Dr. David J. Rushforth: This 55-year-old woman was admitted for evaluation of osteoblastic lesions, which had been noted incidentally during an examination of the colon by barium enema. She had been well until one month previously when she consulted her physician because of watery, painless diarrhea of several weeks' duration. No blood had been noticed in the stool. Other symptoms included mild low-back pain and muscular stiffness, a numb feeling in her feet, and a one-year history of pruritus.
Physical examination disclosed a single, small, fixed supraclavicular lymph node in an obese woman. Results of the remainder of the examination were noncontributory. Findings from neurological examination were described as "physiological." Two examiners thought that the right lobe of the thyroid was slightly enlarged, but not nodular. Her breasts were normal to palpation.
The patient was readmitted three months later for increasing numbness and weakness. On physical examination a neurological deficit