A Pain in the Neck

By LISA SANDERS, M.D. OCT. 24, 2014

The Presenting Problem

A Lifeless Limb

Illustration by Anna Kovecses

The 62-year-old engineer struggled as he put on his pants. His left arm, which had hurt for the
last couple of days, now felt weak, and his left hand hung limp and useless, as if it were
somehow paralyzed. When he went to brush his teeth, he noticed that the foamy toothpaste was
pouring from his mouth. He glanced up at the mirror and was startled to see that his face was
lopsided. The right side, from shaggy brow to toothpaste-covered lip, was lower than the left.
The eyelid sagged, revealing the pink inner lid, and that side of his mouth was immobile.

Was this a stroke? He didnt think so. But his wife wanted to take him straight to the emergency
room. He considered the option but decided against it. He had a follow-up appointment that
morning with Dr. Isaac Moss, an orthopedic surgeon who was treating him for the arm pain. He
figured that seeing a doctor who knew him might be better than going to the E.R. So late that
morning he went to Mosss office at the University of Connecticut Health Center in Farmington.

Possible Muscle Strain

It all started roughly a week earlier, when the patient got this terrible cramp in his neck. He had a
headache as well, but that felt like a mere echo of the ache in his neck. Hed spent the day before
moving tree trunks out of his backyard, so at first he attributed the pain to a pulled muscle. But
nothing he did made his neck feel better. Ibuprofen and acetaminophen were useless. So were
heating pads and massage. Taking oxycodone only made him tired, but even then he couldnt
sleep because the pain was so severe. The ache then began to creep down his left arm. Every
movement was difficult. Even lifting his coffee cup hurt.

He visited his primary-care doctor, who suspected a pinched nerve and sent him to the hospital in
Farmington to get an M.R.I. of his neck.

Moss, the orthopedic surgeon on duty that day, explained to the patient that the M.R.I. showed he
had spinal stenosis a pathological narrowing of the bony enclosure that protects the spine.
Sometimes it gets better on its own, the surgeon said, but sometimes surgery is necessary. Moss
prescribed prednisone to reduce the swelling at the tight spot and ease the pain. That might be all
that was necessary. He told the patient to come back in a few days to see whether he was
improving or might, in fact, need surgery. That was the appointment set for the day his face
began to droop.

What happened to you? Moss asked when he saw him that morning. Closer examination
suggested some kind of injury to the seventh cranial nerve, on the right side of his face. That
kind of paralysis without a known cause is called Bells palsy.

Moss was concerned about the rapid progression from localized pain to weakness in the patients
arm and hand. But he didnt know how, or even if, the two problems were connected. He sent the
patient to the hospital for further tests.

Worse and Worse

In the emergency room, the patient was seen by a neurologist. An M.R.I. of his brain showed no
evidence of a stroke. A spinal tap suggested an infection. Based on the facial droop and the
abnormal spinal fluid, the doctor thought the patient probably had Lyme disease that had
advanced to his central nervous system. The medical team sent blood to the lab to be tested and
started him on an antibiotic appropriate for neurological Lyme. Because they werent certain that
the man had Lyme, and because the test results wouldnt be available for several days, the
doctors asked that the blood and spinal fluid also be tested for other causes of brain infections,
particularly herpes and tuberculosis.

The next morning, the patient was seen by Dr. Frank Senatore, a first-year resident. Senatore
wanted to get a more detailed history. The conversation revealed that the patient had actually
been sick for a few weeks, well before he lifted those logs. A month and a half earlier, on the way
home from a golfing trip, the patient saw a round, red rash on his ankle. It didnt hurt or itch, and
the patient attributed it to a spider bite. But a few days later, he developed fever and fatigue and
went to the emergency room. The patient mentioned the rash. But when an X-ray suggested a
lung infection, the rash was forgotten. He was given an antibiotic for walking pneumonia,
although he had no cough or congestion. The fever and fatigue resolved.

Exhaustion Sets In
A couple of weeks later, the patient started to have the same kind of terrible fatigue that he
experienced with the pneumonia though this time he had no fever. It was a couple of days
later that the patient developed the weakness and pain in his neck, shoulder and arm.

This additional history supported the diagnosis of Lyme disease. Senatore figured that the illness
with the fever and fatigue was the first blush of Lyme. Because the patient had taken only
a few days of an antibiotic and one that may not have been effective in treating Lyme the
disease was slowed but not stopped, and the infection spread. The classic presentation of this
kind of Lyme infection is a headache and a stiff neck, followed by pain and sometimes weakness
that imitates a pinched nerve, along with facial droop. Senatore was convinced that this was
Lyme disease and waited for the test results to prove it.

Over the next few days, however, the patient continued to have new symptoms. After two days
on the antibiotic, he developed a stripe of numbness on the left side of his chest. And the fingers
on both hands became numb and swollen. The following day, he had difficulty urinating. At this
point, the team started to worry: If this was Lyme disease, why wasnt the patient getting better?