A second episode of House in a row that felt shallow and superficial. There were two potentially great concepts in this episode: House kidnapping a soap opera star, and the hospital’s accreditation inspection, but both were essentially squandered in this disjointed episode.
House is convinced that Evan Greer, the star of his favorite soap opera, has brain cancer. House has noticed that Evan’s line readings are slower and he is pausing more which leads him to believe that Evan has bad peripheral vision from an occipital lobe brain tumor. So House does what any other self-respecting doctor would do: he kidnaps his patient by pretending to be a chauffeur.
Arriving at the hospital, House convinces Evan to let him run one test on him — a test of his visual fields to look for blind spots. House informs him that the test showed upper right quadrant blind spot and that he’ll need an MRI. Foreman picks this moment to show up and point out that House is lying and the test is normal. Frustrated, Greer leaves the room; House pauses a minute to grab something from Pyxis, then follows Greer onto the elevator. While having a conversation with Wilson, House reaches over and injects Greer with a sedative, knocking him out, so that the MRI can be performed. Surprisingly (to House at least), the MRI is normal and shows no tumor. Greer wakes up at the end of the test and is furious. He storms off to find Cuddy to complain when his right foot suddenly goes completely numb and he finds himself unable to walk. He is admitted to the hospital — officially, this time.
At this point the differential diagnosis consists of vitamin deficiency or a toxic exposure. Cameron suggests that Greer may have injured a nerve in his foot when he fell after House knocked him out and suggests an EMG. House order Kutner to pretend to perform the EMG (Electromyogram — a test that checks the conductivity of muscles and nerves), but Kutner decides to go ahead and runs the test for real. Meanwhile, House has the rest of the team watching old episodes of the soap opera for subtle diagnostic clues. Taub and Foreman think that there might be some slight neurological symptoms and suggest myxedema or demyelination. The EMG is negative, and Kutner adds atherosclerosis (hardening of the arteries) to the possible diagnoses.
House checks out Greer’s dressing room and talks to his female costar. He learns that even though Greer’s character likes his gin and tonics, Greer himself does not drink — in fact, he’s kind of a health nut. Housee also learns enough to suspect that Greer may be suffering from erectile dysfunction. House suggests that Greer has B6 toxicity and the resultant autonomic dysregulation from eating too many sunflower seeds. The team decides to test whether the impotence is physical or psychological by testing heart rate, blood pressure, and tumescence after giving Greer some pornography. He is able to have an erection, but he also develops a dangerously rapid heart rate that requires defibrillation.
The differential now includes sepsis, paraneoplastic syndrome, and Graves Disease (an autoimmune disease which leads to too much thyroid hormone), with the latter being the most likely. House wants to “nuke” Greer’s thyroid to stop the Graves, but the rest of the team actually wants to test for Graves first by performing a radioactive iodine uptake test. The test shows that his thyroid is normal, but that he is starting to develop kidney failure. Autoimmune diseases are now added to the differential. A short time later, House is talking to Greer and he finds him repeating old lines from the show and discovers that he actually believes himself to be his soap opera character. He is also running an extremely high temperature and has slipped into delirium.
The team now suspects that Greer is septic, in other words he has an overwhelming infection. They are just not sure what infection it is. Pneumococcus, Tetanus, Lyme Disease are suggested, as are fungal infections. House also mentions rat bite fever and listeria. Greer is started on broad spectrum antibiotics, but is not improving.
While helping Wilson shop for a bed, House had an epiphany. Greer is not septic, instead he a rare type of allergic reaction known as allergic vasculitis and he is allergic to the chrysanthemums in his dressing room. House wants to start him on high dose steroids, but Foreman points out that high dose steroids would kill him if her were septic. Cuddy eventually steps in and allows House to start the steroids, but runs some confirmatory allergy tests. After these tests are complete she informs House of the results — negative: Greer has no floral allergies. They return to the patient’s room ready to restart the antibiotics only to find that Greer has greatly improved; the steroids worked. Later, House realized that Greer is allergic to quinine, the chemical in the tonic water his soap opera character drinks.
I can understand why House thought Greer had a brain tumor — that makes at least a little sense (though I think a frontal lobe tumor would fit the suspected symptoms better than an occipital lobe tumor). The rest of the medicine in tonight’s episode barely made sense, and the team basically haphazardly stumbled from one unsupported diagnosis to another to another. Here’s what caught my eye tonight:
The final solution of allergic vasculitis doesn’t really fit the case well. The symptoms Greer had are rarely, if ever, seen in allergic vasculitis and he was missing the common symptoms such as the distinctive rash. I would also like to point out that the team dismissed an autoimmune cause because he had a fever, but no one batted an eye at a fever being caused by allergic vasculitis — another type of overly aggressive immune response (in truth, both autoimmune diseases and allergic vasculitis can cause fever. Just give me a little consistency in logic, please). And why was House convinced that chrysanthemums were the cause — where did that come from? On a daily basis, people are exposed to hundreds if not thousands of allergens, it could have been any of them.
B6 toxicity doesn’t match his symptoms either. It can cause nerve toxicity, but not like Greer had. Sunflower seeds do contain a large amount of B6, but he would have to eat a hell of a lot of them to develop toxicity. An ounce of sunflower seeds contains 0.23mg B6. Toxic doses start around 500mg/day, or over 2000 ounces of seeds per day.
Giving someone porn and then watching them to see if they get an erection is not the way to differentiate physical from psychological causes. That situation is enough to cause psychological impotence in anyone.
Graves disease is an autoimmune disease. An ANA is not the definitive test for autoimmune — there really isn’t any one single test. ESR (”sed rate”) is probably one of the most common, but if the team had run that, they would have figured out the vasculitis much sooner.
100mg of IV methylprednisolone (”Solu-Medrol”) is not that uncommon a dose. When high doses are needed, it’s generally an emergency (acute asthma attack, for instance) and having to wait for Cuddy to sign off on it is a delay in treatment and a lawsuit waiting to happen. And you’d think the pharmacist would learn to lock his door by now.
Ampicillin is not an appropriate drug for sepsis, particularly sepsis of an unknown cause.
Accreditation inspections involve a team of inspectors, not just one, and are not usually carried out on an annual basis unless there is a known problem.
I give the medical mystery a B+ because it was a clever idea: House deducing something is wrong just by watching an actor on television. Unfortunately, neither the final solution nor the medicine leading up to it were all that good; I give them both a C-. The soap opera was fairly average. There were a couple brief glimmers of cleverness, but nothing really memorable, so it deserves no more than a C.
The previous House review
A list of all prior House reviews
The calcaneus is the large bone that makes up the heel.
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