A Red Herring

When Joel Mulholland fell off his garage roof last winter he must have hit every bone in his upper body. The muscular, tattoo-armed, motorcycle-riding fifty-five-year old, who had never complained of pain or even taken a sick day before, became almost unable to work.

His x-rays at the emergency room showed no fractures and his blood tests during our office follow-ups showed no evidence of any inflammatory disease. Our local rheumatologist, Norm Fahler, saw him several times and made a diagnosis of cervical myofascial syndrome. I followed Joel for his cholesterol medication. The blood tests showed no sign of muscle damage from the medication. I even asked him not to take the pills for a month to make sure they weren’t causing his muscle and joint pain.

The muscle relaxant and nonsteroidal medications offered him some relief, but the physical therapy did not. Joel was discouraged. He had a brand new Harley-Davidson motorcycle sitting in his new garage, and he told me he was beginning to wonder if he would be able to ride it when spring came.

Joel’s neck seemed to get slowly better. He had full range of motion and not as much tenderness as before, but his shoulders were in constant pain and his range of motion was not improving.

He had some heartburn, so I gave him an acid blocker, concerned that his arthritis medication might be putting him at risk for an ulcer. That took care of his indigestion, but soon thereafter Joel’s appetite started to dwindle. We did some blood tests again and I made a follow-up appointment for the following week.

The day after our appointment Joel’s wife called. This was unusual; he never let anyone else speak for him. She reported that he was nauseous and had vomited twice that morning. I called in some nausea medication and advised Sandy to bring him to the hospital if the vomiting wasn’t controlled with the medication.

That weekend felt like the first day of spring. The sun was bright, the roads were dry, and there were motorcycles in town and on the County road. I kept thinking of Joel and his new Harley-Davidson. What was wrong with him?

Monday morning’s faxes from the hospital brought the answer: Joel was admitted for intractable vomiting. His blood tests were normal, except for some signs of dehydration. His scans showed a normal looking liver, pancreas and gallbladder, but there was a little fluid at the bottom of his right lung and in the upper lobe there was a large tumor that had not been visible on plain x-rays.

I copied the hospital reports to the rheumatologist, who called me right back. Joel’s muscle and joint symptoms, in retrospect, were part of a paraneoplastic syndrome. “We were fooled”, Dr. Fahler said. “The fall from the roof was a red herring. It was cancer pain all along.”

Joel did get to ride his Harley-Davidson just a few times during the two short months of therapy he had before his cancer got the upper hand again.

1 Response to “A Red Herring”

  1. 1 Eileen February 21, 2011 at 4:34 pm

    Much of that clinical description initially sounds like that of a patient with polymyalgia rheumatica triggered by the accident. With your heritage I’m sure you know about it and that one of the things to be excluded is neoplasm. Would you have considered PMR if the ESR had been elevated? If so, why wasn’t it considered anyway – 20% or so of patients, especially men and younger women, present with no abnormal blood values.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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