Heading Down the Wrong Path

A 52-year-old woman experienced the sudden onset of bilateral arm tingling and numbness, and noted that the words on her computer screen appeared “mixed up.” She improved over the next 24 hours, but then difficulty swallowing and slurred speech developed, progressing over the next three days to no speech. A 52-year-old woman experienced the sudden onset of bilateral arm tingling and numbness and noted that the words on her computer screen appeared “mixed up.” Difficulty swallowing and slurred speech developed. Foreword In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage A 52-year-old woman who had undergone renal transplantation 13 years earlier was brought by her family to the emergency department of a community hospital. Five days earlier, she had suddenly begun to have tingling and numbness of her arms and she noted that the words on her computer screen appeared “mixed up.” Her condition improved during the next 24 hours, but difficulty swallowing and slurred speech developed and worsened during the next three days until she was unable to speak. The day before presentation, bilateral impairment of the left visual field developed and she became lethargic. Her family sought . . .