An 82‐year‐old man with cervical spondylosis presented to his PCP in mid‐August for acute neck pain with radiation to the hghl arm. The patient was treated for similar pain with steroid injections in the past. Prior imaging confirmed degenerative changes in the neck. The patient's last visit to his PCP was for a febrile illness in July, diagnosed as a UTI (Lyme serology negative at that Lime). His exam was notable for a subtle decrease in right arm strength. He was referred for CT c‐spine and head, showing mild cervical canal encroachment. Within 48 hours, the patient developed right facial droop. He was started empirically on acyclovir 800 mg 5 Times daily. After developing mild confusion, he was admitted to the hospital. Initially the patient was afebrile but hypotensive (71/46 mm Hg), with right facial droop, neck pain, and weakness in the right arm. He was admitted to the ICU and covered empirically for CNS infection with vancomycin, ceftriaxone, ampicillin, and acyclovir. Lumbar puncture revealed 399 WBC/μL(51%L,20% M, 17% P), 122 RBC/μL, total protein of 172 mg/dL, glucose 63 mg/dL, gram stain with 2+ PMN, and no organisms. Serum WBC 12.6 K/μL (82.4% PMNs), Hct 39.9%, Pit 280 K/μL, electrolytes and liver function normal. Blood and urine cultures, CSF culture, HSV/VZV PCR. and serum Lyme serology were sent. He improved clinically and was transferred to the medical floor. On the floor his facial nerve palsy became bilateral. Neurology evaluation revealed facial diplegia and dysarthria, with right deltoid, biceps, and wrist extensor weakness, consistent with bilateral Bell's palsy and C5‐C6 radiculopathy. All cultures returned negative, except for a positive serum Lyme serology, confirmed by Western blot. Infectious disease confirmed disseminated Lyme disease as the probable cause. We initiated 3 weeks of ceftriaxone with noted neurologic improvement at discharge. The patient's only risk factor included yard work in an endemic city area, but no identified tick exposure.
Neck pain and radiculopathy from cervical spondylosis are commonly seen in our aging population. Though many of these patients will not be admitted to the hospital for such complaints, these symptoms will be present in many admitted medical patients, requiring a hospitalist's increased attention. Moreover, these symptoms may mimic a more serious diagnosis. Though Lyme disease occurs in endemic areas of Ixodes scapulars ticks, it remains the most common vector‐borne disease in the United States, causing significant morbidity. Furthermore, many cases of Lyme disease occur without documented tick exposure or inhabitance in high‐risk areas. Interestingly, neurologic features of disseminated Lyme disease can include radiculopathy, Bell's palsy, and meningoencephalitis.
This case illustrates the interesting symptomalology of a common vector‐borne illness masquerading as a common anatomic illness. The cautions of diagnostic anchoring are reaffirmed.
M. Hill, none.