House - Episode 10 (Season 2)
This medical review of House contains lots of words (probably too many) and several spoilers, so don’t say I didn’t warn you…
Fletcher Stone, a famous journalist, is at an office function when he falls and hits his head on a desk. There is some confusion whether he tripped or fell. He was knocked unconscious briefly, and when he came to he was unable to speak normally. He had developed aphasia and he only spoke in random words. He could understand what was being said, but was unable to talk intelligibly. When he was later examined in the hospital, he was also noted to have agraphia, the inability to write. Both aphasia and agraphia are signs that something very bad is going on in the brain.
Stone had apparently been the stereotypical “wild journalist” for most of his life. He had volunteered for risky assignments, drank copious amounts of alcohol, and indulged in frequent recreational drug use. He gave up all his vices when he got married a few years before the episode occurs.
House is away in Baltimore and Cuddy wants to transfer Fletch to another hospital. Foreman convinces her to let the rest of the team handle the case, though they keep in touch with House by phone for most of the episode. They initially suspect that Fletch may have had a stroke, suffered a seizure, or may be having a medication reaction. A carotid Doppler was normal as was an EEG. Fletch suddenly develops a coughing spell and has trouble getting oxygen. He is emergently intubated and placed on a ventilator. A chest x-ray shows pulmonary edema (fluid build-up in the lungs). He is given a diuretic (a “water pill”), which apparently worked very well because he is never shown intubated or having breathing problems again.
Meanwhile, his drug screen has come back positive for amphetamines. His editor confesses that Fletch had found difficulty sleeping in his new married life, so he started taking sleeping pills. Those made him too tired during the day, so he started taking amphetamines. Of course his wife knows nothing about this.
Fletch starts running a fever of 101. The team is now concerned about infection (encephalitis or meningitis) or an autoimmune disease. The treatment for these two conditions is very different, and treating both would be counterproductive, so they have to choose one treatment and go with it. House suggests treating the suspected infection with antibiotics and antivirals. He also insists the team obtain an MRI. The MRI shows brain swelling; it also shows scarring in the brain — as if from an old injury — but not in the areas of the brain that would cause aphasia.
Feeling they’ve reached a dead end, the team falls back on an old House standard: breaking and entering. Foreman and Chase search Fletch’s office and home. They find the sleeping pills and amphetamines, as well as a bottle of Topamax (officially a seizure medication, though it has many unofficial uses). At the hospital, Fletch starts complaining of a metallic taste and Cameron realizes that he is going into kidney failure (a metallic taste in the mouth is a symptom of kidney failure).
A lumbar puncture is performed. This can be a dangerous procedure on a patient with elevated intracranial pressure or brain swelling. When the puncture is performed, a sudden drop in intracranial pressure can occur. In patients with swelling, this can be enough to smash the brainstem against the spinal column, causing death. Luckily, Fletch’s test is performed safely and shows some non-specific signs of infection.
Belatedly, the team realizes that Fletch is hiding some of his past from his wife. They lure her out of the room and are able to discover that Fletch has bipolar disorder, which is why he had been taking the Topamax (one of its unofficial uses is as a mood stabilizer). To “cure” his bipolar disease before getting married, he had crossed the border into Mexico or the Caribbean and had an experimental brain surgery designed to cure bipolar. It didn’t work, but it did cause the scarring that the MRI revealed. Also, while he was “south of the border” he contracted malaria, and that is the underlying disease that had been causing all his problems. Fletch is soon cured of malaria, but sadly, his wife had left him because he kept too many secrets from her.
The writers played very loose with the diagnosis of aphasia. The symptoms shown by Fletch (sentences seemingly composed of random words – yet retaining understandable syntax) are not common in any type of aphasia, particularly the “expressive aphasia” Cameron mentioned. In addition, the idea that one can “decode” aphasia is simply ludicrous.
The final solution of malaria was a bit of a letdown as well. Malaria can certainly cause kidney failure and pulmonary edema, but it’s very rare and only in very severe cases. I’m not certain how the malaria caused the aphasia — a stroke maybe? — as that part was conveniently left unexplained. I find it hard to believe that malaria severe enough to cause renal, pulmonary and neurological disease would not have been easier to diagnose; there are many more common early symptoms including the classical cyclical fever (a high fever recurring like clockwork every 24-36 hours). According to the timeline of the episode, Fletch would have to have had malaria for several years without knowing it — something unheard of. While a mechanically tested blood sample would not show malaria specifically, it would show other abnormalities that could be picked up on. Finally, intravenous quinidine is not routinely available in the United States and must be shipped directly from the CDC so the hospital would not just have some on hand.
The soap opera aspect consisted of House and Stacey flying to Baltimore to defend House’s Medicare billing. A snowstorm leaves them stranded in Baltimore and in a single hotel room. There is some mutual smooching going on, but then the case intervenes. Things are left up in the air between House and Stacey, but with a definite “this is never going to work” undertone. I’m not sure why they had to fly to Baltimore (except to get them together and out of the hospital). The billing inquiry could have been handled over the phone or by mail.
