had to give up playing altogether. At that time, he sometimes missed the brake and accelerator pedals of his car. Walking became increasingly difficult. Sometimes he almost fell due to weakness of his left leg, and he had to use a walking stick. From the age of 50 onwards he used a wheelchair for outdoor transportation. At 52, he could only work part-time as his dexterity decreased. Urinary continence was not an issue, but when he felt the urge, he had to rush to the toilet. His family history was not informative.