Another episode of House that focuses more on the applicants (or hirelings, if you prefer) and soap opera rather than the medicine. That’s not necessarily a bad thing, and it was an enjoyable episode soap opera wise. I just wish it had better medicine. Spoilers below!
The main patient tonight is Stark, a 37 y/o man with Spinal Muscular Atrophy, an incurable and progressive neurological disease that weakens muscles. He is wheelchair bound and assisted by his dog Hoover. While crossing the street, Stark faints without warning and is nearly hit by a car. He is admitted to the hospital to find out why he had the fainting spell.
House divides the ten remaining applicants into two teams of five each: boys versus girls. The team that diagnoses Stark correctly wins and gets to remain. The losing team is fired. Everybody’s favorite alpha-female Amber wants to join the men’s team but they rebuff her.
Both teams initially consider that Stark may have picked up a bacterial infection from his dog Hoover, but discard the idea. The women’s team now decides that he must have become infected with Strongyloides (threadworm) on his recent trip to Thailand. They treat him with Ivermectin, an antihelminthic drug (i.e. an anti-worm drug). The men have no working diagnosis and want to run a full battery of tests on Stark’s hair, blood, and stool. During this conversation, it is revealed that Stark is also incredibly constipated. Amber manages to finagle her way onto the men’s team by convincing them to try xenodiagnosis — basically, have a bug bite the patient, and test the bug for any parasites that the patient may have (of course, this would only test for blood-borne parasites, not ones in the intestines or other organs). In the middle of the test, Stark starts choking and coughing.
The next morning, House reveals that the patient has suffered an aspiration, but is improving on oxygen and chest PT (though the patient is shown receiving a nebulizer. Aspiration pneumonia, a nasty type of pneumonia, would be a concern in this patient). House seems intrigued by the women’s diagnosis of Strongyloides and dismayed that the men have only managed to run test after test. He places the men’s team in the “penalty box” — making them sit in his office and not talk about the case while the women go about proving theirs. Their plan is to perform a tilt table test on Stark and try to induce a fainting spell. If the test is negative and there is no fainting, then their diagnosis and treatment must be right (but not necessarily, the tilt table test only reproduces certain types of syncope — and not the type the patient has — and/or he might be getting better for other reasons beside their treatment).
Amber and the guys have not given up. They want to know whether Stark’s choking is dysphagia (difficulty swallowing) or achalasia (an esophageal motility disorder). The old guy suggests paraganglioma — a tumor in the neck that presses against the vagal nerve, thus causing fainting, whenever the patient eats. The tilt table test is negative, seeming to confirm the women’s diagnosis and treatment, but Amber runs a CT on Stark anyway. No tumor is revealed, but she believes the results are consistent with scleroderma, a type of connective tissue disease that commonly affects the skin and esophagus. House disagrees and fires the men and Amber. She’s not done though, she talks Chase into running labs on the patient for her. She wants to run an anti-centromere antibody test, a blood test that is sensitive for scleroderma. When she draws the patient’s blood, it turns out to be green.
With this finding, House “rehires” the men’s team and Amber because the diagnosis he thought was right clearly is not. The plastic surgeon deduces that the blood is green because the contrast for the CT the patient had the day before has not been filtered out by the kidneys meaning that Stark has kidney failure. (Who runs a contrast CT on a hospitalized patient without checking kidney function first? That’s very sloppy medicine by Amber, even if she did run the test herself).
The differential is now a gram negative bacterial infection from his indwelling catheter versus scleroderma. House orders Stark to be started on Ampicillin and Gentamicin, two potent antibiotics, for the possible infection; he also orders skin and lymph node biopsies to look for scleroderma. Shortly, the team reveal that the antibiotics are having no effect (though it seems mighty quick to make that judgment) and the biopsies are negative. Or are they? House notices some black specks in the cervical lymph node biopsy and suspects that Stark has melanoma of the eye that has spread throughout the body He wants to remove the eye and manages to talk Cuddy into agreeing with the surgery. Before surgery, the applicants are performing a thoracentesis (draining the fluid from around Stark’s lungs) to make his breathing easier when they notice the fluid is clear. This is not consistent with fluid from a cancer, which tends to be cloudy and bloody. Stepping in after House’s injury (discussed below), Wilson and the team decide that Stark has Eosinophilic Pneumonia, and he is started on corticosteroids and cyclophosphamide (a potent immune suppressant and chemotherapy drug, that has been used for certain types Eosinophilc Pneumonia). The medication doesn’t help and Stark dies quickly and quietly, his faithful dog by his side. When the dog is revealed to be dead a few minutes later, House realizes that Hoover took the patient’s Invermectin (which is fatal to that breed of dog) instead of the patient. Thus, the women were right and the patient had Strongyloides all along, and died of an overwhelming threadworm infection.