I give this episode a B+ for the mystery, bot only a C- for the solution. The medical content also earns a below-average C- (mostly for the “decode the aphasia” scenes). The soap opera earns a B.
January 11th, 2006 at 1:29 am
Asymptomatic malarial infections do occur and the individual can be infected for years. My father lived in India for years and never took any malaria medication nor did he ever have nay symptoms but he did get infected with the malaria parasite. Practically everyone in the tropics has malaria.
January 11th, 2006 at 7:46 am
Actually, they stated that he was going to Baltimore in regards to his MEDICAID billing. While CMS (located in Baltimore) *does* oversee Medicaid somewhat, he would have had to go through his state (NJ) for discrepancies in Medicaid billing, and they certainly wouldn’t have called a “conference” that he’d only need 1 lawyer for. ;) Not to mention that most audits are done when the people in the suits show up in your medical records deparment and start pulling charts.
But I don’t watch House for the realism. :)
January 11th, 2006 at 1:05 pm
Did you think it was neurosyphilis when you saw those spirochetes at the end? Cerebral malaria was such an improbable diagnosis. Especially if you were sick enough to have renal failure you wouldn’t be awake to talk gibberish, Wernicke-wise or otherwise.
January 12th, 2006 at 12:21 am
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January 12th, 2006 at 10:06 pm
Even though Fletcher couldn’t write, was there any reason why they couldn’t have given him a typewriter or a Speak ‘n Spell? Or would his typing skills be inhibited too?
January 13th, 2006 at 4:30 pm
Official Comment
David,
I was so thinking it was syphilis — I even told my wife it had to be. Malaria never crossed my mind…it’s like in a mystery when the cousin they’ve never introduced or even mentioned ends up being the murderer.
Loren,
For most people with aphasia, the communication block affects all forms of outgoing communication. He might be able to draw a picture since that uses a different part of the brain, but for the most part words are words.
January 14th, 2006 at 9:57 pm
My late brother-in-law (a physician) had an enormous fight with Medicare over using the write codes in his billing. He was actually billing LESS by using the “wrong” codes, but it took years and lawyers to get Medicare not to ban him, and to admit he didn’t owe them large quantities of money.
January 15th, 2006 at 11:43 pm
Are a aphasia and dysphasia still different things? I’ve seen a lot of things classified as aphasia that I thought was dysphasia. I had originally learnt that aphasia meant one couldn’t speaking, and dysphasia was the ’saying strange and random things’ one. My learning has been quite sporadic, though, so it could have been wrong there.
June 9th, 2006 at 7:55 pm
I was reading about aphasia, and it apparently seems that you CAN decode aphasia… but only certain kinds of it. Drawing from the information given in the link you (or, I think it’s you…) provided with the word on this page, intonation, identification of spoonerisms, associations, and even rhymes, can be used in decoding it. But… not all different kinds… so it depends (or depended, in Fletch’s case) on what kind of aphasia it is. It’s interesting. :D
(Also, your House reviews are astounding. ^_^)
June 12th, 2006 at 5:17 pm
It seems to me that they could have solved the “decoding aphasia” problem quite easily by going by the route that was used in “The Count of Monte Cristo”: going through the dictionary. Would have taken some time, but still shorter than the time it took for House and his team.
July 21st, 2006 at 12:32 am
I’m a microbiologist and did a presentation on malaria for a class in college once. Scott, as for the cause of aphasia, it seems it was a case of “cerebral malaria”. And they do say so on the show. Cerebral malaria is a know complication of malaria, apparently caused by enlarged red blood cells obstructing capillaries in the brain. That causing aphasia, though, might be a stretch.
The same phenomenon can happen in other organs like liver and kidneys. The liver is also part of the Plasmodium’s life cycle (Plasmodium being the parasitic protozoa that causes malaria).
The disease taking years to present is far from unheard of! It’s quite typical actually. The primary attack can happen up to a year after infection (via mosquito byte), with relapses occurring up to 3 years. Malaria should be considered for any patient showing high fever that has been in central/south America, sub-saharan Africa, and southern parts of Asia, in the last 3 years.
What I found weird in this episode is that the cyclical fever didn€™t tipped them off to Malaria sooner, and that the parasites on the microscope examination of the patients blood looked nothing like the photos I€™ve seen (much like the one you posted, Scott). I think one even needs special colorants in other to see the parasites inside the red blood cells… a normal smear wont do.
I love these medical reviews of House. They have become a must after watching an episode. Thank you Scott!
November 7th, 2006 at 8:06 pm
As a speech-language pathologist, I can tell you that the language output of people with aphasia cannot be decoded. It’s a disorder of symbols…even their gestures are affected (undifferentiated — they tend to use the same gestures for anything they are trying to communicate). Further, they cannot use a dictionary to look up the words they are tryinig to say. People with aphasia WISH there were such a nice answer…there is not. In the case presented on House, the pt clearly thought his expressive language was appropriate…he did NOT recognize his errors. How could a person like that use a dictionary to find the right word? He thinks what he said was right! You cannot decode aphasia.
