This episode was mostly about House, Wilson, and Vicodin, but they did manage to squeeze in some medicine as well. The mystery was fair, the solution clever, but the medicine — even though they ordered less tests than usal — still had too many errors. Here is this week’s review of House (with spoilers, of course):
Abigail is a 15 year-old dwarf with cartilage hair hypoplasia dwarfism (CHH). She was recently in the hospital for a collapsed lung and is now following up in Dr. Cuddy’s clinic. House convinces Cuddy to admit Abigail to the hospital to find out what’s really wrong with her. He presents her case to his team, at this time noting that she also has anemia. Cameron points out that individuals with CHH dwarfism have compromised immune systems and the PPD (tuberculosis test) that Dr. Cuddy placed may not be reliable. A gallium scan is ordered to look for infection. The scan shows no infection, but House notes that the liver is the darkest area of the scan, which makes him suspicious that something is wrong with her liver. He wants an ultrasound of the liver, but at this point, Cuddy intervenes. She removes House from the case until he accepts Tritter’s plea bargain and she takes over as lead physician. She orders a lung MRI to look for lung cancer, but it is negative. As the scan is finishing, Abigail develops a bad coughing spell and begins to cough up blood (hemoptysis). A further work-up reveals variceal bleeding (enlarged easily bleeding blood vessels in the esophagus related to liver problems) and liver failure. The diagnosis at this time includes schistosomiasis (a parasitic infection of the liver), cirrhosis, hepatitis, hepatoma (liver cancer), Budd-Chiari syndrome (an obstructing clot of the hepatic vein), and drug or alcohol abuse.
A liver biopsy shows sclerosing cholangitis. Surreptitiously, House tells Foreman that he believes Abigail has a condition that will affect her whole body, starting with the pancreas. Foreman order an alpha-1 antitrypsin level, but it is normal (This is good thinking on Foreman’s part, sort of; an antitrypsin deficiency can lead to lung and liver disease, so that part is right — but it really has nothing to do with the pancreas). Cuddy discounts House’s theory about the pancreas and orders an ERCP. Just before the test is to begin, Wilson and Foreman realize that Abigail in unconscious. They detect fruity breath and diagnose her with diabetic ketoacidosis. Her pancreas has failed leading to diabetes; House was right.
At this point, the differential includes Langerhans Cell Histiocytosis, cystic fibrosis, Hodgkin’s Lymphoma, and lupus. A lumbar puncture is obtained to look for signs of Hodgkin’s and antibody levels are drawn to look at autoimmune diseases. Cameron visits House who deduces that Abigail has Still’s Disease (better known as Juvenile Rheumatoid Arthritis) — a particularly nasty autoimmune disease. She is started on steroids, methotrexate, and cyclosporin. Sadly, she starts bleeding from her mouth and ears. A head CT is normal. Wilson suspects she has leukemia and wants to perform a bone marrow biopsy but Cameron feels that it is still an autoimmune disorder, as Abigail did initially improve on therapy.
House examines an x-ray of Abigail’s leg to make the diagnosis. The growth plates on her bones are normal, suggesting that she does not have CHH. Instead, she has growth hormone deficiency caused by a pituitary tumor caused by Langerhans Cell Histiocytosis (and Chase was right again).
I thought the idea of Abigail not really being a genetic dwarf was particularly clever, unfortunately the route (and medical care) they used to get there was poor. In several cases, the timing was off. Gallium scans take 2 to 3 days to complete (it takes gallium a while to build up in the tissues), and diabetic ketoacidosis would not kick in that quickly unless the team inexcusably missed some earlier abnormal labs. Neither of Abigail’s diagnoses really fit her case. Look at the signs and symptoms of Still’s Disease and Langerhans cell histiocytosis. Few of them are even close to her symptoms, and nothing explains her lung collapse and liver failure — her main complaints. Finally, people with short limb dwarfism (of which CHH is one) have a different body build than people with growth hormone deficiency; someone should have caught that sooner. I was also a little disappointed that they presented such a rosy ending (or close, anyway), apparently forgetting that poor Abigail still has liver failure, pancreatic failure, and diabetes. She has a rough road ahead.
The soap opera/personal relationship aspect of the episode was good again this week, with several good scenes involving House and Wilson, House and Cuddy, and then House and Foreman and Cameron. I’m still not sure how much of House’s actions are signs of addiction, or are signs of an obnoxious person with pseudoaddiction. I’m certainly no lawyer or policeman, but I was confused why Tritter was offering the deal. Isn’t that what lawyers are for? Sure, he mentioned the DA, but at this point House hasn’t been arrested or even indicted.
This episode earns a B for the mystery and an A for the solution. The medicine, however, was only average (for House at least) and deserves a C. The soap opera was good, but not as good as last week’s and earns an A-.
The previous House review
A list of all prior House reviews
Grand Rounds, the weekly collection of the best medical blogging on the ‘net, is held this week at Anxiety, Addiction and Depression Treatments
Tags: television medicine house vicodin langerhans
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