While the team is treating Stark, House sees a patient in clinic who pulls out a knife and sticks it in the wall socket right in front of him. House manages to revive him and the patient admits that he was in a car accident a few days previous and experienced a near death experience. He reports that it was the happiest that he’s ever been and wants to replicate the experience.
Later, when Wilson accuses House of not knowing for sure whether there is an afterlife or not, House decides to find out for himself, and sticks the patient’s knife in a wall socket (but not before paging Amber). She performs CPR and manages to revive him, though he suffered a burned hand and an extended loss of consciousness. Because of this, Wilson had to take over Stark’s case in the end. |
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Meanwhile, at a hospital across town, Foreman is running his own diagnostic team, only he is trying to make it friendlier and more supportive than House’s. They have a patient with fever, boggy lungs, and blurry vision who the antibiotics aren’t helping. The team diagnoses Apergillosis and starts the patient on Amphotericin B. It doesn’t help, and the patient now develops yellow gums, a sign of jaundice. Foreman believes that the patient has anaplastic large cell lymphoma, a rare and aggressive cancer. He wants to start treatment right away. His boss disagrees and feels that a severe infection is most likely. He has Foreman start a potent antibiotic. Foreman’s gut feeling gets the best of him and he stops the antibiotic and starts the cancer therapy. He is correct and saves the patient life, but his boss fires him for not following the guidelines and putting his gut feelings ahead of medicine. |
Medically, the episode was rather limited — which is to be expected in a story with six patients and more than a dozen doctors. The ultimate solution was interesting and not expected. I’m not sure exactly how the Strongyloides led to fainting, unless it was a severe case of disseminated Strongyloides, and even then it’s a stretch. The women never confirmed, or even tested for, the diagnosis of Strongyloides. Stool samples are the most common test, but it can take up to seven, but there is a good blood test for the infection. Most experts recommend at least two doses of Ivermectin, if not more. The disease progressed remarkably rapidly, but then Stark was in a debilitated condition, and given immunosuppressants, which are a bad idea with disseminated Strongyloides. It’s not generally the physician’s responsibility to make sure the patient takes the medication (I’m not sure whose it is — at some point, you just have to assume the patient wants to get better and trust that he will take the medication). I’m also unclear why the dog ended up with medication. Did he eat it of his own accord (his name “Hoover” suggests this may be a possibility), or did Stark feed it to the dog? If it’s the former, why wouldn’t Stark tell someone that he didn’t get his medication?
Just because a tilt table test was negative does not prove the diagnosis of Strongyloides. Tilt tables are best for certain kinds of fainting — for instance, orthostatic hypotension that occurs when people stand up suddenly. When was the last time Stark stood up? It’s a poor choice of tests to begin with, and did they have a positive test before treatment to compare it to? It’s basically a post hoc ergo propter hoc error.
Finally, where did House get the idea that the suspected cancer cells must come from the eye because the eye is the only thing that drains to that lymph node? Lymph node drainage is a lot more complex than that. An eye may indeed drain to one lymph node, but it is not the only part of the body that drains there.
As for the clinic patient — I am not an electrician — but wouldn’t you need to complete the circuit, that is have metal in both parts of the socket, for the electricity to flow (assuming the hospital is grounded correctly)?
I give the medical mystery a
C, as it was vague and not particularly unusual (fainting?). The final solution I give a
B- because it was unexpected but should have been diagnosed and treated better. The medicine was uninspiring, and either team came close to convincing of their cases (and nor did House); it earns a
C-. Once again, the soap opera was the best part, though — with the exception of Amber and Dr. 13 — the female characters were bland. Seeing Cameron and Chase was good (Cameron was easily manipulated, but Chase caught on — but still went for it), though I would have liked to see more depth in the Foreman scenes. Still, I give the soap opera an
A.
The previous House review
A list of all prior House reviews
Tomorrow night I’ll be taking a look at the new ABC show Private Practice (Last week’s review can be found here)
Tags: television medicine house syncope spinal muscular atrophy strongyloides ivermectin scleroderma melanoma
This PSA comes from various April 1965 issues of DC comics and asks what you would do if you saw a hit and run driver.
The John Ostrander version would feature the injured man — or his wife — swearing vengeance and hunting down the hit and run driver. 
More serious — and thankfully less common — injuries following head trauma are the hematomas and hemorrhages — bleeding on (or around) the brain. 
Of course, I do have a couple of small nitpicks, all regarding the art. Overall — as always — Medina does a good job with both the action scenes and the quieter moments. However:
In the destined-to-be-classic 