January 4th, 2007 at 6:42 pm
My grandmother, who had recently been hospitalized when she fell and broke her hip, suffered a bout of aphasia last month, and has only been home about a week. It was fairly disturbing to see a patient on “House” behaving in much the same fashion. (She also collapsed, though it was after I had noticed her speech impairment and called the paramedics.) Even as a total layman, the “decoding” scenes seemed a bit ridiculous. A question - in the hospital, my grandmother claimed to remember not being able to speak correctly, but someone with aphasia believes they are. Is it possible, or is this an example of House’s theory that “everybody lies?” (Believe me, it wouldn’t be the first time - my grandmother still denies that she’s diabetic.)
Also interesting in this episode to see Cameron displaying a modicum of cynicism. I’ve never liked Cameron - which isn’t to say that she’s a bad character. She’s always been an interesting counterpart to House. She’s just as unprofessional - but in her case it stems from her being *too* empathetic, as if House is lacking in bedside manner because it’s all been stolen by Cameron.
January 4th, 2007 at 6:59 pm
Official Comment
Max,
There are different kinds of aphasia. Usually, the person thinks that they are speaking sense when in reality they are speaking nonsens. Sometimes, the patient does realize that it is not coming out right. Often, this is from the reactions of others, but there are occasions where the patient realized exactly what is wrong but can do nothing about it.
February 6th, 2007 at 9:33 pm
For him to have cerebral malaria with multiorgan failure (although he was FAR too well for someone who has cerebral malaria and multiorgan failure) this would most certainly be Plasmodium falciparum malaria. And that one doesn’t incubate for years. And although I’m not completely sure of this, I think the primary agent of malaria in Mexico is Plasmodium vivax - which also doesn’t incubate for long periods of time.
On the contrary, I disagree when you state malaria does not incubate for too long. Plasmodium malariae, which usually causes mild disease or a well tolerated chronic infection, as the ability to incubate for many years - as long as 30 years, actually.
Just my two cents.
May 31st, 2007 at 10:27 pm
For interesting reading on what a transitory attack of aphasia feels like to the person suffering through it, may I suggest this entry?
He was aware that the words were coming out wrong, although I understand that that is not necessarily the case.
June 28th, 2007 at 7:33 am
I have only watched a few episodes of ‘House’ so far, sadly not sure if I can tolerate any more! I know that many medical professionals (including myself) can turn into ’spotters’ when watching medically based dramas, but at least dramas like ‘ER’ seem to do their factual research more thoroughly. I know it is all about entertainment - it is a TV show after all, but that said, I do think the shows researchers have a lot to answer for…perhaps they need to get an updated version of ‘Noddy visits the doctor’.
August 22nd, 2007 at 12:32 pm
Thank you so much, Scott!
Your medical reviews make the show so much more interesting.
November 20th, 2007 at 11:55 am
One does occasionally see patients with the classic “Wernicke” aphasia this patient has. This means that their speech is fluent and sounds “right”, but the words are either totally wrong or intelligible. It is rare, though. Speaking as a geriatrician.
December 27th, 2007 at 6:55 pm
Hari:
From what I remember from my parasitology course,
Although it’s true that P. falciparum doesn’t have a long incubation time, it can go dormant for years after initial symptoms. P. malariae, from what I can remember, can stay dormant for much longer (like the 30-40 years that you mentioned).
The cause of this is that the Plasmodium sporozite (the infectious stage of the organism) does not always go on to develop into the full adult form (go check out the CDC site for the full life cycle.. it’s long, complicated, and I don’t remember as much of it as I wish I did). These “hypnozites” stick around in your liver and can cause relapses in malaria after your body cleans out the initial batch of adult Plasmodium.
However, cerebral malaria (most likely cause by P. falciparum) would definitely be preceeded by other malarial symptoms like cyclic fever before it got to the point of being cerebral.. So yeah, malaria was kinda out-of-the-blue.
January 27th, 2008 at 6:45 pm
Hey, if you see Topamax, you don’t think “weight loss”, you think “major brain thing”. Official uses are temporal lobe epilepsy and migraines; it’s probably most often prescribed for bipolar disorder, though. I can’t see how they can just dismiss Topamax.
March 22nd, 2008 at 12:12 pm
Да, что то намудрили они с малярией и связью её с афазией.
April 2nd, 2008 at 4:44 pm
I’ve had an episode of transient aphasia—diagnosed as an atypical migraine—and it was an extremely weird and scary experience. I actually first noticed it while I was typing on my computer: I couldn’t get words to come out correctly or in the correct order. I could see that they were wrong, but not fix them. With great difficulty, I managed to call my flatmate’s name, and spent the next while trying desperately to express myself while she was trying to find out what was wrong. After about 5 minutes, I was gradually able to put words together again if I thought about it carefully and kept the sentences simple. After another few minutes, I was back to normal. I was very definitely aware of what was happening, and I was able to think quite coherently about health insurance worries.
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