Within hours of his presentation to the ED, he developed tongue fasciculation which, to me, usually means alcohol withdrawal; however, there are many other causes such as lower motor neuron disease, muscle-specific receptor tyrosine kinase, myasthenia gravis, brainstem lesions, base of skull tumors, radiation of the skull base, unilateral hypoglossal neuropathy, and syringomyelia.2 Following his MRI, he required intubation for altered mental status. This evidence concerns the gene NTRK1 and myasthenia gravis.