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JAMA Neurology Clinical Challenge
October 10, 2016

Acute Neck Pain Progressing to Hemiparesis With Brain and Spinal Cord Lesions

Author Affiliations
  • 1Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
  • 2Department of Neurosurgery, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
JAMA Neurol. Published online October 10, 2016. doi:10.1001/jamaneurol.2016.1365

A man in his 50s presented with weakness in the distal right hand and leg and paresthesias of the right hand. Four days before presentation, he experienced sudden, severe neck pain that swiftly progressed to neck stiffness and bilateral shoulder pain. The next day, he noticed weakness in the right arm and leg. The day before hospitalization, the weakness progressed, and he lost the ability to ambulate. Until 18 months ago, he had worked as a clerk, but he retired because of a history of hypertension and diabetes. His family history revealed no neurological disorders, except for a brother who had a brain lesion excised. On examination, he was afebrile, and his vital signs were normal. He was fully alert but had weakness in the right distal arm (medical research council [MRC] grade 3/5) and the right leg (MRC grade 4/5) with sensory impairment to pinprick and temperature in the left leg. Laboratory values revealed an elevated γ-glutamyltransferase level of 615 U/L (reference range, 10-71 U/L). Analysis of the cerebrospinal fluid indicated xanthochromia; normal white blood cell count, 1 cell/µL; red blood cell count, 2.19 × 10/μL; increased glucose level at 133 mg/dL (reference range, 40-80 mg/dL); increased total protein level at 0.10 g/dL (reference range, 0.03-0.05 mg/dL); and increased lactate level at 28.8 mg/dL (reference range, 9.9-21.6 mg/dL). Magnetic resonance imaging (MRI) of the brain and the entire spinal cord revealed patency of the intracranial vessels and multiple abnormal signals throughout the brain on T1-, T2-, and susceptibility-weighted sequences (SWIs) and 1 lesion at the level of the fifth cervical vertebra (Figure).

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